Moose Lake Village

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. A manufacturer sign posted next to the dishwasher instructed the final rinse cycle range should be 180-195 degrees F.During an interview on 7/6/26 at 1:58 p.m., culinary director (CD) indicated the dishwasher was a high temperature machine and stated the final rinse cycle must reach 180 degrees F. CD confirmed the low temperature and stated they needed to call the dishwasher company for service.During an interview on 7/9/26 at 9:25 a.m., the infection preventionist (IP) expected the dishwasher temperature to be hot enough to prevent…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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). Instructions identified staff were to report to the supervisor any time the temperature was out of range. Licensed practical nurse (LPN)-A verified the temperature for July was recorded only one time during July.A review of the medication temperatures for the past four months identified the following:-June there were only four…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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. R 60 also had one open lesion that was not a pressure ulcer, rash or cut. R60's infectious disease progress note dated 7/6/26, indicated R60 had an ulceration to the abdominal wall. On 11/6/26 at 3:48 p.m., a contact precautions sign was observed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and document review the facility failed to complete a Self-Administration of Medication (SAM) assessment and acquire a physician order for self-administration for 1 of 1 resident (R72) who was observed to have medications left at bedside.Findings include: R72's Brief Interview for Mental Health performed on admission indicated moderate cognitive impairment. R72's electronic medical record (EMR) indicated diagnoses of urinary tract infection and chronic obstructive pulmonary disease. The EMR Lacked a SAM assessment or orders to keep medications at bedside. R72's care plan undated lacked a care plan related to ability to self-administer medications On 7/6/26 at 3:05 p.m., medications including nystatin cream and refresh eye drops were observed in a pink wash basin on the counter in R72's room. On 7/7/26 at 1:21 p.m., nystatin cream, refresh eye drops, and diclofenac cream were observed in the pink basin in R72's room. On 7/8/26 at 10:32 a.m. nystatin cream, refresh eye drops, and diclofenac cream were again observed in the pink basin on the counter in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review the facility failed to ensure orders for blood sugar readings were followed for 1 of 5 residents (R19) reviewed for unnecessary medications. Findings include:R19's Face Sheet dated 7/9/26, identified he had diagnoses which included chronic heart failure (a chronic progressive condition where the heart muscle does not pump blood effectively), recurrent dislocation of right shoulder, type 2 diabetes mellitus with diabetic neuropathy, and hypertension. R19's admission Minimum Data Set, dated [DATE], identified he was cognitively intact, had no rejections of care, and required substantial assistance with activities of daily living.R19's care plan identified he was at risk for a decline in medical condition related to diabetes mellitus. Interventions included to administer medications and treatments per the medical doctor's order.R19's Physician Order Report dated 6/1/26, identified the following: Test blood sugars QID (four times a day), before meals, and prior to bedtime.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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. R34 stated the water takes a while to get hot, but then it gets very hot, and she had to blend it with cold water to use it. R34 stated she and nursing assistants (NA)s had talked about it before. During an observation and interview on 5/14/25 at 2:17 p.m., maintenance worker (MW)-A, who…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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. R19's care plan last reviewed 5/13/25, didn't identify diagnoses or problem statements for hypertension, constipation, fluid retention, or issues with the skin in the perineal area. R19's provider orders identified the following medications without…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to provide a financial statement to 1 of 2 residents (R4) who had requested to receive a quarterly statement of their personal funds account. Findings include: R4's annual Minimum data Set (MDS) dated [DATE], identified R4 was cognitively intact. During an interview on 5/12/25 at 3:27 p.m., R4 stated she had a personal trust account but was not getting any statements. R4 stated she was not sure how much money she had in the account. During an interview on 5/14/25 at 1:46 p.m., business office manager (BOM)-F verified R4 had a personal trust account and identified the statements were going to her old home address. BOM-F verified R4 should have been receiving her statements. During an interview on 5/14/25 at 2:12 p.m., the administrator verified the facility should follow the procedure in their policy. During a phone interview on 5/14/25 at 2:27 p.m., the corporate associate vice president of revenue cycle management verified R4's statement should have…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to identify and update the care plan with resident specific fall prevention interventions for 1 of 2 residents (R49) reviewed for multiple falls at the facility. Findings include: R49's admission Minimum Data Set (MDS) dated [DATE], indicated R49 was cognitively intact. R49's Resident Profile dated 5/15/25, included diagnoses of osteomyelitis, pain, chronic respiratory failure, congestive heart failure, diabetes type II, repeated falls, muscle weakness, unsteadiness on feet, and unspecified abnormalities of gait and mobility. R49's Care plan dated 3/27/25 to 5/15/25, included the following: Resident needs assistance with ADL's, start date 3/27/25 ---Dressing: staff to provide assist of one for dressing. ---Toileting: staff to provide assist of one with toileting. ---Transfers: -----assist of 1 for transfers using a gait belt and hemi-walker (edited 4/7/25, from mod I) -----provide limited/extensive assist of one with walker for transfers. Cue…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to assess post-traumatic stress disorder (PTSD) symptoms and triggers and carry them forward to the care plan for 1 of 1 resident (R19) reviewed for trauma informed care. Findings include: R19's admission Minimum Data Set (MDS) dated [DATE], identified intact cognition and diagnoses of anxiety, major depressive disorder, psychotic disorder, PTSD, frontotemporal neurocognitive disorder, severe dementia with agitation, delusional disorder, and paranoid delusions. The MDS also identified R19 had hallucinations, delusions, verbal behavior toward others, and had behavior which significantly disrupted the living environment. R19's care plan dated 2/11/25, identified a problem statement for trauma-informed care related to a history of trauma of physical abuse as a minor from alcoholic parents including being tied up by the arms and legs to a bed, having socks placed in her mouth due to screaming, and was burned with cigarettes. The goal for R19 was for care…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview the facility failed to utilize beard coverings in the kitchen to ensure sanitary conditions were maintained in food preparation areas. This deficient practice had the potential to impact all residents who received nourishment from the facility dietary services. Findings include: During an observation on 5/12/25 at 1:26 p.m., the food service consultant (FSC-A) was in the main kitchen area without a beard covering. FSC-A provided a tour of the kitchen food prep area, food dry and cold storage areas, the dishwashing area, and dish storage area while not wearing a beard covering. During an observation on 5/14/25 at 8:00 a.m., the culinary director (CD) was located behind the cook's prep table and did not have a beard covering on. During a continuous observation on 5/14/25 at 10:42 a.m. to 11:46 a.m., both the CD and FSC-A did not wear a beard covering during the following observed events: --10:43 a.m. to 1048 a.m., FSC-A stood in front of the cook's prep area without a beard covering as cook (C-A) pulled food from the oven and temped it. --10:51 a.m.,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure advanced directives for emergency care and treatment were accurately reflected in all areas of the medical chart to ensure resident wishes would be implemented correctly in an emergent situation for 1 of 24 residents (R106) reviewed for advanced directives. Findings include: R106's admission Minimum Data Set (MDS) dated [DATE], identified R106 had moderate cognitive impairment. Diagnoses included dementia and malnutrition. R106's Provider Orders for Life-Sustaining Treatment (POLST) dated [DATE], included: -Section A for cardiopulmonary resuscitation (CPR) patient has no pulse and is not breathing section, directed staff to Attempt Resuscitation/CPR (Note: selecting this requires selecting Full treatment in Section B). -Section B for Medical Treatments patient has a pulse and/or is breathing directed staff to do comfort-focused treatment (allow natural death)' R106's electronic medical record (EMR) banner undated, identified R106 was do not…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, the facility failed to ensure eye drops were disposed of when they were past the 28 day post open date. This had potential to affect 2 of 16 residents who resided on 300 hallway. Findings include: On 3/14/24 at 11:07 a.m., a review of the 300-hallway medication cart was performed. Observation was made of Olopatadine 0.2% solution eye drops that had an open date of 1/31/24. There were also a bottle of artificial tears eye drops open dated on 1/6/24. During an interview on 3/14/24 at 11:16 a.m., licensed practical nurse (LPN)-A reviewed the medications and confirmed the dates on the medications were the open dated. She was unsure how long the medications were good for but believed they were safe to use for six months after opening. During an interview on 3/14/24 at 12:06 p.m., the pharmacy consultant (PC) stated eye drops such as Olopatadine and artificial tears were only good for 28 days after opened since the preservative in them would only be stable for 28 days. After the 28 days they may not be safe to use. During an interview on 3/14/24 at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to notify the medical provider of high blood sugar levels for 2 of 3 residents (R2, R3) reviewed for change in condition. Findings include: The facility Standing Orders revised 10/30/21 directed to notify the medical provider if two blood glucose levels were under 70 or over 300 in a 24-hour period and/or change in condition; if no condition change, notify provider the next business day. R2's Face Sheet indicated diagnoses of type 2 diabetes mellitus with diabetic nephropathy (kidney disease). R2's admission Minimum Data Set (MDS) dated [DATE] indicated R2 received insulin daily. R2's Vital Signs flow sheet indicated the following blood glucose (BG) levels: On 10/24/23 at 5:22 p.m., BG level was 301, and at 8:54 p.m., BG level was 371. On 10/26/23 at 11:24 a.m., BG level was 323 and at 5:39 p.m., BG level was 376. On 11/8/23 at 5:18 p.m., BG level was 313 and at 7:58 p.m. BG level was 465. R2's progress notes during this time frame lacked any entry of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.