A list of the most recent deficiencies for Moose Lake Village. 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? |
|---|---|---|---|---|
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-11-09 | 2024-01-09 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-05-12 | 2023-08-11 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-05-12 | 2023-07-12 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-05-12 | 2023-07-12 | 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 | 2023-05-12 | 2023-07-12 | N |
| Have horizontal exits used in accordance with safety requirements. | Fire Safety | 2023-05-11 | 2023-07-12 | N |
| Install proper backup exit lighting. | Fire Safety | 2023-05-11 | 2023-07-12 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-05-11 | 2023-07-12 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-05-11 | 2023-07-12 | N |
| Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2023-05-11 | 2023-07-12 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-05-11 | 2023-06-30 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-05-11 | 2023-06-13 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-05-11 | 2023-06-08 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-05-11 | 2023-06-01 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-05-11 | 2023-05-31 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-05-11 | 2023-05-15 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-05-11 | 2023-05-15 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2023-05-11 | 2023-05-15 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-05-11 | 2023-05-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-05-11 | 2023-05-12 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-05-11 | 2023-05-11 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-05-11 | 2023-05-11 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2023-05-11 | 2023-05-11 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-01-05 | 2022-02-07 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-01-05 | 2022-02-07 | N |
| Implement emergency and standby power systems. | Fire Safety | 2022-01-05 | 2022-02-07 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-01-04 | 2022-01-20 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-01-04 | 2022-01-20 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-01-04 | 2022-01-07 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-12-01 | 2022-01-06 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-12-01 | 2022-01-06 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-03-08 | 2021-03-25 | Y |
| Observe each nurse aide's job performance and give regular training. | Health | 2020-09-17 | 2020-11-05 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2020-09-17 | 2020-11-05 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-09-17 | 2020-11-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-09-17 | 2020-11-05 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2020-09-16 | 2020-11-05 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2020-09-16 | 2020-09-22 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2020-09-16 | 2020-09-22 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2020-09-16 | 2020-09-22 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2020-09-16 | 2020-09-21 | N |
