Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Fraser Villa during CMS and state inspections, most recent first.
Failure to document AMA discharge information: A resident with muscle weakness, difficulty walking, and impaired cognition left the facility AMA, and the record showed only a later SW note stating the nurse manager was notified, the resident returned home, HHC was arranged, and the family was told to follow up with the PCP. No other progress note was found, the DON said the facility did not use AMA forms, and an LPN stated physician notification and education occurred but no progress note was completed.
Improper Insulin Pen Administration: An LPN administered insulin via a pen device to a resident without priming the needle after attaching it, stating priming was unnecessary because the cartridge had been used before. The same LPN again prepared an insulin dose without priming the pen, and the DON provided information that did not match the manufacturer package insert, which indicated a safety test should be performed before administration. Literature reviewed showed equivalent insulin pen manufacturers recommended priming before each use.
A resident with cognitive impairment and mobility issues eloped from the facility after being mistaken for a family member by the receptionist, who allowed them to exit without signing out. The resident was not missed until hours later when staff attempted to administer medication. The facility's elopement policy was not fully implemented, leading to a delayed response and failure to prevent the resident from leaving.
The facility failed to date food items brought in from outside and maintain sanitary conditions in resident refrigerators. Observations revealed undated and expired food items in various unit refrigerators, including pizza, soup, cinnamon rolls, and salad. Freezers were also found soiled with food spillage. The Dining Services Director confirmed that items should be dated and discarded after three days, which was not followed.
The facility failed to conduct monthly medication regimen reviews for three residents, leading to a deficiency in managing unnecessary medications. The Director of Nursing confirmed the missing reviews, which were identified in an audit by the pharmacist. The facility's policy requires these reviews to ensure no unnecessary medications or interactions, but gaps were found for residents with cognitive impairments and various diagnoses.
Failure to Document AMA Discharge Information
Penalty
Summary
The facility failed to document discharge information in the medical record for one resident who left the facility against medical advice. The resident was admitted with muscle weakness and difficulty in walking, had an MDS BIMS score of 12/15 indicating impaired cognition, and required staff assistance with bed mobility and transfer. The discharge MDS coded the resident as discharged AMA from the facility. The medical record contained a social work note stating that the nurse manager reported the resident left AMA, the resident's daughter confirmed the resident returned home, home health care was arranged per the family's request, and the family was advised to follow up with the PCP within one week. No other progress note related to the resident leaving AMA was found in the record. During interview, the DON stated the facility did not use AMA forms, and an LPN reported that when the resident requested discharge, the physician was notified and education was provided, but no progress note was completed. The facility also stated it did not have a policy related to leaving the facility AMA.
Improper Insulin Pen Administration
Penalty
Summary
The facility failed to ensure proper insulin administration for one resident reviewed for insulin use. On 3/18/26 at 10:34 AM, an LPN administered insulin via a pen device to the resident without performing a safety test, or prime, after attaching the needle; the LPN stated that priming was not needed because the cartridge had been used before. On 3/19/26 at 7:39 AM, the same LPN again prepared an insulin dose for the resident and did not prime the pen. During an interview on 3/19/26 at 1:59 PM, the DON provided information for the pen in current use that did not specifically recommend priming the needle after first use, but this was not a manufacturer package insert. The DON also stated that the same manufacturer is not used at all times, and the package insert does indicate that a safety test should be performed prior to administration. A review of literature showed that equivalent insulin pen manufacturers recommended priming the needle before each use to remove excess air bubbles and test needle patency.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to adequately supervise and prevent the elopement of a resident, identified as R901, who was cognitively impaired and required assistance for mobility. The incident occurred when the receptionist observed the resident exiting the facility with a suitcase and a bag, mistaking them for a family member. The receptionist unlocked the door, allowing the resident to leave without realizing they were a resident. The facility's policy requiring residents to sign out was not followed, contributing to the oversight. The resident, who had been admitted with conditions including hemiplegia, aphasia, and muscle weakness, was last seen by staff at approximately 2:30 PM. It was not until 4:15 PM that the unit manager was informed of the resident's absence when the assigned nurse went to administer medication and found the resident missing. Despite efforts to locate the resident within the facility, it was only after contacting the resident's son that staff learned the resident had left the premises and walked home, a distance of approximately 1.7 miles. The facility's response to the missing resident was delayed, as a missing person code was not initiated, and a full count of residents was not conducted. The facility's elopement policy, which includes notifying authorities and conducting a thorough search, was not fully implemented. The incident highlighted a lapse in communication and adherence to established procedures, resulting in the resident leaving the facility without proper authorization or discharge.
Failure to Date and Maintain Sanitary Conditions in Resident Refrigerators
Penalty
Summary
The facility failed to ensure that food items brought in from outside the facility were properly dated and that resident refrigerators were maintained in a sanitary manner. During an observation with the Dining Services Director, several issues were noted across different unit refrigerators. In the Candlewood Unit refrigerator, there were items such as 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. The Meadow Lane refrigerator contained an undated pizza slice, an undated container of salad, and a freezer soiled with food spillage. The Rehab 1 refrigerator had a container of chicken dated 1/9, while the Rehab 2 refrigerator contained an undated jello salad, an undated container of cut fruit, and a freezer soiled with a large pooled area of a brown substance. The Dining Services Director confirmed that all items should be dated and discarded after three days, as per the facility's policy, which was not adhered to in these instances.
Failure to Conduct Monthly Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that a licensed pharmacist performed a monthly medication regimen review (MRR) for three residents, leading to a deficiency in the management of unnecessary medications. Resident R45, who was admitted with peripheral vascular disease and depression, did not have an MRR documented for February 2024. Resident R52, diagnosed with dementia, lacked MRR documentation for July 2024 and October 2024. Similarly, Resident R60, with diagnoses of dementia and depression, also had missing MRRs for July 2024 and October 2024. These omissions were confirmed by the Director of Nursing (DON), who acknowledged the gaps in the reviews as identified in an audit by the pharmacist. The facility's policy requires the consultant pharmacist to conduct MRRs and make recommendations based on the resident's health record, following CMS guidelines. The DON explained that the purpose of these reviews is to ensure there are no unnecessary medications, interactions, or negative impacts on the resident's organ function. However, the failure to conduct these reviews as per the policy resulted in the identified deficiency, as confirmed by the DON and the email communication from the pharmacist highlighting the gaps.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Fraser
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Medilodge Of Sterling Heights | 1.7 mi | — | 1 | 0 |
| Optalis Health And Rehabilitation Of Sterling Heig | 2.9 mi | — | 2 | 0 |
| Harmony Village Of Clinton | 2.9 mi | — | 1 | 0 |
| The Orchards At Warren | 3.4 mi | — | 22 | 0 |
| Autumn Woods Residential Health | 3.4 mi | — | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.