Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Buffalo Lake Health Care Center during CMS and state inspections, most recent first.
Infection control was not maintained during meal service when staff served food from the steam table, handled multi-use menus, and moved between residents without observed hand hygiene or glove use. A dietary aide, another aide, and a cook all touched plates, serving utensils, and menus while dishing and serving food, and uncovered food remained on the steam table throughout service. Staff stated this was how meal service had always been done and that they did not wash hands between tasks unless touching food directly.
Infection control staff illness tracking failure: The facility did not maintain a formal process to track employee illnesses or determine when staff could return to work based on symptoms. A dietary aide left work with vomiting, later returned to work, and the record did not show when symptoms resolved. The DM said staff illness information was not consistently communicated to the IP, and the IP said there was no ongoing system to record and monitor staff illnesses.
A facility failed to ensure the IP had adequate oversight of the infection control program, including resident surveillance, antibiotic stewardship, and staff illness tracking. Infection logs lacked documentation showing whether antibiotics remained indicated or effective for residents treated for UTI, and employee illness records did not consistently show symptom resolution before return to work. Nursing staff without IP training were assigned to maintain surveillance logs, and antibiotic timeout assessments were not consistently completed.
Failure to timely notify family and the MD of resident changes in condition. A resident with multiple chronic conditions developed pink-tinged urine, dark foul-smelling and black stools, pallor, decreased appetite, sleepiness, nausea, and abdominal pain before being sent for further evaluation and later hospitalized, but the designated family member was not contacted when the bloody urine and possible GI bleeding first appeared. The report also notes failures involving another resident with ongoing hyperglycemia and bloody stools and a third resident with a prior choking episode.
A resident with Parkinson’s disease developed new mental health diagnoses after admission, including anxiety, dementia with anxiety, and major depressive disorder with psychotic symptoms, but the record showed no notification to the county SMHA and no Level II PASARR completion. The resident was receiving antipsychotic, antianxiety, and antidepressant meds, had worsening distress and anxiety, and later psychiatric notes described mood fluctuations, social isolation, and frequent requests for medication changes.
A resident with diabetes and multiple comorbidities had repeated severe hyperglycemia, low BP, thirst, fatigue, pallor, and dark bloody stools, but staff did not timely document or communicate all symptoms to the MD or consistently monitor overnight after insulin orders. The resident was not sent for a face-to-face medical evaluation until she was declining and a glucometer reading could not be obtained; in the ER she was found to have hemorrhagic shock, GI bleeding, low oxygen, and an associated MI.
Therapeutic Diet Not Followed During Meal Service: A resident with dysphagia and dementia was served food that did not match the ordered texture, and he began coughing, turned red, and expelled chunks of hamburger during the meal. An LPN later found him with a purple/maroon face and coughing, and the chart also showed a prior choking episode with no timely MD notification. Staff reported that dietary aides were dishing food from the steam table, containers were not labeled by texture, and the resident’s care plan did not fully reflect ST swallowing instructions.
Failure to complete antibiotic time-out assessments for 2 residents. The infection surveillance logs listed antibiotic use for UTI, but the charting did not show a 48- to 72-hour review of symptoms, lab results, or medication effectiveness to support continued use. One resident had persistent urinary and systemic symptoms with later culture results showing mixed low-growth bacteria, and another resident had UTI treatment documented after a fall and hospital transfer, but progress notes did not show an assessment that the antibiotics were effective.
Infection Control Lapses During Meal Service
Penalty
Summary
The facility failed to maintain appropriate infection control technique during meal service in the dining room. During observation of the noon meal service, a dietary aide served food from the hot holding steam table, placed a plate in front of a resident, and rested a hand on the back of the resident’s wheelchair. The aide then handled a multi-use menu, handed it to another resident, returned to the steam table, and dished up food without being observed washing hands, using hand sanitizer, or wearing gloves. Another aide approached the steam table, reached over the first aide, touched a plate surface, used the serving scoops to dish food, served a resident, handled the multi-use menu, took an order, and returned to dish another plate, also without observed hand hygiene between tasks. A cook was also observed picking up the multi-use menu, handing it to a resident, taking the resident’s order, and then returning to the steam table to dish another plate without washing or sanitizing hands. The dietary aide later picked up a stack of condiment cups and used a thumb inside the cup to separate one from the stack before filling it with coleslaw and serving it to a resident. On a later observation, a cook served food from the steam table in the hallway between two dining areas, with lids removed from the food containers, and walked away from the steam table to give food to residents. The steam table also had uncovered pastries on the bottom shelf about 5 inches above the floor, and all food on the steam table and pastries remained uncovered throughout the food service. Staff interviewed stated this was how meal service had always been done and that they did not wash hands between tasks or wear gloves unless touching food directly.
Infection Control Staff Illness Tracking Failure
Penalty
Summary
The facility failed to ensure employee illnesses were tracked to determine when an employee could return to work after illness, based on symptoms, for 1 of 3 sampled staff, a dietary aide (DA)-A. Review of the dietary absence report log from May 2025 through November 2025 showed employee name, department, and illnesses reported, but the logs were not accurately completed to ensure all necessary information was monitored. In the December 2025 employee illness log, DA-A was documented as leaving work early with vomiting on 12/11/25, and the timesheet showed DA-A worked from 7:10 a.m. to 9:30 a.m. that day. DA-A returned to work on 12/13/25 and worked two shifts that day, but the record did not show when or if symptoms resolved before the return. The dietary manager stated employees were expected to stay home until symptoms improved, but there was no process to ensure employees were symptom-free unless they reported that themselves or had received treatment outside of work. She also stated she did not communicate staff illnesses to the IP, and there was no formal communication process to ensure the IP knew when staff were sick or when they could return to work. The interim administrator, who was also the IP, stated the facility had no formal process to ensure all staff illnesses were recorded on an ongoing basis, department heads did not consistently communicate staff illnesses, and there was a lack of monitoring to determine when an employee was appropriate to return to work.
Infection Control Oversight and Antibiotic Stewardship Deficiencies
Penalty
Summary
The facility failed to ensure the infection preventionist had appropriate oversight of the infection control program, including resident infection surveillance and antibiotic stewardship. Monthly infection summary reports from May 2025 through November 2025 included resident name, infection date, body system affected, symptom resolution date, infection, medication, source, and whether criteria were met, but the logs did not show whether the antibiotic met criteria for continued use. The infection preventionist acknowledged that the surveillance logs were not monitored consistently and that the logs contained discrepancies regarding the indication for antibiotic use. For one resident, the October 2025 infection log showed cefuroxime 250 mg by mouth twice daily for 5 days for UTI beginning 10/17/25, followed by cephalexin 500 mg by mouth twice daily for 7 days beginning 10/24/25 for UTI symptoms. Progress notes documented attempts to obtain urine, transfer to the hospital for evaluation, return with a UTI diagnosis, ongoing complaints of dizziness, chest fullness, inability to urinate, and family concern that the resident was not recovering well. The record lacked evidence from 10/18/25 through 10/21/25 and again from 10/25/25 through 10/28/25 of an assessment showing whether the antibiotic was effective. The hospital note later identified that the urine culture showed less than 10,000 colony-forming units per mL of mixed bacterial growth and that a true bladder infection was unlikely. For another resident, the August and September 2025 infection logs documented cephalexin 500 mg three times daily for UTI and later cefdinir 300 mg twice daily for 5 days for UTI, but the log lacked an end date for one antibiotic and did not show whether a urine culture was obtained. Progress notes showed the resident was sent to the hospital after a fall, returned with a UTI diagnosis and antibiotic orders, and later was readmitted with a fracture and new antibiotic orders. The progress notes on multiple days stated the resident had a UTI and was on antibiotics, but they lacked documentation of an assessment to determine whether the antibiotic was effective. Employee surveillance was also incomplete. The dietary absence report logs from May 2025 through November 2025 listed employee name, department, and illnesses reported, but did not accurately capture all necessary information. One employee illness log showed an employee left work with vomiting, and the timesheet showed the employee returned to work two days later, but the log did not state when or whether symptoms resolved before the employee returned. The interim administrator stated that evening nursing staff without IP training or certification were assigned to update and maintain resident surveillance infection logs monthly, that antibiotic timeout assessments were expected within 48 to 72 hours, and that pharmacy reminders were not consistently followed. The infection control program was discussed at QAPI meetings, but there was no discussion identifying improvement of staff illness tracking or expectations for when employees could return to work.
Failure to Timely Notify Family and Physician of Resident Changes in Condition
Penalty
Summary
The facility failed to provide timely notification to the designated family member of a change in condition for a resident who had moderate cognitive impairment, required moderate assistance with ADLs, and used a wheelchair after transfer by ceiling sling lift. The resident had multiple diagnoses including kidney infection, osteomyelitis of the left foot, heart failure, diabetes, hypertension, MRSA, hydronephrosis, diabetic ulcer of the right foot, and COPD. Progress notes showed pink-tinged urine, then large dark foul-smelling stools, black stools that smelled like old blood, pallor, decreased appetite, sleepiness, nausea, and abdominal pain. The physician was faxed updates, and the resident was later sent for further evaluation and hospitalized, but the family was not contacted when the bloody urine and possible blood in the stool first appeared. The facility also failed to update the physician of additional signs and symptoms of physical decline for another resident with continued high blood sugar levels and bloody stools, and failed to timely notify the physician about a previous choking episode for a third resident. For the resident with the notification issue, staff documented the change in condition and provider updates, but interviews confirmed the family was not notified until transportation was being arranged for urgent evaluation, despite the facility policy requiring notification of the physician, family, and/or responsible person when a resident experienced a change in condition and documentation of the notification time and date in the medical record.
Failure to Notify SMHA After New Mental Illness Diagnoses
Penalty
Summary
The facility failed to notify the county designated State Mental Health Authority when a resident developed new-onset mental illness after admission. The resident’s March 2023 PASARR showed Parkinson’s disease and no current mental illness diagnosis, but the medical record later identified Parkinson’s disease with dyskinesia and fluctuations, depressive episodes, generalized anxiety disorder, dementia with anxiety, and major depressive disorder with severe psychotic symptoms. The record did not show any indication that the county SMHA had been notified after these new mental health diagnoses were identified. The resident’s quarterly MDS described the resident as cognitively alert with no behaviors, but also noted little interest or pleasure in doing things, feeling down, depressed, or hopeless from never to 1 day, and sometimes experiencing social isolation. The resident was receiving antipsychotic, antianxiety, and antidepressant medications, and the care plan addressed potential drug-related complications from Seroquel and anxiety symptoms. Progress notes documented escalating distress, requests for increased Xanax, Valium, and baclofen, initiation and later increase of Seroquel, and later psychiatric assessments describing progressive weakness, tremors, medication-related nausea, severe early morning pain, obsessive medication timing behaviors, sadness about missing family activities, frequent calls for medication changes, mood fluctuations, and anxiety that significantly affected daily functioning. Survey interview confirmed that a Level II PASARR had not been completed.
Failure to Monitor and Escalate High Blood Sugar and Bloody Stools
Penalty
Summary
The facility failed to appropriately assess, monitor, update the physician about additional signs and symptoms of physical decline, and intervene for a resident who had continued high blood sugar levels and bloody stools. The resident had a history of diabetes, psychotic disorder with hallucinations, major depression, hypertension, peripheral vascular disease, Alzheimer’s disease, insomnia, long-term aspirin use, low magnesium, low iron, and a history of stroke. She was on a diabetic diet and had physician orders for daily Lantus insulin, with instructions to cut the dose in half if she had not eaten and to call the physician if blood sugar was lower than 60 or greater than 400. The resident’s blood sugars repeatedly rose into the 400s, 500s, and higher, and staff documented multiple notifications to the physician with additional insulin orders. After one evening blood sugar of 391, staff were instructed to give Humalog, increase Lantus, and watch her closely overnight, but there was no indication staff monitored her blood sugars throughout the night or obtained other vital signs to identify a change in condition that warranted a face-to-face physician evaluation. The next morning, staff documented a blood sugar of 508 with low blood pressure of 91/44, and later blood sugars remained elevated at 493. Staff also documented that the resident was very thirsty, tired, pale, waxy, and not feeling well. The record also showed dark, loose, bloody stools were reported by staff, including black, tar-like stools and blood when wiping after toileting, but there was no documentation that all staff were aware of the bloody stools or that the physician was notified of them. The resident was not sent for medical evaluation until staff were unable to obtain a blood sugar reading and noted she was declining, pale, and waxy. In the emergency room, she was found to be pale with high blood sugars and very low blood pressure, and the physician identified hemorrhagic shock, GI bleeding, low oxygen, and an associated heart attack. The resident was placed on comfort care and returned to the facility, and the primary physician was updated.
Therapeutic Diet Not Followed During Meal Service
Penalty
Summary
The facility failed to ensure that one resident with dysphagia and dementia received the therapeutic diet ordered by the physician and documented in the care plan. The resident had a history of swallowing difficulty and a prior choking episode on ground turkey earlier in the year, after which staff questioned whether pureed meat was needed for safety. Speech therapy later recommended pureed meats with moisture, bite-size cut food, supervision at meals, upright positioning for oral intake, and use of safe swallowing strategies. The resident’s care plan identified an NDD3 diet with thin liquids and pureed meats, but it did not reflect the speech therapy instructions for cutting food into bite-size pieces and the other swallowing strategies. On the day of the incident, the resident was seated in the dining room eating when he began coughing, turned red, and was observed with food in his mouth. A nurse aide patted him on the back and told him to spit out the food, and he expelled chunks of hamburger. A medication aide summoned the charge nurse, who found the resident’s face purple/maroon and coughing, applied oxygen, and removed him from the dining area. The resident maintained an open airway, his color returned to normal, and he was alert and talking. The charge nurse documented that the resident did not receive the appropriate texture diet of pureed meat per his care plan. Survey findings also identified that the physician was not timely notified after the earlier choking episode, and the dining process did not follow the facility’s policy for serving therapeutic diets. Staff reported that food was dished from the steam table by dietary aides, even though the containers were not marked to identify contents or texture. The dietary aide who served the resident’s meal stated he was moving too fast, did not pay close attention, and thought the meat looked pureed from the top. The facility’s dining service policy stated the cook was to prepare food according to texture requirements and serve it using tray cards, but the resident received food that was not the ordered texture.
Failure to Document Antibiotic Time-Out and Continued Need
Penalty
Summary
The facility failed to complete a comprehensive assessment for continued antibiotic use for 2 of 3 sampled residents reviewed for antibiotic stewardship. The report states that the facility’s monthly infection summary logs from May 2025 through November 2025 listed resident name, infection date, body system affected, date symptoms resolved, infection, medication, source of infection, and whether criteria were met, but the logs did not show evidence that the antibiotics were reviewed for continued need or effectiveness after they were started. For one resident, the record showed treatment for a UTI with cefuroxime 250 mg by mouth twice daily for 5 days beginning 10/17/25, followed by cephalexin 500 mg by mouth twice daily for 7 days beginning 10/24/25. Progress notes documented symptoms including dizziness, fatigue, lightheadedness, low blood pressure, chest pain, inability to urinate, chest fullness, and edema of the lower legs. The resident was sent to the hospital, returned with a UTI diagnosis, and later returned with a new antibiotic order after family and staff reported that symptoms had not improved. The record lacked documentation from 10/18/25 to 10/21/25 and from 10/25/25 to 10/28/25 showing an assessment of whether the antibiotic was effective. The hospital note later identified urine culture growth of less than 10,000 colony-forming units per milliliter of mixed bacteria, and stated a true bladder infection was unlikely. For the second resident, the record showed cephalexin 500 mg three times daily for UTI beginning 8/31/25 and later cefdinir 300 mg twice daily for 5 days beginning 9/05/25 for acute cystitis with hematuria. Progress notes documented a fall, transfer to the hospital, return with evidence of UTI, elevated WBC, and later readmission for a fracture with a new antibiotic order. Notes on 9/06/25, 9/07/25, and 9/08/25 stated the resident had a UTI and was currently on antibiotics, but the progress notes did not include an assessment showing whether the antibiotic was effective. During interview, the interim administrator acknowledged that evening nursing staff without IP training or certification updated the surveillance logs, that antibiotic timeout assessments were to be completed within 48 to 72 hours, and that the logs were not monitored consistently and contained discrepancies regarding the indication for antibiotic use.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Buffalo Lake
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Harmony River Living Center | 15.4 mi | ★★★★★ | 8 | 0 |
| Olivia Restorative Care Center | 18.2 mi | ★★★★★ | 2 | 0 |
| Franklin Restorative Care Center | 19.6 mi | ★★★★★ | 13 | 0 |
| Glenfields Living With Care | 23.4 mi | ★★★★★ | 0 | 0 |
| Bayside Manor Llc | 23.5 mi | ★★★★★ | 13 | 1 |
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