Citizens Care and Rehabilitation Center of Frederi

In the surveyor’s words

From the most serious findings on record at Citizens Care and Rehabilitation Center of Frederi, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF804Mar 20, 2026

  Based on interviews and record review, it was determined that the facility failed to ensure that residents received their meals at a safe and palatable temperature. This deficient practice has the potential to affect all residents. During an initial tour of the facility on 3/16/26, several residents reported that the facility's food was typically cold for hot foods. A review of the facility's food service temperature logs for January 2026 was conducted on 3/17/26 at 2:02 PM. The review revealed missing internal cooking temperatures for: lunch and dinner on 1/4/26, lunch and dinner on 1/5/26, dinner on 1/6/26, lunch and dinner on 1/7/26, lunch and dinner on 1/8/26, lunch and dinner on 1/9/26, lunch and dinner on 1/10/26, lunch and dinner on 1/11/26, lunch and dinner on 1/12/26, lunch and… […]

• No harm, potential for more than minimal, widespreadF812Dec 23, 2024

  Based on observation, interview, and review of the facility policy, the facility failed to ensure all food in the freezer, refrigerator, and dry storage was labeled, dated, and not expired as well as failed to ensure newly washed dishes were allowed to properly air dry and staff wore the appropriate hair coverings. These failures had the potential to affect all 158 residents in the facility who consumed food from the kitchen. Findings include: Review of the facility's policy titled, Food Safety Product Labeling and Dating Guidelines, dated [DATE], revealed .Sodexo policy does not specify a date marking label. An establishment can choose to be as precise as needed in date marking if the parameters set forth within the Sodexo policy are met. […]

• No harm, potential for more than minimal, patternF761Dec 23, 2024

  Based on observations, interviews, record review and review of facility policy, the facility failed to ensure expired insulin pens were discarded from five medication carts (respiratory care unit (RCU) cart two, second floor long-term care unit (LTC) medication carts one, second-floor LTC medication cart two, third floor LTC medication cart medication cart one, and memory care medication cart one) of nine medication carts reviewed. This failure placed residents at risk of ineffective medication. Findings included. Review of the facility policy titled, Medication Administration, dated [DATE] revealed, . Ensure that the open date is documented on the vial or pen .Check the expiration date prior to administration to ensure it is within the usage date. […]

• No harm, potential for more than minimal, patternF880Dec 23, 2024

  Based on observation, interview, record review, and review of facility policy, the facility failed to ensure infection control measures were appropriately implemented and maintained hand hygiene related to blood glucose testing for four of four residents (Resident (R) 35, R16, R77, and R14) who were observed during testing. Also, the facility failed to ensure wound care was performed in a manner to prevent infection for R115. These failures placed the residents at risk for infections and a decrease in quality of life. Findings include: 1. Review of the facility's policy titled, Glucometer Disinfection reviewed 10/14/24 indicated, Policy Explanation and Compliance Guidelines .5. Procedure: a. […]

• No harm, potential for more than minimal, isolatedF550Mar 20, 2026

  Based on observation and interviews, it was determined that the facility failed to treat residents with respect and dignity, as evidenced by failing to knock and request permission before entering residents' rooms. This was evident for 1 (Resident #75) of 1 resident reviewed for dignity. The findings include:An observation was made during an interview on 3/16/26 at 12:28 PM with the representative of Resident #75 in the resident's room. Staff #3 and #4, both nursing assistants, entered the resident's room with a lunch tray. The observation did not show that both staff members knocked or announced their entry, and waited for permission before entering the resident's room. […]