Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 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.
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.
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.
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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.
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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 | — | 7 | 0 |
| Burnett Medical Center | 14 mi | — | 14 | 0 |
| Dove Healthcare - St Croix Falls | 17.9 mi | — | 20 | 0 |
| Shell Lake Health Care Center | 19.2 mi | — | 9 | 0 |
| Care And Rehab - Cumberland | 22.5 mi | — | 14 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.