Fraser Villa: Pain Med Delayed While Staff Slept - MI
The resident, identified in inspection records as R700, had been admitted to Fraser Villa on April 29, 2026, following a fracture of the left femur and a left hip replacement. Their cognition was fully intact, scoring 15 out of 15 on a standard mental status assessment. That night, their leg was hurting worse than usual.
"Last night my leg was hurting, more than usual," R700 told investigators on May 15. "It hurts everyday but not this bad. The man came and called the police for me."
R700's Tylenol was scheduled every four hours around the clock, with a 2:00 AM dose on the books. According to the intake complaint called into the state agency, R700 had been waiting for medication since around 1:30 AM. The nurse assigned to that hallway, LPN A, thought she was still on break and believed other staff would cover for her. Nobody did.
The facility's nursing home administrator told inspectors the call light had been activated for roughly an hour, from approximately 3:20 AM to 4:20 AM, until law enforcement arrived and found staff in what appeared to be sleeping positions. LPN A then came and gave R700 the medication.
LPN A's own statement, dated May 19, said she gave R700 Tylenol at 3:00 AM but forgot to sign it out on the medication administration record until 5:00 AM that same morning.
The records tell a different story about the timing. The intake complaint documented R700 waiting since 1:30 AM. The administrator placed the call light activation starting at 3:20 AM. LPN A claims she administered the medication at 3:00 AM, before the call light was even noted as active, yet didn't document it for two more hours. No pain score was recorded at all during the midnight shift covering the night of May 14 into May 15.
R700's care plan listed an active goal of keeping left hip pain at or below a 4 on a 10-point scale following the hip replacement surgery. When day shift arrived and a pain assessment was finally completed, R700 scored a 7. An X-ray taken that day showed why: the hip replacement had dislocated. R700 was sent to the hospital.
Federal inspectors cited Fraser Villa for failing to provide treatment and care in accordance with professional standards of practice and R700's care plan, related to pain management. The deficiency was tagged at a level of minimal harm or potential for actual harm, affecting few residents.
When inspectors asked the facility to produce a pain management policy, Fraser Villa said it did not have one.
R700 had been a resident for just over two weeks when they spent the early morning hours of May 15 waiting, calling, and finally reaching for whatever help they could find. The help that came wore a badge, not scrubs. By the time the sun came up, the hip that surgeons had worked to repair was out of its socket.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Fraser Villa from 2026-05-28 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 20, 2026 · Our methodology
Fraser Villa in Fraser, MI was cited for violations during a health inspection on May 28, 2026.
Their cognition was fully intact, scoring 15 out of 15 on a standard mental status assessment.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.