Frederic Nursing and Rehab Community

Inspectors wroteBased on observation, interview and record review, the facility did not ensure sufficient nursing staff was provided to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This has the potential to affect all 54 residents residing at the facility. The facility's Payroll Based Journal (PBJ) triggered for excessively low weekend staffing for Quarter 3 2025 and Quarter 1 2026. Resident Council interviews voiced concerns with short staffing on weekends and longer call light wait times. Staff interviews voiced insufficient staffing levels to meet resident needs.

Inspectors wroteBased on interview and record review, the facility did not ensure the facility wide assessment developed by the facility included all relevant details to ensure the facility provided care and services to residents to meet their individual needs within the facility's identified resources. This has the potential to affect all 54 residents. The Facility Assessment did not indicate how resident needs are assessed to determine sufficient staffing levels.

Inspectors wroteBased on observation and interview, the facility did not ensure that each resident has a safe, clean, comfortable, and homelike environment, including, but not limited to, receiving treatment and support for daily living for 5 (R38, R25, R41, R47, R48) of 6 resident rooms observed and in the hallway on Evergreen unit.

Inspectors wroteBased on interview and record review, the facility did not make a prompt effort to resolve resident grievances for 4 of 4 residents (R13, R24, R54, and R59). In March 2026, R13 and R24 filed a grievance to report missing clothing. The facility did not complete an investigation, resolve or follow-up on grievance. In April 2026, R54 and R59 filed a grievance to report missing clothing. The facility did not complete an investigation, resolve or follow-up on grievance.

Inspectors wroteBased on record review and interview, the facility failed to ensure proper discharge documentation was completed for 4 of 15 residents (R) (R56, R54 R8, R9) reviewed for discharge and transfer from the facility. R56, R54 and R9 were missing documentation of notification of the Office of the State Long-Term Care Ombudsman. R8 was missing Bedhold and Transfer notice and the Ombudsman was not notified of the transfer.

Inspectors wroteBased on interview and record review, the facility did not promote and facilitate resident self-determination through support of resident choice for 1 of 18 sampled residents (R12). R12 reported his dissatisfaction with the facility not allowing R12 to have his self-purchased coffee maker in R12's room.

Inspectors wroteBased on interview and record review, the facility did not immediately report to the physician on call of R3's rib pain post fall for 1 of 4 residents (R) reviewed for falls (R3). R3 fell on [DATE] and had multiple complaints of rib pain on 03/23/26, 03/25/26, and 03/26/26. Facility did not notify the physician on call until 03/26/26.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect resident's right to be free from physical and verbal abuse by a resident for 2 of 2 residents (R40 and R57.) R40 was not protected from physical abuse when R57 struck R40 on the face and head multiple times. R57 was not protected from verbal and mental abuse when R40 yelled, threatened, and threw items at R57.

Inspectors wroteBased on record review and interview, the facility must ensure each resident is free from unnecessary medications as evidenced by completing adequate behavior monitoring for 2 of 5 residents (R28, R1) reviewed for unnecessary medication reviews. R28 receives 4 psychotropic medications including, Aripiprazole tablet; 10 mg; amt: 10mg; oral Special Instructions: bipolar 1 disorder Once a Morning 08:00 AM 3/31/26, Clonazepam - Schedule IV tablet; 0.5 mg; amt: 0.25mg; oral Special Instructions: GAD (general anxiety disorder) At Bedtime 08:00 PM 3/31/26, Fluoxetine capsule; 40 mg; amt: 2 capsules; oral Special Instructions: GAD/OCD (obsessive compulsive disorder) Once A Morning 08:00 AM 3/31/26, and Mirtazapine tablet; 45 mg; amt: 1 tab; oral Special Instructions: GAD/OCD At Bedtime 08:00 PM 3/31/26 without behavior and effectiveness monitoring. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act when an allegation of abuse was not reported immediately but not later than 2 hours after the allegation is made, to the administrator of the facility and to other officials for 1 of 2 resident reviewed for abuse. (Resident (R) 40 and R57). -On 05/16/26, R57 struck R40 along the side of head and top of head from behind multiple times. Facility did not report the physical abuse to state officials.

Inspectors wroteBased on interview and record review, the facility did not ensure a thorough investigation was completed to protect R40 and R57 from further potential abuse during a resident-to-resident interaction on 5/16/26 when R40 hit R57 on the head multiple times.

Inspectors wroteBased on record review and interviews, the facility did not ensure acceptable parameters of nutritional status, such as usual body weight or desirable body weight range by obtaining routine weights routinely for 1 of 2 residents reviewed for nutrition (R28). R28 had an 8% weight loss in a month, which is a significant weight loss. The facility policy titled Unresolved Weight Loss, dated 1/2026, states: A. Definition of Weight LossWeight loss that is unresolved. (5% in 30 days, 7.5% in 90 days, and 10% in 180 days)B. Tips:~Residents that shows significant weight loss must be re-weighed to ensure accuracy.~Perform monthly weight on those residents that show stable weights and weekly weights on those residents that show any weight loss. R28 was admitted to the facility on [DATE], with diagnoses including unspecified protein-calorie malnutrition, and dysphagia. [...]

Inspectors wroteBased on observation, interview, and record review, 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 with the potential to affect all 23 residents on the Maple hallway in facility.~CNA H used soiled gloved hands to clean care area in R7's room, wipe out the wash basin, and put the basin in a clean garbage bag for next use.~CNA I used soiled hands to assist R7 with eating.~CNA I placed R7's catheter on the floor of the SPA room without barrier, while preparing R7 for his bath.~RN G and CNA F did not carry the dirty linen and garbage bags away from their bodies. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure each resident is offered a pneumococcal and influenza immunization, unless the immunization is medically contraindicated, or the resident has already been immunized for 1 of 5 residents (R7) reviewed for immunizations. R4 signed a consent for pneumococcal and influenza immunizations and did not receive them.

Inspectors wroteBased on interview and record review, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and help to prevent the development and transmission of communicable diseases and infections for 2 (R1 and R2) of 4 residents (R) reviewed. R1 tested positive for covid R1 but was not on the facility line list. R2 had Clostridioides Difficile (C-diff); the facility did not document infection control education in R2's medical record prior to discharge. The facility policy titled Outbreak Identification and Management, last reviewed 01/2025, states: This policy is intended to provide guidance in identifying an outbreak timely, measures to take in the event of an outbreak to reduce the spread of infections. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure residents received services in the facility with reasonable accommodation of resident needs reviewed for 1 of 12 residents (R), R5. R5's call light was observed to be out of reach and cord not long enough to reach bed. This is evidenced by: R5 was admitted to the facility on [DATE], with pertinent diagnoses of memory deficit following other cerebrovascular disease, age-related osteoporosis, nonexudative age-related macular degeneration, diabetes mellitus type 2, and long-term use of anticoagulants. R5's most recent quarterly Minimum Data Set (MDS) assessment, dated 04/03/25, noted a Brief Interview for Mental Status (BIMS) score of 10/15, indicating moderate cognition impairment, makes self-understood and understands others. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not provide pharmaceutical services that ensure the accurate administering of all drugs and biologicals reviewed for 1 of 1 resident (R), R4.

Inspectors wroteBased on interview and record review, the facility did not ensure immunizations were administered to 1 of 3 residents (R), R9 reviewed. R9 had a signed consent to receive the influenza, covid-19, and Respiratory Syncytial Virus (RSV) vaccination and never received it. This is evidenced by: Facility policy, titled Influenza Vaccine Policy, with a review date of 01/2025, states in part: It is the policy of this facility to minimize the risk of acquiring, transmitting or experiencing complications from influenza by offering our residents, staff members, and volunteer workers annual immunization against influenza. Policy Explanation and Compliance Guidelines: 2. [...]

Inspectors wroteBased on record review and interview, the facility did not ensure residents/representatives were notified of the rate to reserve the resident's bed and was not documented in the Wisconsin Bed Hold and Notice of Transfer. This has the potential to affect all 53 residents. R4, R8, and R11 received a bed hold notice with no daily rate documented. This is evidenced by: Facility's policy titled Bed Hold with reviewed date of 01/25 read in part, .2. The facility shall provide the bed hold policy Acknowledgement to the resident or the resident representative with any resident initiated therapeutic leave or transfer to alternative healthcare community including a hospital admission. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure the accurate dispensing and administration of all drugs. The facility did not ensure that R2 took their 8:00 AM medications. This is based on 1 of 1 random observation.

Inspectors wroteBased on interview and record review, the facility did not provide written notice of reason for transfer to the resident or resident representative for 4 of 4 residents (R) reviewed for hospitalization. (R27, R56, R47, R48)

Inspectors wroteBased on observation, interview and record review, 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 for 2 of 5 residents (R49 and R25) observed during medication administration. Staff did not perform hand hygiene before putting on gloves before performing a nursing procedure.

Inspectors wroteBased on observation, interview and record review, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety by not wearing hairnets appropriately, and did not ensure proper hand hygiene with food handling. This has the potential to affect all 45 of the 45 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility did not ensure that the mandatory staffing data that had been submitted from 7/1/23-9/30/23 was complete, accurate, and auditable. This has the potential to affect all 45 residents that reside in the facility. This is evidenced by: The Payroll Based Journal (PBJ) Staffing Data Reports that were generated quarterly document that the facility triggered for Excessively low weekend staffing from 7/1/23-9/30/23 for specified dates. The specified dates are as follows: FY (Fiscal Year) Q4 (Quarter 4) 2023 (July 1-September 30). The facility was not able to produce the data that was submitted during this time frame for the specified dates therefore Surveyor was not able to audit the exact document(s) that were submitted. [...]

Inspectors wroteBased on observation and interview, the facility did not ensure the privacy and confidentiality of resident medical records. Staff left the Medication Administration Record (MAR) open and visible when unattended during medication administration. This occurred for 4 of 9 residents (R) during medication administration. (R23, R33, R37, and R24)

Inspectors wroteBased on observation, interview and record review, the facility did not maintain an infection prevention and control program to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Staff did not perform appropriate hand hygiene during cares and medication administration for 2 of 4 resident (R) observations. (R21 and R6) Staff did not sanitize multi-use equipment between residents for 5 of 5 observations. (R21, R198, R5, R38, R15)

Inspectors wroteBased on observation, interview and record review, the facility did not provide appropriate care and treatment when a pressure cushion was not placed in wheelchair for pressure relief for 1 of 2 sampled residents (R) R15 who have a pressure injury.

Inspectors wroteBased on observation and interview, the facility did not ensure all drugs and biologicals were stored a in accordance with currently accepted professional principles and did not ensure only authorized personnel had access to medication carts. This occurred for 2 of 2 medication carts/storage rooms observed. During the three-day survey, 2 of 9 observations were made of medication carts left unlocked when unattended and out of view of staff.