Inspection Reports for
The Oaks at Byron Center

R 325.1922 Admission and retention of residents: one resident tuberculosis screening could not be located or found in the record.

R 325.1923 Employee's health: two employees’ tuberculosis screenings could not be located in the record.

R 325.1975 Laundry and linen requirements: clean linen closets contained medical supplies and crafts posing cross contamination risk; soiled linen closets contained metal chairs, tray table, and brooms posing cross contamination risk.

R 325.1976 Kitchen and dietary: dishwasher sanitization records had missing or blank entries for multiple dates in March, April, and May 2025.

R 325.1976 Kitchen and dietary: multiple food items were found unlabeled without open dates in assisted living, memory care, and main kitchen areas.

R 325.1979 General maintenance and storage: hazardous and toxic chemicals were stored in unlocked cabinets accessible to residents with impaired cognition or function.

F 0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Resident #9's code status documentation was inconsistent, with the physician order not updated to reflect the recent change to DNR.

F 0880 Provide and implement an infection prevention and control program. The facility failed to provide personal protective equipment (PPE) such as gowns and eye protection in soiled utility rooms and resident rooms on transmission-based precautions. Staff did not consistently don required PPE when providing care to residents on enhanced barrier precautions, including Residents #3, #5, #29, #53, #67, and #74. Nebulizer equipment for Resident #10 was not cleaned or stored properly, posing a risk of cross contamination. The Water Management Plan was not tailored to the facility and lacked documentation of control measures.

F 0561 Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice: Resident #8's request to be up by 8:00 AM for breakfast was not consistently accommodated, causing frustration and potential harm.

F 0623 Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights: Resident #15 was not provided a written notice of transfer to hospital.

F 0625 Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave: Resident #15 was not notified of the facility bed hold policy upon hospital transfer.

F 0693 Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube: Facility failed to discard expired tube feeding supplements, increasing risk of food borne illness.

F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards: Food service staff failed to wash hands properly, dish machine did not reach required sanitizing temperatures, and kitchen areas had accumulations of debris and sticky residues.

F 0880 Provide and implement an infection prevention and control program: Facility failed to maintain infection control surveillance, provide infection prevention education, and document infection control audits over the past year.

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations: Residents #8 and #10 were not screened or offered pneumococcal or influenza vaccines as required; immunization records were missing.

F 0887 Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status: Resident #25 was not offered COVID-19 immunization in 2023; immunization records were missing.

F 0919 Make sure that a working call system is available in each resident's bathroom and bathing area: Call lights for Residents #35 and #5 were not functioning properly, resulting in delayed assistance and a fall for Resident #5.

Failure to notify a physician of missed medication doses and changed medication administration time, risking resident health.

Failure to assess a resident's oxygen flow rate properly, resulting in oxygen being set incorrectly.

Failure to label and date oxygen tubing in 3 residents, increasing risk of infection and improper care.

F 0803 Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident: Resident #25 was served a meal containing his known food allergen green/red peppers, resulting in emotional upset and potential for harm.

F 0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured: Resident #25's care plan did not identify his food allergies or approaches to avoid allergen exposure; Resident #40 had no care plan or nursing orders for monitoring anticoagulant medication side effects.

F 0695 Provide safe and appropriate respiratory care for a resident when needed: Resident R27's oxygen tubing was not dated or changed as required, oxygen flow was set incorrectly at 1.5 LPM instead of 2 LPM, and the oxygen concentrator filter was covered with lint and dust, risking infection and inadequate oxygen delivery.

F 0760 Ensure that residents are free from significant medication errors: Resident #307 received two doses of lasix 40 mg on 9/20/23 due to incorrect order entry, resulting in a higher than ordered dose without provider notification or proper order verification.