Moose Lake Village

In the surveyor’s words

From the most serious findings on record at Moose Lake Village, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Jul 9, 2026

  Based on observation, interview, and document review, the facility failed to ensure minimum dishwasher temperatures were attained during the rinse cycle for 1 of 1 dishwasher. This had the potential to affect all current residents, as well as staff or visitors, who ate food served from dishes and tableware that were cleaned in the dishwasher.Findings include:During an observation on 7/6/26 at 1:58 p.m., the dishwasher wash cycle reached 153 degrees Fahrenheit (F) and the final rinse cycle reached 150 degrees F per the temperature gauges on the machine. […]

• No harm, potential for more than minimal, patternF761Jul 9, 2026

  Based on observation, interview and document review the facility failed to ensure medication refrigerators were kept within the recommended temperature range for 1 of 2 medication refrigerators. This deficient practice had the potential to affect any resident who received medications stored in the refrigerator.Findings include:During an observation on 7/7/26 at 2:07 p.m., the medication refrigerator in the main medication storage room had a reading of 42 degree's Fahrenheit (F). The medication log for July documented the last reading recorded as 39 degrees F. There were no temperatures recorded for July 1, 2, 3, 4, 6. The temperature log identified the safe range as 32 degrees to 41 degrees F (staff were using the food refrigerator temperature logs). […]

• No harm, potential for more than minimal, patternF880Jul 9, 2026

  Based on observation, interview, and document review, the facility failed to ensure that all staff (including outside contracted staff) wear appropriate personnel protective equipment (PPE) and perform appropriate hand hygiene while completing wound care on a resident. This affected 1 of 1 (R60) residents reviewed for infection control. The facility also failed to change oxygen tubing timely to decrease the risk of infection for 1 of 1 (R37) reviewed for respiratory care. Findings Include: Wound Care: R60's quarterly Minimum Data Set (MDS) dated [DATE], indicated R60 had intact cognition. Diagnoses included peripheral vascular disease. Section M indicated R60 was at risk for pressure ulcers/injuries and had one stage two pressure ulcer that was not present on admission. […]

• No harm, potential for more than minimal, patternF689May 15, 2025

  Based on observation, interview and document review, the facility failed to ensure hot water temperatures were at safe temperatures at point-of-use for 27 of 27 residents who resided on the 200 hallway and the specialty care unit. In addition, the facility failed to ensure staff provided adequate supervision for transfers and activities of daily living for 2 of 2 residents (R49 and R40) and the facility further failed to follow the care plan related to transferring for the prevention of falls for 3 of 5 (R49, R40, R44) residents at risk for falls. Findings include: During a resident screening on 5/13/25 at 10:19 a.m., the hot water in bathroom of R34 felt very hot to touch after running the hot water for a couple of minutes. […]

• No harm, potential for more than minimal, patternF757May 15, 2025

  Based on interview and document review, the facility failed to ensure medication orders for residents contained an indication for the medication for 3 of 5 (R19, R37, R49) residents reviewed for unnecessary medications. Findings include: R19: R19's admission Minimum Data Set (MDS) dated [DATE], identified intact cognition and diagnoses of frontotemporal neurocognitive disorder (a type of dementia), severe dementia with agitation, delusional disorders, paranoid delusions, hypothyroidism, asthma, restless leg syndrome, urinary incontinence, post-traumatic stress disorder (PTSD), major depressive disorder, weakness, and fatigue. R19's MDS also identified hallucinations, delusions, verbal behavior toward others, and behavior significantly disrupts the living environment. […]