Fraser Health Center

In the surveyor’s words

From the most serious findings on record at Fraser Health Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Apr 10, 2025

  Based on observation, document review, interview, and policy review, the facility failed to ensure staff were taking meal temperatures to ensure they were served at safe temperatures before each meal was served. This had the potential to affect all residents who consumed food from the kitchen. Findings include: Review of the facility ' s policy titled Food Preparation and Service dated 2001 revealed that Food and nutrition services employees prepare, distribute, and serve food in a manner that complies with safe food handling practices. Proper hot and cold temperatures are maintained during food distribution and service. Foods that are held in the temperature danger zone are discarded after 4 hours. […]

• No harm, potential for more than minimal, widespreadF812Jul 27, 2023

  Based on observation, interview and record review, the facility failed to ensure accurate labeling and dating of foods and removal of expired foods from the Production Cooler. Findings include: Review of facility policy titled, Policy & Procedure Manual: Food Storage revealed Refrigerated food storage:. All foods should be covered, labeled and dated and routinely monitored to assure that foods (including leftovers) will be consumed for their safe use by dates, or frozen (where applicable), or discarded. During observation on [DATE] at 11:19 AM, the Production Cooler contained opened, unlabeled cream cheese and two pieces of unlabeled cheese. There were 7 pieces of expired Boursin Garlic and Fine Gourney Cheese 5.2 pounds that had an expiration date of ,d+[DATE]. […]

• No harm, potential for more than minimal, isolatedF550Apr 10, 2025

  Based on observation, record review and interview, the facility failed to ensure a dignified experience by ensuring a catheter bag that was in view of staff, visitors and residents was placed in a privacy bag for one of one resident (R25) reviewed for indwelling urinary catheter use. This had the potential to affect residents who require a catheter. Findings include: Review of R25's Admission Record, located in the Profile tab of the electronic medical record (EMR) revealed admission to the facility on [DATE]. During an observation on 04/08/25 at 10:27 AM and on 04/09/25 at 1:05 PM, R25 was lying in bed with the indwelling urinary catheter bag hanging on the right side of the bed visible from the door. […]

• No harm, potential for more than minimal, isolatedF657Apr 10, 2025

  Based on record review and interview, the facility failed to update a care plan for a resident who had a change in their skin condition for one of one resident (Resident (R) 24) reviewed for accident hazards. This deficient practice has the potential to affect residents who have a change in their plan of care. Findings include: Review of R24's Face Sheet located in the electronic medical record (EMR) under the Profile tab revealed the resident was admitted to the facility on [DATE] with diagnosis of dementia. Review of R24's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/25/25 and located in the EMR under the MDS tab revealed a Brief Interview for Mental Status (BIMS) score of 10 out of 15, which indicated the resident was moderate cognitively impaired. […]

• No harm, potential for more than minimal, isolatedF689Apr 10, 2025

  Based on record review, interview and policy review, the facility failed to ensure a residents' safety during a transfer after Resident (R)24 sustained a laceration to her leg during a transfer that resulted in a skin tear. This had the potential to affect residents who required staff assistance during transfers. Findings include: Review of the facility's policy titled Safe Lifting and Movement of Residents dated 2001 revealed that in order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. […]