Fraser Villa
Fraser Villa in Fraser, MI — inspection on May 28, 2026.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
plan, and the resident's choices, related to pain management, out of five reviewed for pain medication
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. A review of an Intake called into the State Agency noted the following, (R700) had been waiting for [their] meds (medication) since around 1:30am and had not received it.
Licensed Practical Nurse (LPN) A was the one who was supposed to give (R700) the meds. LPN A thought [they] were still on break and other staff covers [them] when [they] are on break. LE (Law Enforcement) had to help (R700) move around and get [their] meds.Further review of a R700's interview statement dated 5/15/2026 noted the following, Last night my leg was hurting, more than usual, it hurts everyday but not this bad.
The man came and called the police for me.A review of the physician's orders noted R700's Tylenol was scheduled every four hours-2:00AM,6:00AM,10:00AM,2:00PM,6:00PM, and 10:00PM. A review of LPN A's statement dated 5/19/2026 noted they gave R700 Tylenol at 3:00 AM, but they forgot to sign out on the May 2026 Medication Administration Record (MAR) the medication until 5:00 AM that morning (5/15/26).Further review of the care plan noted the following goal, At risk for Pain left hip with a goal of 4 (10 being the highest and 1 being the lowest level of pain) R/T (Related To) weakness, s/p (status post) left hip hemiarthroplasty (left hip replacement).
Status: Active.On 5/15/2026 during day shift (7:00 AM-7:00PM) a pain score of 7 was recorded and a leg Xray revealed R700s hip replacement was dislocated and R700 was sent to the hospital for treatment.Further review of pain assessments showed no recorded pain score for midnight shift (7:00PM-7:00AM) on 5/14/2026 into 5/15/2026. On 5/28/2026 at 12:49 PM, an interview was conducted with the Nursing Home Administrator (NHA).
The NHA reported R700's call light was activated, and they believe it had been on for about an hour from approximately 3:20 AM-4:20 AM until the police came and found staff in what appeared to be sleeping positions, then LPN A came and gave R700 their pain medication. A request for a policy related to pain management was requested, and facility informed they did not have a policy related directly to pain management.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.