Moosehaven

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF585Feb 25, 2021

  Based on staff interviews and a review of the facility's policies and procedures, the facility failed to ensure its grievance policy contained all mandated requirements. All 25 residents had the potential to be affected by the omissions in the facility-wide policy. The findings include: A review of the facility's grievance policy (undated) revealed the following purpose: It is the policy of this facility to assist residents, their representatives (sponsors), other interested family members, or advocates in filing grievances or complaints when such requests are made. The form listed procedural steps one should take to file a grievance. […]

• No harm, potential for more than minimal, isolatedF656Jun 5, 2026

  Based on observation, interview, record review and review of the facility's policy and procedure titled Care Plans, Comprehensive Person-Centered (revised March 2022), the facility failed to develop and implement a comprehensive person-centered care plan that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs and included the resident's goals, desired outcomes, and preferences for the use of psychotropic medications, for one (Resident #6) of six residents reviewed for unnecessary medication administration, from a total of 22 residents in the sample. […]

• No harm, potential for more than minimal, isolatedF695Sep 1, 2022

  Based on observation, interview, and record review, the facility failed to ensure that a resident who required respiratory care, was provided such care, consistent with professional standards of practice and the comprehensive person-centered care plan, for one (Resident #75) of 10 residents receiving respiratory treatment, from a total of 13 residents in the sample. The findings include: On 8/29/2022 at 10:16 a.m., Resident #75 was observed asleep in bed. Her nasal cannula was lying across her chest and an oxygen concentrator was observed at bedside. The concentrator was set to administer oxygen at a rate of 4 liters per minute (LPM). During a follow-up attempt to interview the resident at 1:11 p.m. the same day, she was again observed sleeping. […]

• No harm, potential for more than minimal, isolatedF657Feb 25, 2021

  Based on medical record reviews and staff interviews, the facility failed to revise resident care plans following the completion of a signed Do Not Resuscitate (DNR) order for three (Residents #80, #22 and #1) residents sampled for a review of their care plans, from a total sample of 25 residents. The findings include: 1. A review of the medical record for Resident #80, revealed a DNR order dated 10/1/2018. A review of Resident #80's hard chart revealed an admission care plan that stated the resident was a Full Code (the resident desired resuscitation in the event of respiratory/[MEDICAL CONDITION]). The hard copy admission care plan was dated 9/28/2018. A review of Resident #80's current comprehensive care plan, revealed the care plan was not revised to include the current DNR order. […]

• No harm, potential for more than minimal, isolatedF758Feb 25, 2021

  Based on interviews and record reviews, the facility failed to 1) Ensure as needed (PRN) [MEDICAL CONDITION] medications ordered for greater than fourteen days included justification for extended use for one (Resident #9) of five residents reviewed, and 2) Ensure the provision of adverse consequence monitoring for two (Residents #14 and #11) of five residents reviewed for [MEDICAL CONDITION] medications, from a total of 25 residents in the sample. The findings include: 1. A review of the medical record for Resident #9 revealed he was admitted on [DATE]. He had a [DIAGNOSES REDACTED]. On 09/03/2020, a new order was written for 0.5 mg of [MEDICATION NAME] every 6 hours PRN for 90 days. On 01/02/2021, a new order for 1.0 mg of [MEDICATION NAME] every 6 hours PRN was written. […]