Buffalo Lake Health Care Center

Based on observation and interview, the facility failed to ensure appropriate infection control technique was maintained during 1 of 1 meal service. This had the potential to affect all 42 residents. Findings include: Observation on 1/5/26 at 12:25 p.m., in dining room during noon meal service identified dietary aid (DA)-A serving food from the hot holding steam table in the dining room. After dishing up the food and passing it to the resident, she placed the plate in front of the resident while resting her hand on the back of the resident's wheelchair. DA-A reached for a multi-use menu sitting in the center of the table, handed it to another resident and asked her what her food choices were. She returned to the steam table, picked up a plate, and used the serving utensils to dish up the food. DA-A was not observed to wash her hands, use hand sanitizer, or wear gloves. While DA-A was standing at the steam table dishing food, another aide, DA-B approached and picked up a plate. DA-B reached over DA-A and started dishing up another resident's food. He picked up a plate touching the…

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 interview and document review, the facility failed to ensure employee illnesses were tracked to identify when employee would be able to return to work after an illness, dependent upon their symptoms for 1 of 3 sampled staff (dietary aide) (DA)-A. This had the potential to affect all 41 residents in the facility. In addition, the facility failed to ensure a comprehensive ongoing infection control surveillance log to adequately track all staff illnesses and failed to update their infection control policies, annually. Findings include: Review of Dietary Absence Report log from May 2025 to November 2025 identified employee name, department and illnesses reported. However, the facility did not accurately complete the logs to ensure all necessary information was monitored. December 2025 employee illness log identified; DA-A was noted to have left early from work with symptoms of vomiting on 12/11/25. Review of DA-A timesheet identified that DA-A had worked on 12/11/25 from 7:10 a.m. to 09:30 a.m., for a total of 2.33 hours. DA-A returned to work on 12/13/25 and worked 11:05 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.

Based on interview and document review, the facility failed to ensure 1 of 1 infection preventionist (IP) had appropriate oversight of the infection control (IC) program to ensure thorough infection control and antibiotic stewardship program. This had the potential to affect all 42 residents in the facility.Findings include: Review of Monthly Infection Summary reports from May 2025 to November 2025 identified the columns for resident's name, infection date, body system affected, date symptoms resolved, infection, medication, source of the infection and if the criteria was met. However, the log lacked evidence that the antibiotic met criteria for continuation of use. R19Review of October 2025 infection log identified that R19 was to take cefuroxime (antibiotic) 250 milligrams (mg) by mouth twice a day for 5 days related to urinary tract infection (UTI) with a start date of 10/17/25 and was to end on 10/22/25. The organism was listed as Escherichia coli (E. coli) (a type of bacteria found in the intestines of humans and animals leading to diarrhea, vomiting, and fever) had met…

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 interview and document review the facility failed to provide timely notification to the designated family member of a change in condition for 1 of 1 resident (R47) with a change of condition requiring hospitalization, failed to update the physician of additional signs and symptoms of physical decline for 1 of 1 resident R45, who had continued high blood sugar levels and bloody stools, and timely notify the physician to a previous choking episode for 1 of 1 resident R7. Refer also to F684 and F808.Findings include: R47's 12/23/25-Significant Change Minimum Data Set (MDS) assessment identified she had moderate cognitive impairment and required moderate assistance with activities of daily living (ADLs). She was transferred via ceiling sling lift and utilized a wheelchair for mobility. R47 had diagnosis including a kidney infection, bone infection of her left foot, heart failure, diabetes, high blood pressure, Methicillin-resistant Staphylococcus Aureus (MRSA) (bacterial infection resistant to several common antibiotics), cognitive impairment, hydronephrosis (swelling of one or…

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 interview and document review, the facility failed to notify the county (designated State Mental Health Authority (SMHA) when 1 of 12 (R17) sampled residents had new on-set of mental illness since admission.Findings include: R17's, March 2023 Preadmission Screening Results (PASAR) had a diagnosis of Parkinson's disease and did not have a current diagnosis of a mental illness. R17's, undated, current medical dx sheet, identified R17 had a diagnosis of Parkinson with dyskinesia with fluctuations 4/16/24 and depressive episodes on 3/23/25. R17 received a new diagnosis of generalized anxiety disorder on 3/25/25, dementia with anxiety on 9/16/25, and major depressive disorders with severe psychotic symptoms on 9/24/25. R17s medical record lacked any indication that the county SMHA had been notified since the new onset of R1's mental illnesses. R17's, accepted 11/04/25 at 3:05 a.m., quarterly Minimum Data Set (MDS) identified R17 was cognitively alert and had no behaviors. R17 had little interest or pleasure in doing things, felt down, depressed or hopeless never to 1 day, and…

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 appropriately assess, monitor, update the physician of additional signs and symptoms of physical decline, and intervene for 1 of 1 sampled resident (R45) who had continued high blood sugar levels and bloody stools, and intervene when immediate medical evaluation warranted a face-to-face by a physician. Findings include: R45's [DATE], hospital discharge summary identified R45 had been sent to the emergency room (ER) for concerns of high blood sugar. At the ER, R45's family reported R45 had been passing dark/bloody stools since yesterday as well. An occult stool test was administered and was positive for blood. Upon arrival and during treatment, R45 presented to the ER as pale in color, with high blood sugars and very low blood pressure. ER evaluation by the medical doctor revealed evidence of hemorrhagic shock (life-threatening condition caused by significant blood loss, leading to inadequate blood flow and oxygen delivery to vital organs), GI…

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 observations, interview, and document review, the facility failed to ensure 1 of 1 resident (R7) had received the appropriate therapeutic diet as ordered by the physician, timely notify the physician of a previous choking episode, and follow policy and procedure by having only cooks dish up food from the serving line to serve to residents in order to ensure diets were accurately given as ordered to each resident. Findings include: Review of the 12/25/25, facility reported incident to the State Agency identified R7 had been seated at a table in the dining room. Nursing assistant (NA)-A observed R7 coughing and turning red. NA-A approached R7 and patted him on the back and directed him to spit the food out of his mouth. R7 was able to cough up the food, and he spit a piece of hamburger out and told staff he was okay. NA-A reported R7 had spit out chunks of hamburger. Medication Aid (TMA)-A summons the charge nurse licensed practical nurse (LPN)-B to the dining room. LPN-B arrived in the dining room and noted R7's face to be purple/maroon in color and was coughing. His oxygen…

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 interview and document review, the facility failed to complete a comprehensive assessment for continued use of antibiotics for 2 of 3 sampled residents (R19 and R31) reviewed for antibiotic stewardship.Findings include: Review of the current, undated, Centers for Disease Control (CDC): The Core Elements of Antibiotic Stewardship for Nursing Homes, Appendix A: Policy and Practice Actions to Improve Antibiotic Use, located at https://www.cdc.gov/antibiotic-use/core-elements/pdfs/core-elements-antibiotic-stewardship-appendix-a-508.pdf, identified facilities should evaluate the clinical signs and symptoms when a resident is first suspected of having an infection. Once the resident is placed on an antibiotic, they should be comprehensively reviewed within 48-72 hours after starting the medication to ensure they have been prescribed an effective medication. This is accomplished by reviewing the residents' current symptoms and any laboratory results to identify medication effectiveness. The CDC identifies this process as an antibiotic time-out [ATO]. Review of Monthly Infection…

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 allegations of abuse were reported immediately, within two hours, to the State Agency (SA) for 1 of 3 residents (R1) reviewed for allegations of abuse. R1's significant change Minimum Data Set (MDS) dated [DATE] indicated R1 had impaired cognition, and exhibited physical and verbal behaviors directed towards others daily that significantly interfered with R1's care. On 12/20/23 at 2:00 p.m. a Facility Reported Incident (FRI) submitted to the SA indicated nursing assistant (NA)-A had threatened to hit R1. On 12/28/23 at 12:10 p.m., registered nurse (RN)-A stated she was the charge nurse on 12/19/23. At approximately 10:30 p.m. on 12/19/23, NA-B told RN-A she had observed NA-A place her hands on R1 shoulders while speaking harshly to R1. RN-A could not remember what the exact words were reported to her. RN-A reported the incident to the director of nursing (DON) via text at approximately 10:45 p.m. on 12/19/23. On 12/28/23 at 1:03 p.m., the DON…

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 interview and document review, the facility failed to notify a provider of a drop in blood pressure for 1 of 1 residents (R4) reviewed for orthostatic blood pressure (a measure of blood pressure before and after a change in position). Findings include: R4's face sheet printed 12/20/23, noted diagnoses included hypertension and type 2 diabetes mellitus. R4's signed physician's orders dated 12/6/23, included an order to check orthostatic blood pressure (blood pressure checked first when lying, then sitting, then standing) every four weeks. The order failed to provide instructions for updating the physician. Review of R4's orthostatic blood pressure results 10/2023-12/2023 were as follows: - 10/8/23 lying 154/89, sitting 147/54 - 11/5/23 sitting 167/74, standing 94/48 - 12/3/23 lying 138/65, sitting 151/112 R4's nurse notes for 10/2023 thru 12/20/23 failed to note changes in R4's orthostatic blood pressures or action taken as a result. On 12/20/23 at 9:23 a.m., R4's primary provider stated she did not recall being notified of the change in R4's blood pressure on 11/5/23, if…

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 confidentiality of health conditions for 1of 1 residents (R42) who was reviewed for right to privacy. Findings include: R42's admission MinimumData Set (MDS) dated [DATE], identified resident as having intact cognition and frequent incontinence of bowel and bladder. R42's order summary report dated 12/20/23, indicated resident was taking Vancomycin (an antibiotic medication) for enterocolitis (inflammation of the inner lining of the small intestine and colon) due to clostridium Difficile (C. diff- an infection in the colon). R42's care plan dated 12/18/23 indicated the potential for complications r/t (C.diff) and instructed staff contact precautions were in place due to C. diff infection. During observations 12/18/23 at 2:33 p.m., 12/19/23 at 9:24 a.m., and 12/20/23 at 8:56 a.m., a cart with personal protective (PPE) supplies was present in the hall outside R42's room door and signage was hung on the outside of R42's door. The…

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 the resident or their representative a written bed hold policy at the time of hospital transfer for 2 of 2 residents (R24 and R40) who was reviewed for hospitalization. Findings include: R24's significant change Minimum Data Set (MDS) dated [DATE], indicated R24 had moderately impaired cognition. R24's progress notes indicated R24 was hospitalized on [DATE] and returned to the facility on [DATE]. R24 was re-hospitalized on [DATE] and returned to the facility on [DATE]. R24's medical record lacked evidence a bed hold was provided at the time of transfer for either hospitalization. R40's MDS dated [DATE], indicated R40 had moderately impaired cognition. R40's progress notes indicated R40 was hospitalized on [DATE] and returned to the facility on [DATE]. R40's medical record lacked evidence a bed hold was provided at the time of transfer for hospitalization. During an interview on 12/20/23 at 9:40 a.m., the director of nursing (DON) expected…

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 3 of 5 residents (R26, R31 and R40) reviewed for immunizations were offered and/or provided the pneumococcal vaccine series as recommended by the Centers for Disease Control (CDC) to help reduce the risk of associated infection(s). Findings include: A CDC Pneumococcal Vaccine Timing for Adults feature, dated 3/15/2023, identified various tables when each (or all) of the pneumococcal vaccinations should be obtained. This identified when an adult over [AGE] years old had received the complete series (i.e., PPSV23 and PCV13; see below) then the patient and provider may choose to administer Pneumococcal 20-valent Conjugate Vaccine (PCV20) for patients who had received Pneumococcal 13-valent Conjugate Vaccine (PCV13) at any age and Pneumococcal Polysaccharide Vaccine 23 (PPSV23) at or after [AGE] years old. R26's face sheet, dated 12/20/23, indicated he was [AGE] years old. The immunization record, dated 12/20/23, indicated he received a PPSV23 on…

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.