Buffalo Crossings Healthcare & Rehabilitation Cen

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure residents' preference for shower was honored for 1 (Resident #19) of 3 residents reviewed for activities of daily living. Findings include: Review of Resident #19's admission record showed the resident was admitted on [DATE] with diagnoses including muscle weakness, unsteady on feet, chronic respiratory failure, chronic obstructive pulmonary disease, congestive heart failure, and gout. During an interview on 7/14/2025 at 10:23 AM, Resident #19 stated, I have not received anything I asked for. Tissues, shower, hair wash. I have been asking for it since 7 AM this morning [7/14/2025]. I have wounds on legs that need to be covered or changed. I don't want to wait for a dressing change to take a shower. They can just cover my legs if dressing gets wet, then change it. During an interview on 7/15/2025 at 11:54 AM, Resident #19 stated, I did not get my shower yesterday [7/14/2025]. I did get washed up. That is not a shower and my hair washed. My son is…

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 develop and implement a baseline care plan within 48 hours of a resident's admission for 1 (Resident #148) of 3 residents reviewed for skin conditions. Findings include: During an observation on 7/14/2025 at 11:44 AM, Resident #148 was sitting in a wheelchair in his room. There was a foam dressing on his right lower leg dated 7/11. Review of Resident #148's admission record showed the resident was admitted on [DATE] with diagnoses including lobar pneumonia, acute respiratory failure, hypocalcemia, hypo-osmolality and hyponatremia, hypocalcemia, [NAME] syndrome, hypothyroidism, depression, atopic dermatitis, hyperlipidemia, essential hypertension, atherosclerosis of aorta, obstructive sleep apnea, pulmonary hypertension, emphysema, and cirrhosis of liver. Review of Resident #148's physician order dated 7/10/2025 read, Cleanse skin tear to the back of L [Left] calf with NS [normal saline], cover with adaptic [sic] and foam dressing Q3…

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 record review, the facility failed to ensure physician- ordered parameters for administering hypertension medications were followed for 1 (Resident #40) of 5 residents reviewed for unnecessary medications and failed to ensure wound dressing was changed as per physician order for 1 (Resident #148) of 3 residents reviewed for skin conditions. Findings include: 1) Review of Resident #40’s admission record showed the resident’s diagnoses included essential (primary) hypertension, hypertensive heart and chronic kidney disease without heart failure, with stage 1 through stage 4 chronic kidney disease, unspecified atrial fibrillation, and hyperlipidemia. Review of Resident #40's physician order dated 6/11/2025 read, “Hydralazine HCl Oral Tablet 10 MG [milligrams] (Hydralazine HCl), Give 1 tablet by mouth every 8 hours as needed for HTN [hypertension], Give if SBP [Systolic Blood Pressure] > [greater than]160 mmHg [millimeters of mercury].” Review of Resident #40’s Weights and Vital Signs Summary from 6/1/2025 through 6/30/2025 showed on 6/12/2025 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.

Based on record review and interview, facility failed to ensure residents received restorative services for 1 (Resident#4) of 3 residents reviewed for range of motion. Findings include: During an interview on 7/14/2025 at 10:11 AM, Resident #4 stated, My main concern at this time is therapy services. I have not seen therapy, and I do not know what the plan is. Review of Resident #4's physician order dated 6/6/2025 read, Pt [patient]. D/C [discharge] from PT [Physical Therapy] services with RNP [Restorative Nursing Program] in place. Review of Resident #4's physician order dated 6/26/2025 read, Admit to RNP for AROM [Active Range of Motion]-omnicycle BUE [Bilateral Upper Extremities] and BLE [Bilateral Lower Extremities] prosthetic leg donned, transfers, donning/doffing prosthetic leg 3x [3 times] week for 60 days as per therapy recommendations. Review of Resident #4's PT Discharge Summary for service dates of 4/9/2025 through 6/6/2025 read, D/C Reason: Maximum Potential Achieved, referred to RNP. STG [Short Term Goal] #4.2- Met on 06/06/2025: Patient will increase LLE [Left Lower…

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 ensure residents received respiratory services consistent with professional standards of practice for 2 (Residents #19 and #147) of 4 residents reviewed for oxygen therapy. Findings include: 1) Review of Resident #19's admission record showed the resident was admitted on [DATE] with diagnoses including muscle weakness, unsteady on feet, chronic respiratory failure, chronic obstructive pulmonary disease (COPD), congestive heart failure, and gout. During an observation on 7/14/2025 at 10:29 AM, Resident #19's nebulizer mask was on top of the bedside table not bagged. During an observation on 7/15/2025 at 11:54 AM, Resident #19's nebulizer mask was on top of the bedside table not bagged (Photographic evidence obtained). Review of Resident #19's physician order dated 6/27/2025 read, Ipratropium-Albuterol Solution 0.5-2.5 (3) mg/ml (milligram/milliliter) 3 ml inhale orally four times a day for COPD please schedule 0800 [8:00 AM], 1400 [2:00…

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 ensure food items were dated, labeled and stored in a sealed container in nutrition rooms on 3 residential halls, Prairie, [NAME] and Meadows, of 4 residential halls.Findings include: During an observation on 7/14/2025 at 10:14 AM, there was one undated and unlabeled package of 12 waffles stored in the refrigerator in the nutrition room on the Prairie Hall. During an observation on 7/14/2025 at 10:17 AM, there was one undated and unlabeled Styrofoam cup of liquid stored on the counter in the nutrition room on the [NAME] Hall. During an observation on 7/14/2025 at 10:22 AM, there was one undated and unlabeled package of 12 waffles stored in the refrigerator in the nutrition room on the Meadows Hall. During an interview on 7/14/2025 at 10:14 AM, the Certified Dietary Manager confirmed the packages of waffles on the Prairie Hall and the Meadows hall should be dated and labeled when taken out of original containers and placed in nutrition…

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 record review and interview, the facility failed to ensure resident records were complete and accurate for 1 (Resident #62) of 3 residents reviewed for medication administration, 2 (Residents #8 and #148) of 3 residents reviewed for skin conditions, and 1 (Resident #117) of 3 residents reviewed for nutrition. Findings include: 1) Review of Resident #62’s physician order dated 6/4/2025 read, “Antianxiety side effects: 0= No side effects observed 1= Drowsiness 2= Slurred Speech 3= Dizziness 4= Nausea 5= Aggressive/Impulsive Behavior, every shift for Monitoring document applicable code.” Review of Resident #62’s physician order dated 6/4/2025 read, “Please document appropriate number that best matches behavior observed: 1= No behaviors noted 2= Kicking/Hitting 3= Grabbing/Pushing 4= Sexually Inappropriate 5= Yelling/Screaming/Cursing 6= Refusing Care (ADL [Activities of Daily Living], Meds [medications] etc ) 7= Wandering/Pacing 8= Exit Seeking 9= Crying 10= Wringing Hands 11= Withdrawn 12= Loss of appetite 13= Other (document in Progress Notes) every shift for psychoactive…

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 record review and interview, the facility failed to ensure resident representative was informed of a change in the resident's status for 1 of 3 residents reviewed for change in status, Resident #1. Findings include: Review of Resident #1's admission record revealed the resident was most recently admitted on [DATE] with diagnoses including periprosthetic fracture around internal prosthetic left hip joint, anxiety, depression, and left artificial hip joint. Review of Resident #1's care plan dated 6/3/2024 read, Focus: Surgical/Incision: Staples- I have surgical incision with staples. (D/C [discontinued] 6/10) . Interventions . Observe surgical staples for infection, drainage, increased swelling, warmth and surgical site reopening. Review of Resident #1's care plan dated 6/4/2024 read, Focus: I have impaired cognitive function or impaired thought processes r/t [related to] impaired decision making, Long term memory loss, Short term memory loss. Review of Resident #1's progress notes dated 6/17/2024 read,…

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 record review, the facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected the resident's status for 1 (Resident #106) of 1 resident reviewed for hospitalization and 1 (Resident #80) of 5 reviewed for hospice services. Findings include: 1. Review of the Discharge-Return Not Anticipated Minimum Data Set assessment dated [DATE] documented Resident #106 was discharged to a Short-Term General Hospital (acute hospital, IPPS (Inpatient Prospective Payment System)). Review of the progress note dated 1/18/2024 for Resident #106 read, Resident discharged to ALF (Assisted Living Facility) at 1215 [12:15 PM]. Questions answered and confirmed understanding. Education provided. During an interview on 4/16/2024 at 9:10 AM, the Minimum Data Set (MDS) Coordinator stated, For [Resident #106 Name] the Minimum Data Set Section A should have read ALF (Assisted Living Facility) instead of hospital. For [Resident #80's name] MDS Section O, hospice question should have said Yes…

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 record review and interview, the facility failed to ensure that resident records were complete and accurate for 2 of 5 residents sampled for medication administration record review. (Resident #92 and #262) Findings include: 1. Review of the admission record for Resident #92 documented the resident was admitted with a diagnosis of Hypertension, Acute on Chronic Systolic Heart Failure, Atrial Fibrillation, Ischemic Cardiomyopathy, an Automatic implantable Cardiac Defibrillator, and Atherosclerosis of Coronary Artery Bypass Graft. Review of the Medication Administration Record (MAR) for Resident #92 for 4/13/2024 and 4/14/2024, the MAR documents that the scheduled 9 AM medication administration for Amiodarone HCL Tablet 200 mg (milligrams), Ascorbic Acid 500mg, Aspirin 81mg tablet, Multiple Vitamin Tablet, Potassium Chloride 20meq tablet, Zinc Capsule 220mg, Acidophilus Capsule 100mg, Eliquis 2.5mg tablet, Gabapentin 100mg capsule, and Protein Oral Liquid 30ml, and Metoprolol 50mg tablet was refused (Chart…

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 record review, the facility failed to prevent the possible spread of infection by not performing hand hygiene during medication administration in 2 out of 6 observations for medication administration and clean blood pressure cuff monitors between residents in 2 out of 6 observations. Finding include: During an observation of medication administration for Resident #92 on 4/14/2024 at 9:20 AM Staff B, Registered Nurse (RN) was observed entering the resident's room to check the resident's blood pressure with an automatic wrist cuff without performing hand hygiene. Staff B, RN returned the automatic blood pressure monitoring wrist cuff to the medication cart without cleaning the equipment after use. During an observation of medication administration for Resident #92 on 4/14/2024 at 9:32 AM, Staff B, RN started preparing the medications for Resident #92 without performing hand hygiene. Staff B, RN locked the medication cart, entered the resident's room without performing hand hygiene before medication administration. Staff B, RN exited the resident's…

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 maintain accurate and complete medical records for central venous catheter dressing changes and documentation of pain scale for 3 of 51 residents sampled, Residents #71, #240, and #139. Findings include: 1. Review of Resident #71's admission records revealed the resident was admitted to the facility on [DATE] with diagnoses including infection of right lower extremity amputation stump, chronic obstructive pulmonary disease, hyperlipidemia (high cholesterol), personal history of transient ischemic attack (a brief stroke like attack) and cerebral infraction (a stroke) without residual deficits, peripheral vascular disease (a disorder that causes narrowing, blockage or spasms in the blood vessels), essential hypertension (high blood pressure), acquired absence of right leg above knee, unspecific atrial fibrillation (an irregular heartbeat), pleural effusion (fluid around the lungs due to poor pumping of the heart), infective myositis…

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.