A list of the most recent deficiencies for Fraser Villa. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2024-01-11 | 2024-02-07 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-01-11 | 2024-02-07 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2024-01-11 | 2024-02-07 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-10-06 | 2022-11-12 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2022-10-06 | 2022-11-12 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2022-10-06 | 2022-11-12 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-10-06 | 2022-11-12 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-10-06 | 2022-11-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-10-06 | 2022-11-12 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-10-06 | 2022-11-12 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2022-10-06 | 2022-11-12 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-10-06 | 2022-11-12 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-10-06 | 2022-11-12 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-10-06 | 2022-11-12 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-06-25 | 2021-08-06 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-06-25 | 2021-08-06 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-06-25 | 2021-08-06 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-06-25 | 2021-08-06 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-06-25 | 2021-08-06 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2021-06-25 | 2021-08-06 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2021-06-25 | 2021-08-06 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-06-25 | 2021-08-06 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-06-25 | 2021-08-06 | N |
| Ensure proper storage of liquid oxygen. | Fire Safety | 2021-06-25 | 2021-08-06 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2021-06-23 | 2021-07-28 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-06-23 | 2021-07-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-06-23 | 2021-07-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-06-23 | 2021-07-28 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-06-23 | 2021-07-28 | Y |
