Cycle 1
Health 2025-02-18 · Fire 2025-02-18
7 health deficiencies
Top issue: Resident Rights (3 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Frederic, WI
Frederic Nursing And Rehab Community
4-star overall rating with 4-star inspections with 7 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
205 United Way, Frederic, WI
(715) 327-4297
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
60
Certified beds
Average residents
53
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Atrium Centers
Operator or chain grouping
Approved since
2002-05-25
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
26 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.76
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
0.32
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.14
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
3.23
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
1.08
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
2.72
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
0.44
Weekend registered nurse coverage · state 0.66 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.86
CMS adjusted RN staffing hours
Adjusted total hours
3.65
CMS adjusted total nurse staffing hours
Case-mix index
1.21
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
49%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,070
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
24.83
Composite VBP score used to determine payment impact.
Payment multiplier
0.9836
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.38
Baseline 18.73% · Performance 20.33% · Measure score 2.38 · Achievement 2.38 · Improvement 0
Healthcare-associated infections
4.21
Baseline 6.69% · Performance 6.58% · Measure score 4.21 · Achievement 4.21 · Improvement 0.14
Total nurse turnover
3.35
Baseline 63.04% · Performance 50.00% · Measure score 3.35 · Achievement 3.35 · Improvement 2.92
Adjusted total nurse staffing
0
Baseline 3.54 hours · Performance 2.98 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.34% |
10.72%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 75 · Observed rate 12% · Lower 95% interval 7.44% |
| Discharge to community | 58.44% |
50.57%
7.9 pts better
|
No Different than the National Rate · Eligible stays 66 · Observed rate 56.06% · Lower 95% interval 47.98% |
| Medicare spending per beneficiary | 1.05 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 67 · Denominator 67 |
| Falls with major injury | 1.49% |
0.77%
0.7 pts worse
|
Numerator 1 · Denominator 67 |
| Discharge self-care score | 45.65% |
53.69%
8 pts worse
|
Numerator 21 · Denominator 46 |
| Discharge mobility score | 36.96% |
50.94%
14 pts worse
|
Numerator 17 · Denominator 46 |
| Pressure ulcers or injuries, new or worsened | 4.48% |
2.29%
2.2 pts worse
|
Numerator 3 · Denominator 67 · Adjusted rate 6.04% |
| Healthcare-associated infections requiring hospitalization | 6.58% |
7.12%
0.5 pts better
|
No Different than the National Rate · Eligible stays 35 · Observed rate 2.86% · Lower 95% interval 3.68% |
| Staff COVID-19 vaccination coverage | 5.08% |
8.2%
3.1 pts worse
|
Numerator 6 · Denominator 118 |
| Staff flu vaccination coverage | 18.9% |
42%
23.1 pts worse
|
Numerator 24 · Denominator 127 |
| Discharge function score | 52.17% |
56.45%
4.3 pts worse
|
Numerator 24 · Denominator 46 |
| Transfer of health information to provider | 97.56% |
95.95%
1.6 pts better
|
Numerator 40 · Denominator 41 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 46.67% |
25.2%
21.5 pts better
|
Numerator 14 · Denominator 30 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.5 |
1.6
1.1 pts better
|
1.9
1.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.5 · Observed 0.4 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 4.2 |
2.2
2 pts worse
|
1.8
2.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 4.2 · Observed 3.6 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 89.3% |
95.7%
6.4 pts worse
|
93.4%
4.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 89.7% · Q2 94.9% · Q3 91.1% · Q4 82.2% · 4Q avg 89.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 90.5% |
95.0%
4.5 pts worse
|
95.5%
5 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 90.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.0% |
3.2%
2.8 pts worse
|
3.3%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 7.7% · Q3 4.4% · Q4 6.7% · 4Q avg 6.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 6.1% |
5.0%
1.1 pts worse
|
11.4%
5.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 0.0% · Q3 4.7% · Q4 13.6% · 4Q avg 6.1% |
| Percentage of long-stay residents who lose too much weight | 3.4% |
4.9%
1.5 pts better
|
5.4%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 2.8% · Q3 7.9% · Q4 0.0% · 4Q avg 3.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 29.6% |
16.6%
13 pts worse
|
19.6%
10 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.3% · Q2 27.0% · Q3 32.5% · Q4 25.0% · 4Q avg 29.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.6% |
16.7%
3.1 pts better
|
16.7%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 16.7% · Q3 11.8% · Q4 14.7% · 4Q avg 13.6% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 6.1% |
21.1%
15 pts better
|
16.3%
10.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q4 3.6% · 4Q avg 6.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 7.9% |
17.3%
9.4 pts better
|
14.9%
7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 10.8% · Q3 10.0% · Q4 5.0% · 4Q avg 7.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.8% |
2.3%
1.5 pts better
|
1.0%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.8% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
3.0%
3 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.4% |
25.5%
2.1 pts better
|
19.8%
3.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 40.0% · Q2 26.9% · Q3 16.5% · Q4 14.0% · 4Q avg 23.4% |
| Percentage of long-stay residents with pressure ulcers | 4.9% |
5.5%
0.6 pts better
|
5.1%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 4.7% · Q3 4.0% · Q4 7.7% · 4Q avg 4.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 81.5% |
86.8%
5.3 pts worse
|
81.7%
0.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 84.8% · Q2 80.6% · Q3 83.3% · Q4 76.8% · 4Q avg 81.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.6% |
15.0%
1.4 pts better
|
12.0%
1.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.6% · Observed 13.6% · Expected 11.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.0% |
1.3%
0.7 pts worse
|
1.6%
0.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 2.7% · Q3 0.0% · Q4 2.8% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 75.0% |
82.2%
7.2 pts worse
|
79.7%
4.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 75.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.1% |
22.7%
2.4 pts worse
|
23.9%
1.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.1% · Observed 22.7% · Expected 21.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-23 · Fire 2024-01-23
6 health deficiencies
Top issue: Administration (1 deficiency)
5 fire-safety deficiencies
Top issue: Miscellaneous (2 deficiencies)
Cycle 3
Health 2022-12-08 · Fire 2022-12-08
5 health deficiencies
Top issue: Administration (1 deficiency)
7 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-02-18
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-03-18
E · Potential for more than minimal harm
2025-02-18
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2025-03-18
D · Potential for more than minimal harm
2025-02-18
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-03-18
F · Potential for more than minimal harm
2024-01-23
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-02-16
D · Potential for more than minimal harm
2024-01-23
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-02-16
D · Potential for more than minimal harm
2024-01-23
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-02-16
D · Potential for more than minimal harm
2024-01-23
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2024-02-16
D · Potential for more than minimal harm
2024-01-23
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2024-02-16
F · Potential for more than minimal harm
2022-12-08
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-01-08
F · Potential for more than minimal harm
2022-12-08
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2023-01-08
F · Potential for more than minimal harm
2022-12-08
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-01-08
F · Potential for more than minimal harm
2022-12-08
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-01-08
F · Potential for more than minimal harm
2022-12-08
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2023-01-08
E · Potential for more than minimal harm
2022-12-08
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2023-01-08
D · Potential for more than minimal harm
2022-12-08
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-01-08
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-07-01
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-07-18
D · Potential for more than minimal harm
2025-07-01
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-07-18
D · Potential for more than minimal harm
2025-07-01
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-07-18
C · Minimal harm
2025-07-01
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-07-18
D · Potential for more than minimal harm
2025-04-07
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-04-17
E · Potential for more than minimal harm
2025-02-18
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2025-03-18
D · Potential for more than minimal harm
2025-02-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-18
F · Potential for more than minimal harm
2024-01-23
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-02-16
F · Potential for more than minimal harm
2024-01-23
F851 · Administration Deficiencies
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2024-02-16
E · Potential for more than minimal harm
2024-01-23
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-02-16
E · Potential for more than minimal harm
2024-01-23
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-02-16
D · Potential for more than minimal harm
2024-01-23
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-02-16
D · Potential for more than minimal harm
2024-01-23
F761 · Pharmacy Service Deficiencies
Health
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 2024-02-16
E · Potential for more than minimal harm
2022-12-08
F839 · Administration Deficiencies
Health
Employ staff that are licensed, certified, or registered in accordance with state laws.
Corrected 2023-01-08
D · Potential for more than minimal harm
2022-12-08
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2023-01-08
D · Potential for more than minimal harm
2022-12-08
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-01-08
D · Potential for more than minimal harm
2022-12-08
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-01-08
D · Potential for more than minimal harm
2022-12-08
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-01-08
Penalties and ownership
What sits behind the stars
Ownership
Orion Operating Services LLC
5% Or Greater Direct Ownership Interest · Organization
Albright Ross, Susan
Operational/Managerial Control · Individual
Atrium Centers Management LLC
Operational/Managerial Control · Organization
Atrium Centers, Inc.
5% Or Greater Indirect Ownership Interest · Organization
Bailey, Essel
5% Or Greater Indirect Ownership Interest · Individual
Bailey, Essel
Corporate Director · Individual
Ferkany, James
Corporate Officer · Individual
Finney, Donald
5% Or Greater Indirect Ownership Interest · Individual
Finney, Donald
Corporate Director · Individual
Linehan, Patricia
W-2 Managing Employee · Individual
Lockhart, Dennis
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
United Pioneer Home
Luck, WI
3-star overall rating with 3-star inspections with 7 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Burnett Medical Center
Grantsburg, WI
2-star overall rating with 3-star inspections with 13 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Dove Healthcare - St Croix Falls
St Croix Falls, WI
2-star overall rating with 2-star inspections with $129,124 in total fines with 9 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
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