Buffalo Valley Lutheran Villag

In the surveyor’s words

From the most serious findings on record at Buffalo Valley Lutheran Villag, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Sep 1, 2023

  Based on observation and staff interview, it was determined that the facility failed to store and prepare food in a safe and sanitary environment in the facility's main kitchen. Findings include: Observation of the facility's main kitchen on August 29, 2023, at 10:05 AM with Employee 4, chef, revealed the following: A foot pedal garbage inside the entrance of the kitchen to the preparation area was covered in dried debris and dried food splatter on the exterior of the can. The exterior door and sides of an upright ice cream freezer contained dried food and food splatter. The backsplash of the stove was observed covered with dried food splatter, which extended to the walls behind the stove area, the sides of the stove, and the lower shelf of a preparation table to the left of the stove. […]

• No harm, potential for more than minimal, widespreadF812Oct 8, 2021

  Based on observation, staff interview, and review of facility documents, it was determined that the facility failed to store and serve food in a safe and sanitary manner and implement measures to assure equipment used for food storage and sanitization of preparation/serving supplies were maintained in a manner to prevent the potential spread of food borne illness in the facility's main kitchen and on one of five nursing units ([NAME]). Findings include: Initial tour of the facility's main kitchen on October 5, 2021, at 9:15 AM with Employee 3, dining director, revealed the following: An upright cooler contained multiple food items stored on trays of a rolling rack placed in the cooler. […]

• No harm, potential for more than minimal, patternF756Aug 27, 2026

  Based on a review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to ensure that the resident's attending physician appropriately addressed pharmacy recommendations for three of five residents reviewed for unnecessary medications (Residents 17, 40, and 69). Findings include: The facility policy entitled Drug Regimen Review, last reviewed without changes April 10, 2026, revealed that a licensed pharmacist will review the resident drug regimen including the resident chart at least once a month. The licensed pharmacist will report in writing any irregularities to the attending physician, the facility's medical director, and the Director of Nursing to be acted upon. […]

• No harm, potential for more than minimal, patternF689Sep 26, 2025

  Based on a review of select facility policies and procedures, observation, clinical record review, and staff interview, it was determined that the facility failed to appropriately implement a safety intervention to prevent potential resident injury for one of eight residents reviewed for accidents (Resident 6); and failed to ensure an environment free from potential accident hazards for residents with elopement behaviors for one of one resident reviewed for elopement concerns (Resident 4). Findings include: The State Operations Manual, Appendix PP, Guidance to Surveyors for Long Term Care Facilities, requires facilities to provide an environment that is free from accident hazards over which the facility has control, which includes implementing interventions to reduce hazards and risks. […]

• No harm, potential for more than minimal, patternF726Sep 26, 2025

  Based on review of facility documentation and staff interview, it was determined that the facility failed to ensure that nursing staff possessed the appropriate competencies and skill sets related to the care and assessment of residents with enteral tube feeding, who utilize a lift, catheter care, medication administration, transmission based precautions, intravenous therapy, and dressing changes for four of four employees reviewed for competencies (Employees 2, 3, 4, and 5). Findings include: A review of the facility documentation revealed that the facility had a total of 87 residents receiving medications, 25 residents that utilize lifts, five residents with indwelling urinary catheters (insertion of a tube into the bladder to remove urine), 12 residents with dressing changes, 23… […]