Cycle 1
Health 2025-05-15 · Fire 2025-05-15
6 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Moose Lake, MN
Moose Lake Village
4-star overall rating with 4-star inspections with 6 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
710 South Kenwood Avenue, Moose Lake, MN
(218) 351-9400
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
60
Certified beds
Average residents
53
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1987-07-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.72
Registered nurse staffing · state 1.06 · national 0.68
LPN hours / resident day
0.57
Licensed practical nurse staffing · state 0.62 · national 0.87
Aide hours / resident day
3.48
Nurse aide staffing · state 2.56 · national 2.35
Total nurse hours
4.78
All reported nurse hours · state 4.23 · national 3.89
Licensed hours
1.30
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
4.19
Weekend nurse staffing · state 3.68 · national 3.43
Weekend RN hours
0.26
Weekend registered nurse coverage · state 0.68 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.81
CMS adjusted RN staffing hours
Adjusted total hours
5.34
CMS adjusted total nurse staffing hours
Case-mix index
1.22
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
46%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,822
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
47.51
Composite VBP score used to determine payment impact.
Payment multiplier
1.0011
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
3.01
Performance 6.93% · Measure score 3.01 · Achievement 3.01 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
3.35
Baseline 38.03% · Performance 50.00% · Measure score 3.35 · Achievement 3.35 · Improvement 0
Adjusted total nurse staffing
7.89
Baseline 4.83 hours · Performance 5.32 hours · Measure score 7.89 · Achievement 7.89 · Improvement 4.70
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.5% |
10.72%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 51 · Observed rate 13.73% · Lower 95% interval 7.81% |
| Discharge to community | 51.41% |
50.57%
0.8 pts better
|
No Different than the National Rate · Eligible stays 43 · Observed rate 51.16% · Lower 95% interval 38.27% |
| Medicare spending per beneficiary | 0.87 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 98.33% |
95.27%
3.1 pts better
|
Numerator 59 · Denominator 60 |
| Falls with major injury | 1.67% |
0.77%
0.9 pts worse
|
Numerator 1 · Denominator 60 |
| Discharge self-care score | 41.3% |
53.69%
12.4 pts worse
|
Numerator 19 · Denominator 46 |
| Discharge mobility score | 47.83% |
50.94%
3.1 pts worse
|
Numerator 22 · Denominator 46 |
| Pressure ulcers or injuries, new or worsened | 1.67% |
2.29%
0.6 pts better
|
Numerator 1 · Denominator 60 · Adjusted rate 2.01% |
| Healthcare-associated infections requiring hospitalization | 6.93% |
7.12%
0.2 pts better
|
No Different than the National Rate · Eligible stays 26 · Observed rate 3.85% · Lower 95% interval 3.2% |
| Staff COVID-19 vaccination coverage | 7.44% |
8.2%
0.8 pts worse
|
Numerator 9 · Denominator 121 |
| Staff flu vaccination coverage | 36.36% |
42%
5.6 pts worse
|
Numerator 56 · Denominator 154 |
| Discharge function score | 54.35% |
56.45%
2.1 pts worse
|
Numerator 25 · Denominator 46 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 40 · Denominator 40 |
| Resident COVID-19 vaccinations up to date | 48.48% |
25.2%
23.3 pts better
|
Numerator 16 · Denominator 33 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.0% |
97.3%
1.3 pts worse
|
93.4%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.8% · Q2 97.8% · Q3 92.9% · Q4 95.3% · 4Q avg 96.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.0% |
96.1%
1.9 pts better
|
95.5%
2.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
3.9%
3.9 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
4.3%
4.3 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 0.7% |
4.1%
3.4 pts better
|
5.4%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.8% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 9.3% |
12.4%
3.1 pts better
|
19.6%
10.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 11.1% · Q3 12.1% · Q4 8.1% · 4Q avg 9.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 31.0% |
17.5%
13.5 pts worse
|
16.7%
14.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.6% · Q2 27.6% · Q3 32.1% · 4Q avg 31.0% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 25.5% |
22.5%
3 pts worse
|
16.3%
9.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 25.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 20.3% |
18.6%
1.7 pts worse
|
14.9%
5.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 22.6% · Q3 33.3% · Q4 21.2% · 4Q avg 20.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
2.3%
2 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.4% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.1% |
2.6%
1.5 pts better
|
1.7%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.2% · Q3 0.0% · Q4 2.3% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.1% |
24.8%
3.7 pts better
|
19.8%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.5% · Q2 23.8% · Q3 12.1% · Q4 24.3% · 4Q avg 21.1% |
| Percentage of long-stay residents with pressure ulcers | 11.6% |
5.4%
6.2 pts worse
|
5.1%
6.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.3% · Q2 5.2% · Q3 21.1% · Q4 13.7% · 4Q avg 11.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.1% |
88.6%
9.5 pts better
|
81.7%
16.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.4% · Q2 98.5% · Q3 97.1% · Q4 98.5% · 4Q avg 98.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 15.7% |
14.0%
1.7 pts worse
|
12.0%
3.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 15.7% · Observed 16.0% · Expected 11.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.2% |
1.9%
0.7 pts better
|
1.6%
0.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.3% · Q4 2.7% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 92.8% |
82.7%
10.1 pts better
|
79.7%
13.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 92.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 9.1% |
23.1%
14 pts better
|
23.9%
14.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.1% · Observed 8.0% · Expected 20.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-14 · Fire 2024-03-14
2 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-05-12 · Fire 2023-05-12
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
18 fire-safety deficiencies
Top issue: Smoke (7 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-05-15
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-07-16
F · Potential for more than minimal harm
2025-05-15
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-07-16
F · Potential for more than minimal harm
2025-05-15
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-07-16
F · Potential for more than minimal harm
2025-05-15
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-07-16
F · Potential for more than minimal harm
2025-05-15
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-07-16
F · Potential for more than minimal harm
2025-05-15
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-07-16
E · Potential for more than minimal harm
2025-05-15
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-07-16
E · Potential for more than minimal harm
2025-05-15
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2025-07-16
D · Potential for more than minimal harm
2025-05-15
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2025-07-16
D · Potential for more than minimal harm
2025-05-15
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-07-16
F · Potential for more than minimal harm
2024-03-14
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-04-17
F · Potential for more than minimal harm
2024-03-14
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-03-12
F · Potential for more than minimal harm
2023-05-12
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2023-05-15
F · Potential for more than minimal harm
2023-05-12
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-05-11
F · Potential for more than minimal harm
2023-05-12
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-05-15
F · Potential for more than minimal harm
2023-05-12
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-05-11
F · Potential for more than minimal harm
2023-05-12
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2023-06-01
F · Potential for more than minimal harm
2023-05-12
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2023-05-31
F · Potential for more than minimal harm
2023-05-12
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-07-12
E · Potential for more than minimal harm
2023-05-12
K226 · Egress Deficiencies
Fire Safety
Have horizontal exits used in accordance with safety requirements.
Corrected 2023-07-12
E · Potential for more than minimal harm
2023-05-12
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2023-07-12
E · Potential for more than minimal harm
2023-05-12
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-05-15
E · Potential for more than minimal harm
2023-05-12
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-06-08
E · Potential for more than minimal harm
2023-05-12
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-05-15
E · Potential for more than minimal harm
2023-05-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-05-12
E · Potential for more than minimal harm
2023-05-12
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-07-12
E · Potential for more than minimal harm
2023-05-12
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-06-30
E · Potential for more than minimal harm
2023-05-12
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2023-05-11
E · Potential for more than minimal harm
2023-05-12
K927 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Corrected 2023-07-12
C · Minimal harm
2023-05-12
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-06-13
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-05-15
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-06-27
E · Potential for more than minimal harm
2025-05-15
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-06-27
D · Potential for more than minimal harm
2025-05-15
F568 · Resident Rights Deficiencies
Health
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Corrected 2025-06-27
D · Potential for more than minimal harm
2025-05-15
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-06-27
D · Potential for more than minimal harm
2025-05-15
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2025-06-27
D · Potential for more than minimal harm
2025-05-15
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-06-27
D · Potential for more than minimal harm
2024-03-14
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2024-04-17
D · Potential for more than minimal harm
2024-03-14
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-04-17
D · Potential for more than minimal harm
2023-11-09
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-01-09
D · Potential for more than minimal harm
2023-05-12
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-07-12
D · Potential for more than minimal harm
2023-05-12
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-07-12
D · Potential for more than minimal harm
2023-05-12
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-07-12
D · Potential for more than minimal harm
2023-05-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-08-11
Penalties and ownership
What sits behind the stars
Ownership
Cassia
5% Or Greater Direct Ownership Interest · Organization
Cassia
Operational/Managerial Control · Organization
Dahl, Robert
Corporate Director · Individual
Kern, Matthew
Corporate Director · Individual
Mackay, Marshall
Corporate Officer · Individual
Nye, Gerald
Corporate Officer · Individual
Parks, Charles
Corporate Officer · Individual
Ramsdale, Scott
Corporate Officer · Individual
Smith, Shawna
W-2 Managing Employee · Individual
Stadtherr, Seelochani
Corporate Director · Individual
Wilkerson, Gary
Corporate Officer · Individual
Youngquist, Kathryn
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Sandstone Health Care Center
Sandstone, MN
2-star overall rating with 2-star inspections with 10 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Interfaith Care Center
Carlton, MN
5-star overall rating with 4-star inspections with 5 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#3
The North Shore Estates Llc
Duluth, MN
3-star overall rating with 3-star inspections with 6 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
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