Buffalo Lake Health Care Center

In the surveyor’s words

From the most serious findings on record at Buffalo Lake Health Care Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Jan 8, 2026

  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. […]

• No harm, potential for more than minimal, widespreadF880Jan 8, 2026

  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. […]

• No harm, potential for more than minimal, widespreadF882Jan 8, 2026

  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. […]

• No harm, potential for more than minimal, patternF580Jan 8, 2026

  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). […]

• No harm, potential for more than minimal, isolatedF645Jan 8, 2026

  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. […]