Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Frederic Nursing And Rehab Community during CMS and state inspections, most recent first.
The facility did not provide enough nursing staff to meet resident needs, with PBJ data showing excessively low weekend staffing and schedules reflecting repeated open CNA shifts. The Scheduler said the facility did not have enough staff to fill all required shifts, while the DON and NHA could not produce the staffing grid or PPD guide used to determine staffing levels. Residents reported routine 10-15 minute wait times during the week and 20-30 minute waits on weekends, and staff described difficulty completing care in a timely manner, including baths being pushed to the next day.
Facility assessment did not show how staffing needs were evaluated to meet resident care needs. The assessment listed census, ADL assistance levels, and CNA staffing targets by shift, but the DON and NHA stated staffing was determined using a PPD system based on census and budget. The NHA did not provide documentation showing how the facility evaluated whether current staffing levels were sufficient to meet resident needs.
Unsanitary resident rooms and hallway conditions: The surveyor observed debris, food crumbs, trash, stains, and grime in multiple resident rooms and throughout the Evergreen hallway. One contact precaution room had a strong odor and a severe build-up of dirt and sticky substance on the floor, while staff reported rooms were supposed to be cleaned daily but had not been cleaned since the prior week due to staffing shortages.
Failure to Promptly Resolve Missing-Item Grievances: The facility did not promptly investigate, resolve, or follow up on missing-clothing grievances for four residents. Two residents reported missing clothing and said they received no follow-up, and the grievance log showed incomplete or absent documentation for the other missing-item reports. The NHA and SS stated grievances should be investigated and followed up, but that did not occur for these complaints.
Missing discharge, transfer, and bed-hold documentation: The facility did not complete required Ombudsman notifications for several residents’ discharges and hospital transfers, and one resident’s bed hold and transfer notice could not be found. Records showed one resident was cognitively impaired at discharge, another was cognitively intact, and a third had multiple acute hospital transfers for vomiting, abnormal vital signs, aspiration, and an NSTEMI, yet the required notices were absent from the EHR or not completed.
Resident self-determination was not supported when a resident’s self-purchased coffee maker was removed from his room and stored in his closet after the NHA learned he was using it. The resident said he wanted his own coffee, but staff reported no alternate arrangement was made and he was only given facility coffee. The NHA said the restriction was based on a prior survey issue involving a coffee maker and extension cord, even though survey review found no safety concern for the resident’s coffee maker in the room.
A resident with significant cognitive impairment fell and later developed new rib pain that was documented by therapy and nursing over multiple days. Staff noted the resident’s repeated complaints and changes in condition, but the provider was not notified right away. The provider was eventually contacted, pain medication and rib x-rays were ordered, and imaging later showed acute rib fractures.
A facility failed to protect two cognitively impaired spouses from resident-to-resident abuse. One resident repeatedly yelled at and threatened the other, and the spouse later struck the resident on the head and face multiple times. Surveyors found incomplete behavior monitoring, missing documentation, and confusion among staff about reporting and protective interventions while the couple continued to argue and act aggressively toward each other.
Failure to Monitor Psychotropic Medication Effectiveness: The facility did not have behavior or effectiveness monitoring documented for two residents receiving psychotropic medications. One cognitively intact resident with bipolar disorder, GAD, and OCD received aripiprazole, clonazepam, fluoxetine, and mirtazapine without behavior monitoring, despite a pharmacy recommendation for target behavior and mood monitoring. Another resident with Alzheimer’s disease, dementia, and depression received duloxetine, and staff confirmed there was no behavioral/effectiveness monitoring in place.
Failure to Report Resident-to-Resident Physical Abuse: A resident with moderate cognitive impairment struck his spouse multiple times on the head after an argument over where to go outside. Staff separated the residents and interviewed them, but the incident was not documented in either chart until surveyors raised it, and the DON/NHA did not report the abuse to state officials or law enforcement as required by policy.
Failure to Thoroughly Investigate Resident-to-Resident Abuse: Two cognitively impaired residents who shared a room were involved in a physical altercation in which one resident struck the other multiple times on the head and face. The event was not documented in either resident’s chart until brought to the facility’s attention, and the DON and NHA acknowledged that state officials, law enforcement, and staff-wide documentation and education were not completed at the time. Staff interviews also showed the couple had ongoing verbal conflict and that the injured resident was crying and upset after the incident.
A resident with protein-calorie malnutrition and dysphagia had an 8% weight loss in a month, but the facility did not document the ordered weekly weights. The resident was cognitively intact, denied refusing weights, and the DON said the charting order was not set up correctly, leaving no place to record weights after the last documented weight. The NP said the resident should have been re-weighed if a weight error was suspected and confirmed weekly weights were expected.
Infection control practices were not maintained during resident care, catheter handling, meal assistance, and linen transport. A CNA used the same gloves through bed bath, peri care, brief changes, oxygen adjustment, and basin cleaning for a resident who was cognitively impaired, fully dependent, and on hospice. Another CNA handled garbage after hand hygiene and then assisted the resident with eating without washing hands again, and also placed the resident’s catheter on the spa room floor without a barrier. An RN and a CNA were observed carrying dirty linen and garbage bags against their bodies down the hallway.
A resident signed consent for both pneumococcal and influenza vaccines, but surveyor record review found no documentation that either vaccine was given. The DON stated vaccines are usually administered within a couple of weeks after consent, but could not explain why the resident did not receive them or provide additional documentation.
The facility did not maintain an effective infection prevention and control program for two residents. One resident with URI symptoms was placed on droplet precautions, but the COVID case was not on the facility line list and the DON could not provide surveillance documentation for the illness. Another resident developed loose stools, later tested positive for C-diff, was placed on contact isolation after the positive result, and the record did not include discharge education on C-diff management and treatment.
A resident with moderate cognitive impairment and multiple health conditions did not have their call light within reach while in bed, despite care plan instructions. Staff were unaware of the issue, and the call light cord was not long enough to reach the bed, resulting in the resident having to leave the room to seek assistance.
A resident with moderate cognitive impairment was found to have medications left at bedside, despite not being assessed for self-administration. The resident reported that staff left the medications for her to take and did not always retrieve them, leading her to self-administer and sometimes return the medications to staff. The facility failed to ensure medications were administered as ordered and not left unsecured.
A resident with severe cognitive impairment and signed consents for influenza, COVID-19, and RSV vaccinations did not receive these immunizations. Facility records showed no physician orders or documentation of vaccine administration, and the DON could not explain the discrepancies in consent forms or the lack of follow-up.
The facility did not document the daily rate for bed-hold charges on notices provided to residents or their representatives during absences, as required by policy. This deficiency was identified for multiple residents who were transferred to the hospital or on therapeutic leave, with bed-hold acknowledgement forms lacking the specific rate information.
A resident with multiple medical conditions was found to have a cup containing several scheduled medications left unattended on their bedside table, visible from the hallway, while not present in the room. The medications, which included Furosemide, Levetiracetam, Magnesium Oxide, Metoprolol Succinate, Potassium Chloride, and Spironolactone, were not administered as ordered. Facility policy required assessment for self-administration, but the resident had not been approved for this, and staff failed to ensure the medications were taken in their presence.
The facility failed to provide written notice of the reason for hospital transfers for four residents, including those with fractures, stroke-like symptoms, uncontrolled bleeding, and critical lab levels. The Business Office Manager and Regional Clinical Director confirmed the absence of such documentation, indicating a systemic issue in the notification process.
The facility failed to maintain an effective infection control program as two LPNs did not perform hand hygiene before administering eye drops to two residents. Despite the facility's policy requiring hand hygiene before nursing procedures, both LPNs acknowledged their oversight when informed by a surveyor. The Regional Clinical Director confirmed the expectation for hand hygiene before glove use.
Insufficient Nursing Staffing and Open Shifts
Penalty
Summary
The facility did not ensure sufficient nursing staff was provided to meet resident needs, with survey findings showing repeated low CNA staffing on weekends and multiple open shifts across the reviewed periods. The facility’s PBJ data triggered for excessively low weekend staffing for Quarter 3 2025 and Quarter 1 2026. Surveyors reviewed posted and actual schedules and found numerous dates with fewer CNAs than anticipated, including shifts with open positions that were not filled. The census was 54 residents, and the facility posted 2 licensed nurses and 5 CNAs when surveyors arrived on a Sunday morning. During interviews, the Scheduler stated staffing levels were based on census and the DON, but acknowledged the facility did not have enough full-time and part-time staff to fill all required shifts and that schedules usually had openings that might be filled by PRN staff or regular staff picking up extra shifts. The DON stated staffing needs were based on PPD ratios and census, but she did not have the PPD document when asked. The NHA stated the facility used a grid showing PPD to guide staffing levels, but the grid could not be produced. The DON also stated weekdays usually had a 6th CNA for baths, while weekends typically did not, though otherwise staffing should be no different. Resident Council interviews with 9 residents showed consistent concerns about long wait times for assistance, typically 10-15 minutes during the week and 20-30 minutes on weekends, and residents stated the issue was constant. Staff interviews also described staffing shortages and difficulty meeting resident needs in a timely manner. An LPN stated some days staffing was adequate and other days it was not, while a CNA stated schedules were always posted with open shifts, could not recall a schedule with all shifts filled, and often baths were pushed to the next day because there was not enough time to complete them.
Facility Assessment Did Not Show How Staffing Needs Were Evaluated
Penalty
Summary
The facility did not ensure its facility-wide assessment included all relevant details needed to provide care and services to residents according to their individual needs within the facility's identified resources. The assessment, reviewed on 03/09/26, listed an average daily census of 50-53 residents, noted that up to 85% of residents required assistance with activities of daily living at an assist of 1-2 and up to 15% were dependent, and identified direct care staffing needs of 5-6 CNAs on day shift, 4-5 CNAs on evening shift, and 2-3 CNAs on overnight shift. The assessment also stated that department directors and the medical records/staffing clerk for nursing develop a block schedule. During interview, the DON stated staffing was determined using a patient per day system based on census and the overall budget, and that the facility tried to staff more based on resident acuity but this was not always possible. The NHA also stated a PPD system was used, but did not provide additional documentation showing how current staffing methods were evaluated to determine whether resident needs were being met.
Unsanitary resident rooms and hallway conditions
Penalty
Summary
The facility did not ensure a safe, clean, comfortable, and homelike environment for 5 of 6 resident rooms observed and for the Evergreen hallway. On 05/17/2026, the surveyor observed stains, sunflower seeds, trash, dirty napkins, food crumbs, and other debris on the hallway floor and in resident rooms. In R38’s room, used dirty napkins were scattered on the floor with food crumbs around and under the bed. In R25’s room, trash and cracker wrappers were under the bed and brown stains were observed on the floor. In R41’s room, brown stained spots were observed from the entryway to the bed, trash was under the bed, and red stains were observed on the outside wall by the door. In R47’s contact precaution room, the surveyor observed an odor, a severe build-up of dirt and sticky substance on the floor, and cookie crumbles and broken crackers on the floor. The Evergreen hallway also had grime and dirt built up along the walls and hand railings.
Failure to Promptly Resolve Missing-Item Grievances
Penalty
Summary
The facility did not make prompt efforts to resolve resident grievances related to missing clothing for 4 of 4 residents, including R13, R24, R54, and R59. The facility’s grievance policy stated that grievances and concerns were to receive prompt action and residents were to be kept apprised of progress toward resolution. However, the grievance log showed that R13 reported missing pajama pants and R24 reported missing pajama bottoms and socks, with follow-up documented only as “Still looking” and no resolution documented. R54 reported a missing quilt and R59 reported missing jeans and khaki pants, but the log contained no follow-up documentation for R54 and only a note that staff looked in R59’s closet and the items were not found. During a Resident Council interview, R13 and R24 stated they had filed grievances about missing clothing and had not received any follow-up. They also stated that if missing items could not be found, the facility did not offer reimbursement or another resolution. The Nursing Home Administrator stated that all grievances are investigated and followed up with the person who filed them, and that reimbursement or replacement would be offered if items could not be found, with documentation of that process. Social Services stated grievances are investigated, resolved, and followed up with the complainant, but did not know why these four missing-item grievances had not been completed.
Missing discharge, transfer, and bed-hold documentation
Penalty
Summary
The facility failed to complete required discharge and transfer documentation for 4 of 15 residents reviewed. For residents R56, R54, and R9, the record did not contain documentation showing that the Office of the State Long-Term Care Ombudsman was notified of the discharge or transfer. The facility policy stated that written notice must be provided in a language the resident or representative can understand, that the appropriate state forms must be completed with the reason for discharge, proposed discharge date, destination, and appeal rights, and that the local Ombudsman must receive a copy of the notice when the discharge process is initiated. R56 was discharged with a BIMS score of 10/15 and an MDS indicating discharge return was not anticipated, but no Ombudsman notification was found in the EHR and the BOM confirmed none existed. R54 had a BIMS of 15/15 and MDS documentation for discharge with return anticipated, but the EHR also lacked Ombudsman notification, and the BOM stated the Ombudsman was not notified of hospital transfers or discharges. R9 had multiple hospital transfers for vomiting with blood, cold sweats, uncontrollable shaking, tachycardia, decreased oxygen saturation, a distended abdomen, aspiration of vomit, and an NSTEMI in the ED, yet the Ombudsman was not notified for any of those transfers. R8 was transferred to the hospital and returned to the facility, but the bed hold and transfer notice could not be located, and the BOM stated there was no bed hold or transfer form for that hospitalization.
Resident Choice Not Supported for In-Room Coffee Maker
Penalty
Summary
The facility did not promote and facilitate resident self-determination through support of resident choice for one sampled resident who wanted to keep a self-purchased coffee maker in his room. The resident reported that he bought his own coffee maker, but the facility told him he could not have it in his room and required him to place it back in the original box and store it in his cupboard. He stated that he wanted his own coffee because the facility coffee “sucks.” Survey observation confirmed the coffee maker was in an opened box on the top shelf of the resident’s closet. Staff interviews showed the resident had used the coffee maker in his room for about a week and a half before the NHA found out and removed it. The CNA reported that no other arrangements had been made to allow the resident to have coffee of his choice, and that he was only being given facility coffee. The NHA stated the restriction was based on a prior survey citation involving a coffee maker and a power extension cord, and said the facility did not allow any residents to have coffee makers because of that concern, even though survey review found no safety concern for this resident’s coffee maker in the room.
Delayed Provider Notification for New Rib Pain After Fall
Penalty
Summary
The facility failed to immediately notify the physician on call when a resident with significant cognitive impairment developed new rib pain after a fall. The resident was admitted with diagnoses including left hemiplegia, left humerus dislocation, urinary tract infections, left shoulder pain, unsteadiness on feet, and hypertension with congestive heart failure. The resident’s MDS assessment showed a BIMS score of 1/15, indicating moderate cognitive impairment. After the resident fell and was found on the bathroom floor with a small abrasion on the top of the head, staff documented no pain initially and continued to observe the resident. Several days after the fall, therapy and nursing documented repeated complaints of rib pain and changes in the resident’s condition. On one date, therapy reported high pain on the left side of the rib cage and the resident stated the pain occurred when he fell and landed on that side. On subsequent dates, the resident continued to report pain in the rib area and later complained that his ribs were broken and that his hips were bothering him. Nursing notes documented monitoring, repositioning, and ice pack attempts, but the physician on call was not notified until the resident’s rib pain had persisted over multiple days. The provider was eventually notified and ordered oxycodone as needed and rib x-rays, which later showed an acute minimally displaced fracture of the anterior left 5th rib and possible nondisplaced fractures of the anterior left 6th and 7th ribs. During interview, the DON stated the nurse should have notified the provider right away when the new rib pain was identified after the recent fall and that the x-ray should have been scheduled within a reasonable timeframe. The DON also reviewed the record and found documentation of the resident’s rib pain on multiple dates before provider notification was documented.
Failure to Protect Two Cognitively Impaired Spouses from Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect two residents from resident-to-resident abuse. One resident had diagnoses including unspecified fracture of the left pubis, heart failure, type 2 diabetes, and cerebral infarction, and had moderate cognitive impairment with a BIMS score of 11/15. The other resident, the spouse, had dementia with agitation and moderate cognitive impairment with a BIMS score of 9/15. The report states that the couple was placed in the same room, and staff observed ongoing verbal conflict between them, including yelling, threats, and throwing items. The facility’s abuse prevention policy identified resident-to-resident altercations as potential abuse and required immediate investigation and protection of residents during and after an allegation. The report documents that one resident yelled at the spouse, stated, "I want to kill him," and later threatened to throw a cup at him. Survey review found no interventions in place on the behavioral care plan at that time to protect the spouse from the verbal outbursts. The resident’s TAR also contained multiple shifts with no behavior documentation and some entries of "0," which the DON stated was not a proper behavior code. The spouse did not have behavior monitoring in place, and the facility did not have clear documentation in either resident’s record showing that the incident had been addressed in a way staff could follow. The report also describes a physical altercation in which the spouse struck the resident on the head and face multiple times. CNA J reported that the spouse slapped the resident on both sides of the face and then struck her from behind and on top of the head with a closed fist, while the resident was crying and upset afterward. Staff interviews showed confusion about whether the event was reportable and what actions were required, and the facility did not document the incident in the medical record at the time. Surveyors also observed continued arguing and additional aggressive behavior between the two residents, including the resident throwing a TV remote toward the spouse and the spouse slapping the resident’s chest, while the facility’s documentation and monitoring remained incomplete during the period reviewed.
Failure to Monitor Psychotropic Medication Effectiveness
Penalty
Summary
The facility failed to ensure adequate behavior monitoring and documentation of effectiveness for psychotropic medications for 2 of 5 residents reviewed for unnecessary medication use. The deficiency involved one resident who received four psychotropic medications—aripiprazole, clonazepam, fluoxetine, and mirtazapine—for bipolar disorder, generalized anxiety disorder, and obsessive compulsive disorder, and another resident who received duloxetine for depression. The facility policy stated that residents are not to receive psychotropic medication unless necessary for a specific diagnosed and documented condition, and that the effects of psychotropic medications will be evaluated and the resident response documented in the medical record. For the first resident, the record showed diagnoses including bipolar disorder, generalized anxiety disorder, obsessive compulsive disorder, and hypothyroidism, with a BIMS score of 15/15 and an MDS indicating supervision-level assistance for activities of daily living and mobility. The care plan included monitoring for psychotropic drug use and behavior and response to medication, but the surveyor found no documentation in the medical record for behavior monitoring or medication effectiveness monitoring. The monthly medication review pharmacist recommended that appropriate target behavior and mood monitoring be in place for the psychotropic medications, and the physician response stated the resident was doing well and that the benefit outweighed the risk, with no changes made. For the second resident, the record showed diagnoses including Alzheimer’s disease, dementia, and depression, with a BIMS score of 15/15 and duloxetine ordered for depression. The care plan described verbal behavioral symptoms and directed staff to observe for changes in behavior, document, and report to the doctor, but the surveyor could not find behavioral charting in the electronic record. During interviews, the DON stated the facility did not have behavioral/effectiveness monitoring, and the NHA also stated there was no behavioral monitoring for this resident.
Failure to Report Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to develop and/or implement policies and procedures for reporting a reasonable suspicion of a crime under section 1150B of the Act when an allegation of abuse was not reported immediately, and not later than 2 hours after the allegation was made, to the administrator and other required officials. The deficiency involved two residents, R40 and R57, after an incident in which R57 struck R40 multiple times on the head. The facility did not report the physical abuse to state officials, and surveyors found no documentation of the incident in either resident’s medical record until it was brought to staff attention during the survey. R40 was admitted with diagnoses including an unspecified fracture of the left pubis, heart failure, type 2 diabetes, and cerebral infarction. Her MDS assessment dated 05/07/26 showed a BIMS score of 11/15, indicating moderate cognitive impairment. R57 was admitted with diagnoses including unspecified dementia with agitation, and his MDS assessment dated 05/18/26 showed a BIMS score of 9, also indicating moderate cognitive impairment. The facility policy titled Abuse Prevention Program stated that all alleged or suspected violations are to be reported immediately to the Administrator or DON, who are responsible for notifying required officials, including the State Survey Agency and local public safety, and that alleged violations involving abuse are to be reported immediately, but no later than 2 hours after the allegation is made if the events involve abuse or result in serious bodily injury. According to staff interviews, CNA J was the only staff member at the nurse’s station when R40 and R57 asked to go outside. When R40 stated she wanted a different porch than R57, R57 became agitated and struck her alongside the head with open hands and then aggressively struck her from behind and on top of the head multiple times with a closed fist. CNA J intervened, separated the residents, and notified nursing staff. DON B later described being told that R57 was hitting R40 and stated that the nurse interviewed R57, who admitted he hit his wife and said he was trying to get her attention. NHA A and DON B discussed the event, but the facility did not notify state officials or law enforcement, and surveyors found that the incident was not documented in the medical record until after the surveyor brought it to staff attention.
Failure to Thoroughly Investigate Resident-to-Resident Abuse
Penalty
Summary
The facility did not complete a thorough investigation after a resident-to-resident physical altercation in which one resident struck the other multiple times on the head. The facility policy titled Abuse Prevention Program states that resident-to-resident altercations are to be reviewed as potential abuse and that the Administrator or DON is to initiate and coordinate a thorough investigation immediately, with completion as soon as possible and not to exceed 5 days. The report states that the incident was not documented in either resident’s medical record until the surveyor brought it to the facility’s attention, and the facility did not notify state officials or law enforcement at the time of the event. The resident who was struck had diagnoses including unspecified fracture of the left pubis, heart failure, type 2 diabetes, and cerebral infarction, and an MDS assessment dated 05/07/26 showed a BIMS score of 11/15, indicating moderate cognitive impairment. The other resident had diagnoses including unspecified dementia with agitation, and an MDS assessment dated 05/18/26 showed a BIMS score of 9/15, also indicating moderate cognitive impairment. Staff interviews and record review showed the residents were living in the same room and had a history of verbal conflict, with staff describing frequent bickering and yelling between them. According to staff interviews, the incident occurred when the residents disagreed about which porch to go to, and the husband began striking his wife on the head and face. A CNA reported immediately separating the residents and assessing the wife’s head, while the wife was crying and very upset afterward. The DON and NHA acknowledged that the event was not documented in the medical record, that staff were not educated through the charting system, that state officials and law enforcement were not notified, and that interventions to protect the residents from further potential abuse were not implemented until days later. The surveyor also observed that the residents continued to interact in ways that included verbal and physical abuse after the incident had occurred.
Failure to Obtain and Document Routine Weights for Resident With Significant Weight Loss
Penalty
Summary
Provide enough food and fluids to maintain a resident's health was not met for R28, who was admitted with diagnoses including unspecified protein-calorie malnutrition and dysphagia. R28's BIMS score was 15 out of 15, indicating cognitive intactness, and the care plan identified risk for dehydration related to antipsychotic, antidepressant, and antianxiety medications, C-diff infection with antibiotic use, and nectar thick liquids. The physician order called for weekly weights, but the weight record showed no documented weekly weights on 4/8/26 or 4/15/26, and the last documented weight was 87 pounds on 5/1/26 after prior weights of 94.6 pounds on 4/1/26 and 91 pounds on 4/23/25. The report states this reflected an 8% weight loss in a month, which is significant weight loss, and there was no documentation that R28 refused to be weighed. During interview, R28 stated she had lost weight before coming to the facility and had lost more since admission, and she believed she was weighed weekly but could not remember. The DON stated R28 had lost weight and that the facility was working with the provider, dietary manager, and RD, but also stated there was a box that needed to be checked in the medical record order and it was not checked, leaving nowhere to document the weights. The DON could not provide progress notes documenting weights after 5/1/26. The NP stated the facility was aware of the weight loss, believed there may have been a mistake in the weights, and said the resident should be re-weighed if a weight error was suspected; the NP also stated the resident should have been receiving weekly weights.
Infection Control Lapses During Resident Care and Linen Handling
Penalty
Summary
The facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections. The deficiency involved practices observed on the Maple hallway and in the spa room that affected residents, including R7, who was admitted with diagnoses including failure to thrive, fractured rib, compression fractures of multiple vertebrae, intermittent asthma, epilepsy, heart failure, bipolar disorder, and Wernicke's encephalopathy. R7 was admitted to hospice on 4/13/26 due to progression of disease and was cognitively impaired and fully dependent on the facility for mobility and activities of daily living. During morning care, CNA H completed hand hygiene and donned gloves and a gown before entering R7's room, then used the same gloved hands throughout multiple tasks. CNA H provided an upper body bed bath, removed R7's soiled brief, completed peri care, placed a clean brief on R7, pulled blankets up to R7's chin, adjusted R7's oxygen nasal cannula, and then continued with room cleanup while still wearing the same gloves. CNA H picked up dirty linen and clothes, emptied and washed the wash basin, wiped it out with a clean washcloth, and placed the cleaned basin in a plastic bag for next use. CNA H later stated hand hygiene should have been performed after cares and before cleaning up the basin, and the DON stated hand hygiene should have been completed after peri care, touching garbage, and before rinsing out the basin. Additional observations showed CNA I washed hands after transferring R7 to a chair, then handled paper towels on the floor and tied up garbage, soiling hands again, and then assisted R7 with eating breakfast without washing hands again. CNA I also placed R7's catheter on the spa room floor without a barrier while preparing R7 for a bath, then acknowledged the catheter should not touch the ground. RN G and CNA F were observed carrying dirty linen and garbage bags against their bodies down the hallway to the soiled holding room, despite the facility policy stating linens are to be kept away from the body to prevent contamination. The facility's hand hygiene and linen processing policies were reviewed, and the DON and NHA acknowledged the observed practices were not appropriate.
Failure to Provide Offered Flu and Pneumococcal Vaccinations
Penalty
Summary
The facility did not ensure that each resident was offered pneumococcal and influenza immunizations unless medically contraindicated or already immunized, as shown by 1 of 5 residents reviewed. R4 was admitted to the facility and signed consent on 03/05/26 to receive both a pneumococcal and influenza vaccination, but surveyor review of the medical record on 05/19/26 found no documentation that either vaccine had been administered. During an interview on 05/19/26, the DON stated that once a resident signs consent for a vaccine, it is usually given within a couple of weeks, but she did not know why R4's vaccines were not administered and could not provide any additional documentation.
Infection Prevention and Control Program Not Maintained
Penalty
Summary
The facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and help prevent the development and transmission of communicable diseases and infections for 2 of 4 residents reviewed. One resident had a URI and was placed on droplet precautions after reporting a runny nose and body aches, with a negative COVID test on 03/06/2026. The resident remained on droplet precautions the next day with a hoarse voice and intermittent cough, but the facility could not provide documentation of surveillance, transmission-based precautions, or testing for the resident’s illness, and the resident’s COVID infection was not included on the facility line list. Another resident was admitted with a diagnosis of irritable bowel syndrome and developed loose stools during the stay. A C-diff sample was ordered after loose stools were noted, but no isolation precautions were put into place at that time. When the sample returned positive, an antibiotic regimen was ordered for 10 days and contact isolation precautions were started. The resident was discharged home before the expected discharge date, and the medical record did not contain documentation of education on management and current treatment for C-diff as required by facility policy. The infection preventionist stated the DON completed COVID surveillance documentation, and the DON stated she did not complete a log and could not provide documentation for the resident’s illness monitoring or the discharge teaching for the resident with C-diff.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
A deficiency was identified when a resident with moderate cognitive impairment and multiple medical conditions, including memory deficit, osteoporosis, macular degeneration, and diabetes, did not have reasonable accommodation for their needs regarding call light accessibility. The resident's care plan specified that the call light should be kept within reach and that the resident should be reminded to use it and wait for assistance. However, during observation, the call light was found attached to the back of a recliner and not accessible from the resident's bed, which was approximately eight feet away. The call light cord was not long enough to reach the bed, and the resident confirmed that it could not be used from the bed and that she typically went to the hallway or nurse's station for assistance instead of using the call light. Interviews with staff revealed that the CNA was unsure if the call light was accessible to the resident while in bed and demonstrated that the cord did not reach the bed. The DON stated that all residents should have the call light within reach and that longer cords are available if needed, but was unaware of the issue in this case and confirmed that it had not been assessed or care planned. The lack of assessment and failure to ensure the call light was accessible to the resident in all areas of the room led to the deficiency.
Failure to Ensure Accurate Administration and Secure Storage of Medications
Penalty
Summary
A deficiency occurred when the facility failed to provide pharmaceutical services that ensured the accurate administration of medications for one resident. The facility's policy requires a licensed nurse to complete a self-administration of medication observation in the electronic health record if a resident requests to self-administer medications. In this case, a resident with Alzheimer's disease and moderate cognitive impairment, as indicated by a BIMS score of 10/15, was assessed and marked as not wanting to self-administer medication. However, the remainder of the assessment was not completed. Despite the assessment indicating the resident did not wish to self-administer, two medications—fluticasone propionate nasal spray and loteprednol etabonate eye drops—were observed left on the resident's over-bed tray table. The resident reported that staff left the medications for her to take and did not always return to collect them, leading her to sometimes bring the medications to the nurse in the hallway. Physician orders specified scheduled administration times for both medications, but the facility did not ensure these medications were administered as ordered or securely stored, resulting in the resident self-administering medications without proper assessment or supervision.
Failure to Administer Vaccinations Despite Consent
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, as indicated by a BIMS score of 6/15 and diagnoses of cerebral infarction and vascular dementia, was not administered influenza, COVID-19, or RSV vaccinations despite having signed consents on file. The facility's policies required annual offering and documentation of these immunizations unless contraindicated or refused, but there were no physician orders or treatment administration records for these vaccines for the resident during their stay. Surveyor review of the Wisconsin Immunization Record confirmed that no immunizations were administered to the resident while at the facility. Additionally, there were inconsistencies in the vaccination consent forms, with two different consents signed by the resident's parent and a handwritten note referencing verbal consent. The DON was unable to explain the discrepancies in the consents or provide documentation or explanation for the lack of vaccine administration.
Failure to Document Bed-Hold Daily Rate on Resident Notices
Penalty
Summary
The facility failed to ensure that residents and their representatives were properly notified of the daily rate required to reserve a bed during a resident's absence, as required by policy and regulation. Specifically, the bed-hold acknowledgement notices provided to residents or their representatives did not include the actual daily rate for bed-hold charges. This omission was identified through record review and interviews, and it was noted that the deficiency had the potential to affect all 53 residents in the facility. Three residents were specifically cited: one was transferred to the hospital and received a bed-hold notice without the daily rate documented; another was transferred to the emergency room and subsequently hospitalized, with the bed-hold notice again lacking the daily rate; and a third resident went on therapeutic leave and signed a bed-hold agreement that also did not specify the daily rate. During an interview, the NHA confirmed that while the rate is reviewed at admission, it was not documented on the bed-hold acknowledgement notices as required.
Medications Left Unattended and Not Administered as Ordered
Penalty
Summary
The facility failed to ensure the accurate dispensing and administration of medications for a resident with diagnoses including cerebral infarction, chronic systolic heart failure, and aphasia. On the morning of the survey, a surveyor observed a small plastic cup containing seven pills left unattended on the resident's bedside table, visible from the hallway, while the resident was not present in the room or bathroom. The medications included Furosemide, Levetiracetam, Magnesium Oxide, Metoprolol Succinate, Potassium Chloride, and Spironolactone, all of which were scheduled for administration at 8:00 AM but had not been taken as ordered. Facility policy requires that residents may only self-administer medications if the interdisciplinary team has determined it is safe, and the resident in question had previously indicated they did not wish to self-administer medications. When questioned, the LPN was unsure if the resident was assessed for self-administration and acknowledged concern about leaving medications unattended. The DON confirmed that staff are expected to ensure residents take medications in their presence and not leave medications unattended, which did not occur in this instance.
Failure to Provide Written Notice for Hospital Transfers
Penalty
Summary
The facility failed to provide written notice of the reason for transfer to the hospital for four residents, which is a requirement for ensuring residents and their representatives are informed of the reasons for such transfers. Resident 27, who had a fall resulting in fractures, was transferred to the hospital for surgical repair, but no written notice explaining the reason for the transfer was provided. Similarly, Resident 56, who was transferred to the hospital due to stroke-like symptoms, did not receive a written notice of the reason for transfer. The Business Office Manager confirmed that such documentation was not provided for any residents transferred to the hospital. Resident 47, who was sent to the emergency room for uncontrolled bleeding from chronic wounds, also did not receive a written notice of the reason for transfer. The Nursing Home Administrator acknowledged that while the family was verbally informed, no written documentation was provided. Lastly, Resident 48, who was transferred due to critical lab levels, did not receive a written notice of the reason for transfer. The Regional Clinical Director confirmed the absence of such documentation. These omissions highlight a systemic issue in the facility's process for notifying residents and their representatives about the reasons for hospital transfers.
Infection Control Deficiency: Hand Hygiene Lapse
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of two Licensed Practical Nurses (LPNs) during medication administration. Specifically, the LPNs did not perform hand hygiene before putting on gloves and administering eye drops to two residents. This oversight was observed by a surveyor during the administration of eye drops to the residents. The facility's policy on hand hygiene, reviewed in January 2025, clearly states that hand hygiene should be practiced before and after nursing treatments or procedures, including the instillation of eye drops. During the observations, one LPN was seen administering eye drops to a resident without performing hand hygiene after gathering medications and entering the resident's room. Similarly, another LPN repeated this action with a different resident, failing to perform hand hygiene before glove application and eye drop administration. Both LPNs acknowledged their failure to adhere to the hand hygiene protocol when it was pointed out by the surveyor. The Regional Clinical Director confirmed that the expectation was for staff to perform hand hygiene before putting on gloves, indicating a lapse in adherence to the facility's infection control policies.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 75 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Frederic
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| United Pioneer Home | 5.1 mi | ★★★★★ | 8 | 0 |
| Burnett Medical Center | 14 mi | ★★★★★ | 14 | 0 |
| Dove Healthcare - St Croix Falls | 17.9 mi | ★★★★★ | 21 | 0 |
| Shell Lake Health Care Center | 19.2 mi | ★★★★★ | 9 | 0 |
| Care And Rehab - Cumberland | 22.5 mi | ★★★★★ | 14 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Frederic Nursing And Rehab Community.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.