Above average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Moose Lake Village during CMS and state inspections, most recent first.
Dishwasher Rinse Cycle Failed to Reach Required Sanitizing Temperature: The facility failed to ensure 1 of 1 dishwasher reached the required high-temp rinse range. During observation, the wash cycle reached 153°F and the final rinse reached 150°F, below the posted 180-195°F requirement. The CD confirmed the machine should reach 180°F, and the temp log showed multiple rinse cycles below 180°F with no indication of correction.
Medication refrigerator temperatures were not kept within the required range and were not checked consistently. The main med refrigerator was found above range, with missing temperature logs across multiple months. It stored several residents’ insulins and other meds/biologicals, and an LPN later found the unit at about 50 degrees F. The DON stated staff should check refrigerator temperatures daily, and the consultant pharmacist reviewed how long the stored items could remain usable once the safe range was exceeded.
A resident with MRSA and an abdominal wound was observed during wound care with contracted wound care staff entering without proper PPE, touching room items, and performing wound care without consistent hand hygiene or glove changes while moving from dirty to clean tasks; the same staff then went to another resident’s room without gowns despite EBP signage. The facility also failed to timely replace another resident’s oxygen tubing for CPAP/oxygen use, and the tubing had no label showing when it was last changed.
Medications were left at a resident’s bedside without a completed SAM assessment or physician order. The resident had moderate cognitive impairment on admission and diagnoses including UTI and COPD, but the EMR lacked a SAM assessment, bedside medication orders, and a related care plan. Surveyors observed nystatin cream, refresh eye drops, and later diclofenac cream in a basin in the resident’s room, while an LPN, RN, and DON confirmed the assessment was expected before medications were left in the room.
Failure to Follow Blood Sugar Orders: A resident with DM, CHF, HTN, and diabetic neuropathy had physician orders for blood sugar checks before meals and at bedtime, with juice and a 1-hour recheck for readings under 70 and hospice notification for readings of 450 or higher. Records showed several low blood sugar readings were not rechecked within 1 hour, and multiple high readings were not documented as reported to hospice as ordered. Staff interviews confirmed the expectation to follow the order as written.
The facility did not ensure hot water temperatures remained below the safe limit, with measurements reaching up to 134°F in resident areas, and failed to provide adequate supervision or follow care plans for residents needing assistance with transfers and ADLs. Multiple residents at risk for falls were observed or reported to be transferring independently without staff help or required safety equipment, despite care plans specifying assistance and use of gait belts. Staff interviews revealed inconsistent knowledge and adherence to care plans, and facility policies for fall prevention and care planning were not consistently followed.
Surveyors found that several medication orders for multiple residents did not include the required indications for use, despite facility policy mandating that all orders specify the diagnosis or reason for each medication. For example, a resident with dementia and other complex conditions had orders for medications such as Miralax, furosemide, and lisinopril without documented indications, and another resident with severe cognitive impairment had orders for melatonin and ondansetron without specified reasons.
A resident who was cognitively intact did not receive quarterly statements for her personal trust account as required, because the facility sent the statements to her former home address instead of directly to her. Interviews with staff confirmed the error, and facility policy required that such statements be provided to the resident.
A resident with multiple medical conditions and a history of repeated falls experienced several unwitnessed and witnessed falls, many related to self-transfers. Despite changes in transfer assistance after a significant fall, the care plan was not consistently updated with additional fall prevention interventions after subsequent incidents. Staff interviews revealed inconsistent understanding of the resident's needs, and some interventions were implemented but not documented in the care plan, leading to a deficiency in care planning.
A resident with a history of severe childhood abuse and a diagnosis of PTSD did not have their PTSD symptoms or triggers adequately assessed or documented in the care plan. While staff were aware of some triggers through verbal communication, this information was not formally included in the care plan or electronic medical record, contrary to facility policy requiring trauma-informed care planning.
Staff with beards, including the culinary director, food service consultant, and a dietary aide, were repeatedly observed in the kitchen preparing and handling food without wearing required beard coverings. This lapse in sanitary practice occurred during food preparation, serving, and storage activities, and was confirmed by staff interviews.
Dishwasher Rinse Cycle Failed to Reach Required Sanitizing Temperature
Penalty
Summary
The facility failed to ensure minimum dishwasher temperatures were attained during the rinse cycle for 1 of 1 dishwasher. During observation, the dishwasher wash cycle reached 153 degrees Fahrenheit and the final rinse cycle reached 150 degrees Fahrenheit, while the manufacturer sign posted next to the machine instructed that the final rinse cycle range should be 180-195 degrees Fahrenheit. The culinary director confirmed the dishwasher was a high temperature machine and stated the final rinse cycle must reach 180 degrees Fahrenheit, and also confirmed the low temperature and that the dishwasher company needed to be called for service. Dishmachine Temperature Log for 7/2026 showed rinse temperatures logged at less than 180 degrees Fahrenheit for lunch use on 7/3/26 and for dinner use on 7/2/26, 7/3/26, and 7/7/26, with no indications of temperature correction. The infection preventionist stated the dishwasher temperature was expected to be hot enough to prevent the spread of infectious materials, and the administrator stated the dishwasher was expected to sanitize dishes and that staff should stop using it and report it if it was not reaching the correct temperature. The sanitation policy revised 1/10/25 instructed that the dishwasher rinse temperature specification was 180 degrees Fahrenheit and that if temperatures were not reached, culinary staff were to stop using the machine immediately, contact their supervisor, and begin manually washing dishes.
Medication Refrigerator Temperatures Not Monitored Consistently
Penalty
Summary
The facility failed to keep medication refrigerators within the recommended temperature range for 1 of 2 medication refrigerators. During observation, the main medication storage room refrigerator read 42 degrees F, while the temperature log for July showed the last recorded reading was 39 degrees F. The log had no entries for July 1, 2, 3, 4, or 6, and staff were using food refrigerator temperature logs. The temperature log identified a safe range of 32 to 41 degrees F, and instructions directed staff to report any out-of-range temperature to the supervisor. The LPN verified that the July temperature had been recorded only one time. Review of prior months showed the same issue with incomplete monitoring: June had only four recorded temperatures with 26 days missing, May had no temperature readings available, and April had three recorded temperatures with 28 days missing. The refrigerator contained medications and biologicals including multiple residents’ insulins such as Lantus, NovoLog, Humalog, and Basaglar, as well as Trulicity, calcitonin spray, Evenity, Aplisol, Engerix B, and Comirnaty. The DON stated staff should check refrigerator temperatures daily, and an LPN later found the refrigerator temperature was about 50 degrees F and moved the medications to a different refrigerator. The consultant pharmacist reviewed the medications and identified varying time limits for use once the refrigerator exceeded the safe range, based on the last known temperature reading.
Failure to Use PPE During Wound Care and Replace Oxygen Tubing Timely
Penalty
Summary
The facility failed to ensure that all staff, including contracted wound care staff, wore appropriate PPE and performed hand hygiene during wound care for a resident with intact cognition, peripheral vascular disease, an abdominal wall ulceration, and MRSA. A contact precautions sign was posted on the resident’s door requiring hand hygiene, gloves, gown, and dedicated or disposable equipment. During observation, the facility LPN washed hands and donned gown and gloves, but contracted wound care staff entered the room without appropriate PPE, touched the resident’s bedding and items in the room, and later proceeded with wound care after being asked to put on gowns. During the wound care, the contracted staff performed care on the resident’s abdominal wound without changing gloves or performing hand hygiene when moving from dirty to clean tasks. One staff member released the abdominal fold, removed the old dressing, measured the wound, and applied a new dressing while another staff member reached into the wound cart with an ungloved, unwashed hand, opened a sterile package, and handed it to the physician. The physician then leaned over the resident’s bedding and obtained a wound sample. After leaving the room, the staff removed PPE and performed hand hygiene, then went to another resident’s room for wound care without placing gowns on despite the enhanced barrier precautions sign posted there. The facility also failed to change oxygen tubing timely for a resident with COPD, sleep apnea, oxygen therapy, and CPAP use. The resident stated the oxygen tubing had not been changed since admission and that the tubing in use had been provided by the resident because staff used it instead of obtaining one from supply. The tubing was observed without any label showing when it had last been changed, and staff could not confirm the last change because there was no order documenting weekly tubing changes. Facility staff stated oxygen tubing was expected to be changed weekly, but the resident’s orders did not include a weekly tubing change order.
Medications Left at Bedside Without SAM Assessment or Order
Penalty
Summary
The facility failed to complete a Self-Administration of Medication (SAM) assessment and obtain a physician order before medications were left at the bedside for one resident. The resident had a Brief Interview for Mental Health on admission that indicated moderate cognitive impairment and had diagnoses of urinary tract infection and chronic obstructive pulmonary disease. The electronic medical record did not contain a SAM assessment, orders to keep medications at bedside, or a care plan related to the resident’s ability to self-administer medications. Surveyors observed nystatin cream and refresh eye drops in a pink wash basin on the counter in the resident’s room on multiple occasions, and diclofenac cream was also later observed there. During interview, an LPN stated that a SAM assessment and orders were needed before medications could be left at bedside and that the assessment was usually completed about a week after admission. An RN stated the same, and the DON stated the expectation was that the SAM assessment would be completed prior to medications being left at bedside. Facility policy stated a SAM assessment would be performed at admission and orders obtained, if approved, prior to medications being left in the room, and the care plan would be updated to add the SAM assessment.
Failure to Follow Blood Sugar Orders
Penalty
Summary
The facility failed to ensure blood sugar orders were followed for a resident with chronic heart failure, recurrent right shoulder dislocation, type 2 diabetes mellitus with diabetic neuropathy, and hypertension. The resident’s physician order required blood sugar checks four times daily before meals and at bedtime, with instructions to contact hospice if the blood sugar was 450 or higher and to treat readings under 70 with juice and recheck in one hour. The resident’s care plan identified a risk for decline in medical condition related to diabetes mellitus and directed staff to administer medications and treatments per the medical doctor’s order. Review of the resident’s blood sugar records showed multiple low readings that were not rechecked within one hour as ordered, including readings of 62, 68, and 61 with follow-up checks occurring more than one hour later. The record also showed blood sugar readings of 500, 453, and 516, but progress notes did not identify hospice being called for the 500 and 453 readings as required by the order. During interviews, hospice and nursing staff stated they would expect the facility to follow the blood sugar orders, recheck low readings in one hour, and notify hospice when blood sugar was 450 or higher. The DON stated staff needed to follow orders as written and noted that low blood sugar could cause cognition changes, falls, confusion, and/or sedation.
Failure to Maintain Safe Water Temperatures and Provide Adequate Supervision for Transfers
Penalty
Summary
The facility failed to maintain safe hot water temperatures at point-of-use for all residents on the 200 hallway and the specialty care unit. Observations and temperature measurements revealed that hot water temperatures in resident rooms and common areas reached as high as 134 degrees Fahrenheit, significantly exceeding the recommended safe upper limit of 120 degrees Fahrenheit. Residents and staff reported that the water became very hot after running for a few minutes, and maintenance staff confirmed the malfunction of the blender valve responsible for regulating water temperature. Monthly water temperature logs showed repeated instances of temperatures above 120 degrees Fahrenheit, but these were not consistently identified or addressed by facility leadership. Additionally, the facility did not provide adequate supervision or follow care plans for residents requiring assistance with transfers and activities of daily living. Multiple residents with documented fall risks and care plans specifying the need for staff assistance and use of gait belts were observed or reported to be transferring themselves without staff help. Interviews with residents and staff indicated that some residents regularly performed transfers and dressing independently, despite care plans requiring assistance. Staff were not consistently aware of or following the prescribed level of assistance for these residents, and there was a lack of clear communication and adherence to care plans during shift handoffs. Furthermore, direct observations showed that staff did not always use required safety equipment, such as gait belts, during resident transfers. In one instance, a nursing assistant assisted a resident with a pivot transfer without using a gait belt, contrary to the resident's care plan and facility policy. Interviews with therapy and nursing staff confirmed that these residents were not approved for independent transfers and required at least standby or one-person assistance. Facility policies required regular assessment of fall risk and updating of care plans, but these were not consistently implemented in practice.
Medication Orders Lacking Required Indications
Penalty
Summary
The facility failed to ensure that medication orders for several residents included the required indications for use, as identified through interviews and document review. For three out of five residents reviewed, provider orders for multiple medications did not specify the medical reason or diagnosis for which the medication was prescribed. For example, one resident with a complex medical history including dementia, agitation, delusional disorders, hypothyroidism, and other conditions, had orders for medications such as Miralax, furosemide, hydrocortisone cream, magnesium oxide, docusate, Senna S, and lisinopril without documented indications. Additionally, the resident's care plan did not address certain diagnoses or problems related to some of these medications. Another resident with severe cognitive impairment and multiple diagnoses, including stroke, diabetes, hypertension, and dementia with psychotic disturbance, had orders for melatonin and ondansetron without documented indications. The facility's policy required that all medication orders include the name, dosage, route, frequency, and diagnosis for usage, and that nurses verify the completeness and accuracy of transcribed orders. However, the lack of documented indications for these medications constituted a failure to comply with both facility policy and regulatory requirements.
Failure to Provide Resident with Required Personal Funds Statement
Penalty
Summary
The facility failed to provide a quarterly financial statement to a resident who had requested to receive statements for her personal trust account. The resident, who was identified as cognitively intact on her annual Minimum Data Set (MDS), reported that she was not receiving statements and was unsure of her account balance. Interviews with the business office manager and the administrator confirmed that the statements were being sent to the resident's former home address instead of being provided directly to her as required. The corporate associate vice president of revenue cycle management also verified that the statements should have been sent to the resident. The facility's trust fund policy specified that residents or their financially responsible persons are to receive quarterly statements detailing deposits, withdrawals, and interest earned.
Failure to Update Care Plan with Resident-Specific Fall Prevention Interventions
Penalty
Summary
The facility failed to update and individualize the care plan with resident-specific fall prevention interventions for a resident who experienced multiple falls. The resident, who was cognitively intact and had diagnoses including osteomyelitis, chronic respiratory failure, congestive heart failure, diabetes type II, repeated falls, muscle weakness, and unsteadiness, had a care plan that was not consistently revised after each fall event. Although the care plan was updated to change the transfer assistance level after a fall that resulted in a clavicle fracture, there was no evidence that additional or modified fall prevention interventions were implemented following five subsequent falls. Event reports and nursing notes documented multiple unwitnessed and witnessed falls, many of which occurred during self-transfers in the resident's room or bathroom. Interviews with the resident revealed that they often transferred themselves between bed, wheelchair, and recliner, and sometimes did not use the call light or non-skid footwear. Staff interviews indicated inconsistent understanding and communication regarding the resident's transfer status and the need for assistance, with some staff believing the resident was independent and others acknowledging the need for standby or one-person assist. The care plan did not reflect interventions such as increased rounding, toileting assistance, or environmental modifications that were discussed or implemented informally by staff. The facility's policies required that fall risk and appropriate interventions be included in the care plan and updated after each fall review. However, both the RN and DON confirmed that while some interventions were carried out, they were not documented in the care plan. The care plan also did not address the resident's self-transfer behaviors under the behavior section, despite repeated incidents. This lack of comprehensive and updated documentation in the care plan contributed to the deficiency identified by surveyors.
Failure to Assess and Document PTSD Triggers in Trauma-Informed Care
Penalty
Summary
The facility failed to adequately assess and document post-traumatic stress disorder (PTSD) symptoms and triggers for a resident with a significant trauma history. The resident had a documented history of physical abuse as a minor, including being tied up, gagged, and burned, and was diagnosed with PTSD, among other psychiatric and neurocognitive disorders. While the care plan acknowledged the trauma history and included a general intervention stating the resident was fine with both male and female caregivers, it did not specify PTSD symptoms or triggers, nor did it include interventions to address them. The electronic medical record lacked a PTSD-specific assessment, and other care plan sections related to behavior and mood did not reference PTSD triggers or symptoms. Interviews with facility staff revealed that knowledge of the resident's PTSD triggers, such as not closing doors or making the resident feel confined, was communicated verbally rather than documented in the care plan. Staff members were aware of the resident's trauma history and some specific triggers through word of mouth, but this information was not consistently or formally included in the care plan. The facility's policy required the development of a trauma-informed care plan when a history of trauma was identified, but this was not fully implemented for the resident in question.
Failure to Ensure Use of Beard Coverings in Kitchen
Penalty
Summary
The facility failed to ensure that staff in the kitchen wore required beard coverings while preparing, handling, and serving food. Multiple observations over several days documented that the food service consultant, culinary director, and a dietary aide, all with beards, were present in various kitchen areas—including food preparation, storage, and dishwashing—without beard coverings. These staff members were observed performing tasks such as wrapping silverware, placing desserts into containers, removing and temping chicken, and assisting with pureeing food, all without the required beard coverings. Interviews with the culinary director and food service consultant confirmed that staff had not been wearing beard coverings in the kitchen during the observed period. The culinary director acknowledged that beard coverings were required for sanitary and infection prevention reasons and explained that the lapse occurred after mandatory mask wearing was lifted, and the transition back to beard coverings had not been implemented. The deficiency had the potential to impact all residents receiving nourishment from the facility's dietary services.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 24 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Moose Lake
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cura Of Sandstone | 22.2 mi | ★★★★★ | 13 | 1 |
| Interfaith Care Center | 22.9 mi | ★★★★★ | 11 | 0 |
| The North Shore Estates Llc | 33.6 mi | ★★★★★ | 19 | 0 |
| Dove Healthcare - Superior | 35.9 mi | ★★★★★ | 15 | 0 |
| Twin Ports Health Services | 36.4 mi | ★★★★★ | 4 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Moose Lake Village.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.