Fraser Villa

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF812Jan 15, 2025

  Based on observation, interview, and record review, the facility failed to ensure resident food items brought in from outside the facility were dated, and failed to maintain the resident refrigerators in a sanitary manner. This deficient practice had the potential to affect all residents that consume food in the facility. Findings include: On 1/13/25 between 9:15 AM-9:30 AM, the resident refrigerators were observed with Dining Services Director A. In the Candlewood Unit refrigerator, there was a pizza dated 12/23, a container of soup dated 1/3, an undated container of cinnamon rolls, a container with an unidentified food item dated 12/21-12/24, and an opened, undated bottle of ranch dressing. […]

• No harm, potential for more than minimal, isolatedF697May 28, 2026

  Based on interview and record review, the facility failed to ensure one resident (R700) received the treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the resident's choices, related to pain management, out of five reviewed for pain medication management.Findings include:A review of the medical record revealed R700 admitted into the facility on 4/29/2026 with the following medical diagnoses, Fracture of neck of Left Femur and Presence of Left Artificial Hip Joint. A review of the most recent Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental Status (BIMS) score of 15/15, indicating an intact cognition. R700 also required staff assistance with bed mobility and transfers. […]

• No harm, potential for more than minimal, isolatedF627Mar 19, 2026

  Based on interview and record review, the facility failed to document discharge information in the medical record for one resident (R136) out of one reviewed for discharge. Findings include:A review of the medical record revealed that R136 was admitted into the facility on 1/2/2026 with the following medical diagnoses, Muscle Weakness and Difficulty in Walking. A review of the most recent Minimum Data Set (MDS) revealed a Brief Interview for Mental status score of 12/15 indicating an impaired cognition. R136 also required staff assistance with bed mobility and transfer. […]

• No harm, potential for more than minimal, isolatedF760Mar 19, 2026

  Based on observation, interview, and record review, the facility failed to ensure proper insulin administration for one (R150) of three residents reviewed for insulin administration. Findings include:On 3/18/26 at 10:34 AM, Licensed Practical Nurse (LPN) B administered insulin via a pen device to R150. During the preparation process, LPN B did not perform a safety test (prime) on the pen after the needle was attached, a practice that removes any air bubbles, ensures the needle is working, and fills the needle prior to administration. […]

• No harm, potential for more than minimal, isolatedF689Feb 4, 2025

  This intake pertains to Intake: MI00149945. Based on interview and record review, the facility failed to supervise, prevent an elopement, and operationalize the policies and procedures for a missing resident for one resident, (R901) of three residents reviewed for elopement. Findings include: A review of information reported to the State Agency revealed the following, Resident was observed by the receptionist exiting the facility with appropriate outerwear and a suitcase and a bag at approximately 2:30 PM. […]