Inspection Reports for
The Oaks at Byron Center
2280 Byron View Dr SW, Byron Center, MI, 49315
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
6.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
21% worse than Michigan average
Michigan average: 5.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Occupancy
Latest occupancy rate
51% occupied
Based on a May 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Routine
Deficiencies: 3
Date: Dec 3, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to medical record accuracy, infection prevention and control, and facility safety measures.
Findings
The facility failed to maintain accurate medical records for a resident, resulting in inconsistent code status documentation. Infection control deficiencies included lack of proper PPE availability and use, improper cleaning and storage of respiratory equipment, and an inadequate Water Management Plan not tailored to the facility.
Deficiencies (3)
F 0842: The facility failed to maintain complete and accurate medical records for Resident #9, resulting in inconsistent documentation of advance directives and potential non-adherence to resident wishes.
F 0880: The facility failed to provide and implement an effective infection prevention and control program, including lack of PPE in soiled utility rooms and resident rooms, improper PPE use by staff, and inadequate cleaning and storage of nebulizer equipment for Resident #10.
F 0880: The facility's Water Management Plan was not tailored to the facility, referenced another location, and lacked documentation of annual review and control limit monitoring.
Report Facts
Residents sampled for medical records: 24
Residents affected by medical record deficiency: 1
Residents affected by infection control deficiencies: 6
Observation dates: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DON B | Director of Nursing | Reported on Resident #9's code status documentation discrepancy |
| NHA A | Nursing Home Administrator | Reported expectation that code status paperwork should match |
| RN L | Registered Nurse | Observed not wearing eye protection PPE while caring for residents on droplet precautions |
| LPN D | Licensed Practical Nurse | Observed not wearing gown during wound care for Resident #5 |
| MDS-RN BB | Registered Nurse | Observed not donning PPE prior to care for Resident #67 |
| CNA CC | Certified Nursing Assistant | Confirmed not donning gown prior to care for Resident #67 |
| CNA KK | Certified Nursing Assistant | Observed not donning gown prior to care for Resident #67 |
Inspection Report
Renewal
Census: 21
Capacity: 41
Deficiencies: 6
Date: May 21, 2025
Visit Reason
The inspection was conducted as a Renewal Licensing Study to evaluate compliance with licensing requirements and to determine if the facility meets the standards for license renewal.
Findings
The facility was found to be in non-compliance with multiple rules including tuberculosis screening for residents and employees, improper storage of clean and soiled linens, incomplete dishwasher sanitization records, unlabeled food items, and unsafe storage of hazardous chemicals. Violations were established for each of these findings.
Deficiencies (6)
One resident's tuberculosis screening record could not be located, violating admission and retention requirements.
Two employees' tuberculosis screening records were missing, violating employee health screening requirements.
Clean and soiled linen storage rooms were improperly used for storage of non-linen items, posing cross contamination risks.
Dishwasher sanitization records had missing or blank entries for multiple dates, preventing verification of cleanliness and sanitization.
Multiple food items were found unlabeled without appropriate open dates in various facility areas, risking food safety.
Hazardous and toxic chemicals were stored in unlocked cabinets accessible to residents, posing ingestion and injury risks.
Report Facts
Capacity: 41
Number of residents observed/interviewed: 21
Number of staff interviewed/observed: 11
Inspection Report
Routine
Deficiencies: 9
Date: Oct 17, 2024
Visit Reason
The inspection was a routine survey to assess compliance with regulatory requirements related to resident care, infection control, food safety, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to accommodate resident choice for morning care, failure to provide timely transfer and bed hold notices, expired feeding tube supplements, food safety violations, inadequate infection prevention and control program, incomplete vaccination documentation and offerings, and malfunctioning resident call light systems.
Deficiencies (9)
F 0561: The facility failed to accommodate resident choice regarding morning schedule for Resident #8, resulting in frustration and potential inability to meet well-being.
F 0623: The facility failed to provide a written notice of transfer for Resident #15, risking uninformed residents or representatives.
F 0625: The facility failed to notify Resident #15 or representative in writing of the bed hold policy upon hospital transfer.
F 0693: The facility failed to discard expired tube feeding supplements, increasing risk of contaminated foods and foodborne illness.
F 0812: The facility failed to prepare food in accordance with professional standards, including improper hand hygiene and unclean equipment, risking foodborne illness.
F 0880: The facility failed to implement an effective infection prevention and control program, lacking surveillance, education, and audits.
F 0883: The facility failed to ensure residents #8 and #10 were screened and offered pneumococcal and influenza vaccinations as required.
F 0887: The facility failed to ensure Resident #25 was offered COVID-19 immunization, increasing risk of infection and complications.
F 0919: The facility failed to ensure operable call light systems for Residents #35 and #5, resulting in delayed response and a fall incident.
Report Facts
Expired feeding tube supplements: 35
Dish machine wash temperature: 148
Dish machine rinse temperature: 175
Call light malfunction incidents: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DON B | Director of Nursing | Educated staff on Resident #8's morning care request; interviewed regarding care delays. |
| LPN N | Licensed Practical Nurse | Reported challenges in getting Resident #8 up at desired time. |
| NHA A | Nursing Home Administrator | Reported missing transfer and bed hold notices for Resident #15; addressed call light grievances. |
| Scheduling Coordinator G | Observed discarding expired feeding supplements. | |
| FSD F | Food Service Director | Interviewed regarding food safety violations and dish machine issues. |
| IP CC | Infection Preventionist | Reported lack of infection control education and surveillance; vaccination record gaps. |
| CRS AA | Clinical Regional Support | Assisted with infection preventionist role and education verification. |
| DPO E | Director of Plant Operations | Responsible for call light maintenance; reported issues with call light system. |
| CNA C | Certified Nursing Assistant | Reported call light malfunction for Resident #35. |
| CNA GG | Certified Nursing Assistant | Reported call light malfunction and fall incident for Resident #5. |
Inspection Report
Renewal
Capacity: 41
Deficiencies: 0
Date: Mar 26, 2024
Visit Reason
The inspection was conducted as a renewal inspection to review licensing activity for the past year and determine compliance with public health code and administrative rules regulating home for the aged facilities.
Findings
The facility was found to be in compliance with all applicable rules and statutes. Renewal of the license is recommended.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Sep 21, 2023
Visit Reason
The inspection was conducted to investigate complaints related to medication administration errors, oxygen delivery issues, and failure to follow professional standards of care in the nursing facility.
Complaint Details
The investigation was triggered by complaints regarding missed medication doses, improper oxygen flow rate assessments, and unlabeled oxygen tubing. The complaint was substantiated with findings affecting Residents #10, #307, and #27.
Findings
The facility failed to notify a physician of missed medication doses and changed medication administration times, failed to assess residents' oxygen flow rates properly, and failed to label and date oxygen tubing for three residents, resulting in potential worsening of health conditions.
Deficiencies (1)
F 0658: The facility failed to notify a physician of missed medication doses and changed medication administration times. The facility also failed to assess residents' oxygen flow rates and label and date oxygen tubing for three residents, risking potential health complications.
Report Facts
Medication doses not administered: 14
Oxygen flow rate: 1.5
Oxygen tubing date: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN T | Registered Nurse | Reported missing medications for Resident #10 and oxygen flow rate issues for Resident #27. |
| B | Director of Nursing (DON)/Infection Control Preventionist | Stated oxygen tubing should be changed monthly and nurses should check oxygen concentrators. |
| A | Nursing Home Administrator (NHA) | Noted staff corrected missing oxygen tubing date during survey. |
| LPN FF | Licensed Practical Nurse | Reported common missed doses of supplements and vitamins and responsibility of nurses to notify providers. |
| LPN R | Licensed Practical Nurse | Documented medication administration time change and omission without notifying provider for Resident #307. |
| Pharmacist I | Pharmacist | Reported medication refill issues and lack of facility contact for refills for Resident #10. |
Inspection Report
Deficiencies: 5
Date: Sep 21, 2023
Visit Reason
The inspection was conducted to evaluate compliance with regulatory standards related to care planning, medication administration, respiratory care, nutrition, and medication error prevention at The Oaks at Byron Center nursing home.
Findings
The facility failed to develop and implement complete care plans for residents, resulting in unmet nutritional needs and potential medication side effects. Medication errors occurred including missed doses and incorrect administration times. Oxygen management and tubing care were inadequate, posing infection risks. Food allergen exposure occurred due to staff unawareness. Overall, minimal harm or potential for harm was identified in several residents.
Deficiencies (5)
F 0656: The facility failed to develop and implement a person-centered care plan for 2 of 14 residents, resulting in unmet nutritional needs and potential unmet needs related to anticoagulant use.
F 0658: The facility failed to meet professional standards of quality by not notifying physicians of missed medication doses, failing to assess oxygen flow rates, and not labeling or dating oxygen tubing for 3 residents.
F 0695: The facility failed to provide appropriate oxygen management and tubing care for 1 resident, resulting in potential infection risk and harm.
F 0760: The facility failed to prevent a significant medication error in 1 resident who received a higher dose of furosemide than ordered due to incorrect order entry and lack of verification.
F 0803: The facility failed to ensure food provided met nutritional needs for 1 resident, resulting in ingestion of a known food allergen and potential for more than minimal harm.
Report Facts
Residents reviewed for care planning: 14
Residents affected: 2
Residents affected: 3
Medication doses missed: 9
Medication administration times: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN FF | Licensed Practical Nurse | Assisted Resident #25 with eating and reported food allergen incident |
| DON B | Director of Nursing | Confirmed care plan and protocol issues for Residents #25 and #40, and oxygen management deficiencies |
| MDS-RN CC | MDS Registered Nurse | Responsible for creating care plans and reported missed anticoagulant care plan for Resident #40 |
| LPN Q | Licensed Practical Nurse | Reported medication error for Resident #307 and notified MDS-RN CC |
| RN T | Registered Nurse | Administered two doses of lasix to Resident #307 and reported oxygen management issues for Resident #27 |
| LPN R | Licensed Practical Nurse | Documented medication administration and reported failure to contact provider for order changes for Resident #307 |
| Pharmacist I | Pharmacist | Reported medication refill issues for Resident #10 |
| Pharmacist L | Pharmacist | Reported lack of pharmacist questioning of duplicate lasix orders for Resident #307 |
| CENA AA | Certified Nursing Assistant | Assisted Resident #25 with eating and was unaware of food allergies |
| CENA MM | Certified Nursing Assistant | Provided care to Resident #25 and reported no observed allergic reaction |
| Nurse Practitioner K | Nurse Practitioner | Approved admission orders for Resident #307 and reported order discrepancies |
| LPN GG | Licensed Practical Nurse | Entered admission medication orders for Resident #307 and reported order entry errors |
Inspection Report
Renewal
Census: 19
Capacity: 41
Deficiencies: 1
Date: Mar 22, 2023
Visit Reason
The inspection was conducted as a renewal licensing study to assess compliance with regulatory requirements for The Oaks at Byron Center facility.
Findings
The facility was found to be in non-compliance with the rule requiring evidence of tuberculosis screening within 12 months before admission for residents. Two of six resident files reviewed lacked this documentation, resulting in a violation being established.
Deficiencies (1)
Two of six resident files did not have evidence of tuberculosis screening performed within 12 months before admission.
Report Facts
Residents interviewed/observed: 19
Staff interviewed/observed: 11
Resident files reviewed: 6
Capacity: 41
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kathy Corbin | Authorized Representative | Named as authorized representative of the facility |
| Elise Van De Steenoven | Administrator/Licensee Designee | Named as administrator/licensee designee of the facility |
| Julie Viviano | Licensing Staff | Author of the renewal licensing study report |
Inspection Report
Original Licensing
Capacity: 41
Deficiencies: 0
Date: Oct 7, 2020
Visit Reason
The inspection was conducted as an original licensing study to determine compliance with applicable licensing statutes and administrative rules for The Oaks at Byron Center facility.
Findings
The facility was found to be in substantial compliance with home for the aged public health code and administrative rules. The report recommends issuance of a temporary license with a maximum capacity of 41.
Report Facts
Capacity: 41
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kathy Corbin | Authorized Representative | Named as authorized representative of the facility |
| Brian Loos | Administrator | Named as administrator of the facility |
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