Frederic Nursing And Rehab Community

Inspection findings

1. May 19, 2026 Fire Safety · 17 findings
   • Not serious Scope/severity F

     E0039 Emergency Preparedness Deficiencies

     Conduct testing and exercise requirements.

     Corrected Jun 22, 2026 · CMS fire safety

   • Not serious Scope/severity D

     F0561 Resident Rights Deficiencies

     Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

     Corrected Jun 22, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0580 Resident Rights Deficiencies

     Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

     Corrected Jun 22, 2026 · CMS health inspection

   • Not serious Scope/severity E

     F0584 Resident Rights Deficiencies

     Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

     Corrected Jun 22, 2026 · CMS health inspection

   • Not serious Scope/severity E

     F0585 Resident Rights Deficiencies

     Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

     Corrected Jun 22, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0600 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

     Corrected Jun 22, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0605 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

     Corrected Jun 22, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0609 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

     Corrected Jun 22, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0610 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Respond appropriately to all alleged violations.

     Corrected Jun 22, 2026 · CMS health inspection

   • Not serious Scope/severity E

     F0628 Resident Rights Deficiencies

     Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

     Corrected Jun 22, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0692 Quality of Life and Care Deficiencies

     Provide enough food/fluids to maintain a resident's health.

     Corrected Jun 22, 2026 · CMS health inspection

   • Not serious Scope/severity F

     F0725 Nursing and Physician Services Deficiencies

     Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

     Corrected Jun 22, 2026 · CMS health inspection

   • Not serious Scope/severity F

     F0838 Administration Deficiencies

     Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.

     Corrected Jun 22, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Jun 22, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0883 Infection Control Deficiencies

     Develop and implement policies and procedures for flu and pneumonia vaccinations.

     Corrected Jun 22, 2026 · CMS health inspection

   • Not serious Scope/severity F

     K0291 Egress Deficiencies

     Install emergency lighting that can last at least 1 1/2 hours.

     Corrected Jun 22, 2026 · CMS fire safety

   • Not serious Scope/severity F

     K0712 Miscellaneous Deficiencies

     Have simulated fire drills held at unexpected times.

     Corrected Jun 22, 2026 · CMS fire safety

2. May 5, 2026 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected May 28, 2026 · CMS health inspection

3. Jul 1, 2025 Health · 4 findings
   • Not serious Scope/severity D Complaint

     F0558 Resident Rights Deficiencies

     Reasonably accommodate the needs and preferences of each resident.

     Corrected Jul 18, 2025 · CMS health inspection

   • Not serious Scope/severity C Complaint

     F0628 Resident Rights Deficiencies

     Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

     Corrected Jul 18, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0755 Pharmacy Service Deficiencies

     Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

     Corrected Jul 18, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0883 Infection Control Deficiencies

     Develop and implement policies and procedures for flu and pneumonia vaccinations.

     Corrected Jul 18, 2025 · CMS health inspection

4. Apr 7, 2025 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0755 Pharmacy Service Deficiencies

     Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

     Corrected Apr 17, 2025 · CMS health inspection

5. Feb 18, 2025 Health · 5 findings
   • Not serious Scope/severity E

     F0623 Resident Rights Deficiencies

     Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

     Corrected Mar 18, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Mar 18, 2025 · CMS health inspection

   • Not serious Scope/severity E

     K0271 Egress Deficiencies

     Have exits that are accessible at all times.

     Corrected Mar 18, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0712 Miscellaneous Deficiencies

     Have simulated fire drills held at unexpected times.

     Corrected Mar 18, 2025 · CMS fire safety

   • Not serious Scope/severity D

     K0920 Gas, Vacuum, and Electrical Systems Deficiencies

     Ensure proper usage of power strips and extension cords.

     Corrected Mar 18, 2025 · CMS fire safety

6. Jan 23, 2024 Health · 11 findings
   • Not serious Scope/severity E

     F0583 Resident Rights Deficiencies

     Keep residents' personal and medical records private and confidential.

     Corrected Feb 16, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0686 Quality of Life and Care Deficiencies

     Provide appropriate pressure ulcer care and prevent new ulcers from developing.

     Corrected Feb 16, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0761 Pharmacy Service Deficiencies

     Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

     Corrected Feb 16, 2024 · CMS health inspection

   • Not serious Scope/severity F

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected Feb 16, 2024 · CMS health inspection

   • Not serious Scope/severity F

     F0851 Administration Deficiencies

     Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.

     Corrected Feb 16, 2024 · CMS health inspection

   • Not serious Scope/severity E

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Feb 16, 2024 · CMS health inspection

   • Not serious Scope/severity D

     K0324 Smoke Deficiencies

     Provide properly protected cooking facilities.

     Corrected Feb 16, 2024 · CMS fire safety

   • Not serious Scope/severity D

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Feb 16, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0712 Miscellaneous Deficiencies

     Have simulated fire drills held at unexpected times.

     Corrected Feb 16, 2024 · CMS fire safety

   • Not serious Scope/severity D

     K0741 Miscellaneous Deficiencies

     Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

     Corrected Feb 16, 2024 · CMS fire safety

   • Not serious Scope/severity D

     K0919 Gas, Vacuum, and Electrical Systems Deficiencies

     Meet requirements for the use of electrical equipment.

     Corrected Feb 16, 2024 · CMS fire safety

Owners and managers (as published by CMS)

• ALBRIGHT ROSS, SUSAN — operational/managerial control, NOT APPLICABLE, since 01/01/2018
• BAILEY, ESSEL — corporate director, NOT APPLICABLE, since 12/01/2007
• BAILEY, ESSEL — 5% or greater indirect ownership interest, 74%, since 12/27/2012
• FERKANY, JAMES — corporate officer, NOT APPLICABLE, since 08/01/2018
• FINNEY, DONALD — 5% or greater indirect ownership interest, 25%, since 12/27/2012
• FINNEY, DONALD — corporate director, NOT APPLICABLE, since 12/01/2007
• LINEHAN, PATRICIA — w-2 managing employee, NOT APPLICABLE, since 12/01/2007
• LOCKHART, DENNIS — operational/managerial control, NOT APPLICABLE, since 08/01/2018
• ATRIUM CENTERS MANAGEMENT LLC — operational/managerial control, NOT APPLICABLE, since 12/01/2007
• ORION OPERATING SERVICES LLC — 5% or greater direct ownership interest, 100%, since 12/01/2007