Above average — CMS composite of the measures below.
The next survey window likely opens around November 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 The Oaks At Byron Center during CMS and state inspections, most recent first.
Infection control failures were observed across the facility, including missing PPE in rooms under droplet precautions and EBP, staff entering resident rooms without the required gown and gloves, and a nurse wearing only eyeglasses and a surgical mask instead of eye protection. A resident’s nebulizer mask and parts were left exposed and visibly soiled over multiple observations, and the Water Management Plan was not tailored to the facility and lacked documented review, logs, and control limits.
A resident with Alzheimer’s disease and unspecified dementia had conflicting code status documentation in the chart. The DNR form and EMR banner showed DNR, but the physician order listed FULL CODE CPR. The DON stated the resident had changed code status the prior week and the order was not updated, and the NHA said all code status paperwork should match so advance directive wishes may be followed.
The facility failed to meet food safety standards, with a food service employee not following proper handwashing procedures and unsanitary conditions observed in the kitchen. The dishwashing machine was operating below required temperatures, and expired supplements were found in the supply room.
The facility failed to maintain an effective infection prevention and control program due to inconsistent leadership and inadequate documentation. The newly hired Infection Preventionist (IP) CC and Clinical Regional Support (CRS) AA reported that multiple staff members had covered the role over the past year without providing documented infection prevention education. IP CC did not track residents with possible infection symptoms and failed to document infection control audits, contributing to the deficiency.
A resident's preference to be up by 8:00 AM for breakfast was not consistently accommodated by the facility, leading to frustration. Despite being cognitively intact and having a care plan indicating this preference, the resident often remained in bed past the desired time. Staff interviews revealed challenges in meeting this request due to workload, and the DON did not explore further interventions to address the issue.
A facility failed to provide a written notice of transfer for a resident with cognitive impairment who was hospitalized for chest pain and shortness of breath. The notice, which should have included details such as the reason for transfer and appeal rights, was not completed due to oversight by the nursing staff.
A facility failed to provide a written bed hold notice to a resident's guardian upon the resident's transfer to a hospital. The resident, who had cognitive impairments, was discharged to the emergency room due to chest pain and shortness of breath. The Nursing Home Administrator confirmed the absence of the required documentation in the resident's chart.
The facility failed to discard expired tube feeding supplements, with 35 containers of Jevity found past their expiration date. Scheduling Coordinator G was discarding some expired products and noted that the facility sometimes accumulates expired items due to a lack of residents needing them. This oversight increased the risk of contaminated foods and foodborne illness for residents prescribed these supplements.
The facility failed to ensure proper screening and administration of pneumococcal and influenza vaccinations for two residents. One resident, admitted with muscle weakness, lacked a pneumococcal immunization record and was due for a vaccine. Another resident, needing personal care assistance, had no influenza immunization record for 2023. Staffing changes affected the infection control program, and the facility's policy on immunization was not effectively implemented.
A resident with end-stage renal disease was not offered a COVID-19 immunization in 2023, as required by the facility's policy. The last recorded immunization was in 2022, and the facility lacked documentation for the current year. The Infection Preventionist cited staff changes as a reason for the oversight, and the Nursing Home Administrator confirmed the absence of immunization records.
The facility failed to maintain operable call light systems for two residents, leading to potential delays in response. One resident reported intermittent issues with her call light, confirmed by a CNA, while another resident experienced a fall due to a non-functioning call light. The Director of Plant Operations noted a lack of formal work orders for repairs, and some residents may be confused about using the system.
Infection Control Failures With Missing PPE, Improper Equipment Storage, and Incomplete Water Management Plan
Penalty
Summary
The facility failed to provide an infection prevention and control program as evidenced by multiple observations of missing or incomplete PPE use, improper handling of respiratory equipment, and an inadequately maintained Water Management Plan. Surveyors observed that PPE was not available or not fully stocked in soiled utility rooms and outside resident rooms that were under transmission-based precautions or enhanced barrier precautions, and staff did not consistently don the required PPE before entering those rooms or providing care. For residents on droplet precautions, the PPE bins outside the rooms of residents with influenza A did not contain eye protection. An RN entered one room wearing only eyeglasses and a surgical mask, and staff confirmed that eye protection was not available in the room or on the unit. For residents on enhanced barrier precautions, staff entered rooms and provided high-contact care without wearing gowns as required. One CNA made a resident’s bed while wearing gloves but no gown, another nurse provided wound care without a gown, and staff entered another resident’s room to assist with toileting without donning gown and gloves. In another room on enhanced barrier precautions, there was no cart with PPE available outside the door, and staff again entered without the required gown and gloves. The report also documented that Resident #10’s nebulizer mask and accessory pieces were left exposed on the bedside table and later on paper towels next to the sink over multiple observations, with white residue, streaks, and flakes visible on the inside of the mask. The equipment was not stored in a protective barrier and remained in the same condition across several observations. In addition, the facility’s Water Management Plan binder contained a Legionella Water Management Plan that referenced a sister facility rather than this facility, and there was no documentation of an annual review, test results, logs, or control limits. The report also noted uncovered hoppers and missing PPE in multiple soiled utility rooms.
Inconsistent Code Status Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one resident, Resident #9, out of 24 sampled residents reviewed for complete and accurate medical records. Resident #9’s record contained conflicting code status information: the Face Sheet identified him as having Alzheimer’s disease and unspecified dementia with behavioral disturbance, and his General Procedures DO-NOT-RESUSCITATE document was signed by Family Member NN and MD OO indicating that no person shall attempt resuscitation if the resident’s heart and breathing stop. At the same time, Resident #9’s electronic medical record banner identified him as DNR, while a physician’s order listed him as FULL CODE CPR. During interview, the DON reviewed the record and stated the banner indicated DNR, the DNR paperwork indicated DNR, and the physician order was for Full Code CPR. The DON reported the resident had changed code status the week before and the physician order did not get changed but should have. The NHA stated it was her expectation that all code status paperwork matched because if not, resident advance directive wishes may not be followed.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey. During a lunch service observation, a food service employee was seen wiping his gloves on his apron and using towels to clean his gloved hands, which is not in compliance with the FDA Food Code. The employee also changed gloves without washing hands in between, and when he did wash his hands, it was for only five seconds, contrary to the required 20 seconds. These actions have the potential to result in foodborne illness among residents consuming food prepared in the kitchen. Further observations revealed unsanitary conditions in various areas of the kitchen. There was an accumulation of debris and yellow staining under the preparation sink, dirt and debris under and behind the ice machine, and sticky syrup residue on the floor of the pop closet. Additionally, the underside of juice dispensers and the ice machine spout had visible accumulations of sticky debris. These findings indicate a failure to maintain cleanliness in non-food contact surfaces, as required by the FDA Food Code. The dishwashing machine was also found to be operating below the required temperatures for effective sanitization. The machine's wash cycle temperature was below the necessary 160F, and the rinse temperature was below the required 180F. This deficiency was confirmed by a dish machine vendor who identified a burned-out thermostat. Additionally, expired urinary tract supplements were found in the central supply room, which were discarded by the Regional Director of Plant Operations. These findings highlight multiple areas where the facility did not comply with food safety and sanitation standards.
Inadequate Infection Prevention and Control Program
Penalty
Summary
The facility failed to implement an effective infection prevention and control program, as evidenced by the lack of a consistent infection preventionist and inadequate documentation of infection control activities. The newly hired Infection Preventionist (IP) CC, along with Clinical Regional Support (CRS) AA, reported that multiple staff members had been covering the infection preventionist role over the past year, but there was no evidence of infection prevention education provided to staff during this period. Although staff received education at orientation and annually through an online platform, there was no additional infection prevention education documented. IP CC was unable to provide comprehensive infection control surveillance data for the past year, as she had only tracked residents prescribed antibiotics and not those with possible infection symptoms. The facility had a system to track infection events through the Electronic Health Record (EHR), but it was not utilized for residents with potential infection symptoms. Furthermore, IP CC did not document infection control audits, and neither she nor CRS AA could provide evidence of any audits conducted in the past year. The facility's Infection Prevention and Control Program policy outlined the need for surveillance activities to identify, investigate, control, and prevent the spread of infections. However, the facility did not provide documentation of infection control audits or detailed infection prevention education prior to the survey exit. The lack of consistent infection prevention leadership and documentation of infection control activities contributed to the deficiency in the facility's infection prevention and control program.
Failure to Accommodate Resident's Morning Schedule
Penalty
Summary
The facility failed to accommodate a resident's choice regarding their morning schedule, resulting in frustration and the potential for the resident being unable to meet their highest practicable level of well-being. The resident, who was cognitively intact and had a preference to be up by 8:00 AM to have breakfast in the assisted living area, repeatedly expressed concerns about not receiving morning care at the desired time. Despite the care plan indicating the resident's preference, the facility did not consistently meet this request, leading to the resident being in bed and in pajamas past the preferred time. Interviews with staff revealed that the resident's request was challenging to accommodate due to the number of residents requiring assistance on the same hall. The LPN was unsure of the interventions attempted to meet the resident's request, and the DON acknowledged the issue but did not recall how staff were educated on the matter. The DON did not believe staffing was an issue and felt that prioritizing resident care could accommodate the request, yet no additional interventions were explored to ensure the resident's morning care was provided at the desired time.
Failure to Provide Written Notice of Transfer
Penalty
Summary
The facility failed to provide a written notice of transfer for a resident who was hospitalized, which is a requirement to ensure residents and their representatives are informed of the transfer and their rights. The resident, who had a guardian, was admitted to the facility in 2019 and had a cognitive impairment that prevented the completion of a Brief Interview for Mental Status (BIMS). The resident was transferred to the emergency room due to chest pain and shortness of breath and returned to the facility shortly after. Upon review, it was found that there was no evidence of a written notice of transfer being provided to the resident or her guardian. The notice should have included the reason for transfer, the effective date, the location of transfer, and information about the resident's appeal rights, among other details. During an interview, the Nursing Home Administrator admitted that the transfer notice was not completed and was forgotten by the nurse at the time of the resident's transfer to the hospital.
Failure to Provide Bed Hold Notice
Penalty
Summary
The facility failed to notify a resident's guardian of the bed hold policy in writing upon the resident's transfer to a hospital. The resident, who had been admitted to the facility since March 26, 2019, was discharged to the emergency room due to chest pain and shortness of breath. The resident's chart indicated that a guardian was in place, but there was no documentation that the guardian received a written bed hold notice at the time of the hospital transfer. During an interview, the Nursing Home Administrator confirmed that the bed hold notice was not found in the resident's chart, acknowledging that it should have been provided.
Expired Tube Feeding Supplements Not Discarded
Penalty
Summary
The facility failed to discard expired tube feeding supplements, specifically 35 bolus containers of Jevity supplement, which were found to have a manufacturer's expiration date of May 1, 2024. This was observed during a tour of the 500 hall central supply storage room. Scheduling Coordinator G was present and discarding some expired products at the time. During an interview, Scheduling Coordinator G mentioned that the facility sometimes does not have residents who need these items, leading to the accumulation of expired products. This oversight resulted in an increased risk of contaminated foods and foodborne illness for residents who might be prescribed these specific supplements.
Failure to Administer and Record Vaccinations
Penalty
Summary
The facility failed to ensure that residents were properly screened for eligibility and administered pneumococcal and influenza vaccinations, as evidenced by the cases of two residents. Resident #8, who was admitted with a diagnosis of muscle weakness, did not have a pneumococcal immunization record in their Electronic Health Record (EHR). The Infection Preventionist (IP) reported that Resident #8 had last received the PVC 13 vaccine in November 2022 and was due for the PVC 20 vaccine, but it was unclear if the resident had been offered this vaccine. Similarly, Resident #10, admitted with a need for assistance with personal care, lacked an influenza immunization record in their EHR. The IP noted that Resident #10 had last received an influenza vaccine in October 2022, but there was no confirmation of an offer for the 2023 vaccine. The facility's failure to maintain accurate immunization records and ensure timely vaccination offers was compounded by staffing changes affecting the infection control program. The Nursing Home Administrator confirmed the absence of immunization records for both residents. The facility's policy, revised in December 2023, outlined procedures for providing immunization information and obtaining informed consent upon admission, as well as annually for influenza vaccines. However, these procedures were not effectively implemented, leading to the deficiency in vaccination administration and record-keeping for the residents involved.
Failure to Offer COVID-19 Immunization to a Resident
Penalty
Summary
The facility failed to ensure that COVID-19 immunizations were offered to a resident, identified as Resident #25, which was a deficiency noted during a survey. Resident #25 was admitted to the facility with a diagnosis of end-stage renal disease. Upon review of the resident's electronic health record, it was found that there was no documentation of COVID-19 immunization administration for the year 2023. The last recorded COVID-19 immunization for Resident #25 was on October 6, 2022. During an interview, the Infection Preventionist (IP) reported that they were unable to confirm if Resident #25 had been offered a COVID-19 immunization in 2023. The IP mentioned that there had been multiple changes in staff covering the infection preventionist role, which led to a backlog in updating resident vaccines. Additionally, the Nursing Home Administrator confirmed that the facility did not have immunization records for Resident #25. The facility's policy on immunizations, last revised in December 2023, outlines the procedures for providing education and offering immunizations to residents, but these procedures were not followed in this case.
Deficiency in Call Light System Functionality
Penalty
Summary
The facility failed to ensure that the call light systems for two residents were operable, which could potentially lead to delayed responses and negative outcomes. Resident #35, who was cognitively intact, reported that her call light was intermittently malfunctioning. During an observation, a CNA confirmed the issue, and the call light was replaced. The Director of Plant Operations (DPO) acknowledged receiving verbal reports about call light issues but noted a lack of formal work orders. Resident #35 expressed concerns about the communication process for addressing maintenance issues, stating that it often took days for repairs to be made. Resident #5, who was also cognitively intact, experienced a fall in her room due to a non-functioning call light. She reported having to call out for help after the fall. A CNA confirmed the call light was not working at the time of the incident, and it was replaced afterward. The nursing progress notes documented the fall and the malfunctioning call light, and an interdisciplinary team reviewed the incident. The resident was found on the floor without injuries, and the call light was immediately replaced with a functioning one. The DPO explained that the call lights operate on a wireless system, and issues such as dead batteries are automatically reported, but problems with cords or bulbs require staff to submit work orders. The DPO also mentioned that some residents might be confused about how to use the call system, which could contribute to the issues. Despite these explanations, the facility's failure to maintain operable call lights for these residents was identified as a deficiency during the survey.
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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 Byron Center
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Optalis Health & Rehabilitation Of Wyoming | 6.6 mi | ★★★★★ | 41 | 0 |
| Harbor Post Acute Center | 6.6 mi | ★★★★★ | 11 | 0 |
| Medilodge Of Wyoming | 6.8 mi | ★★★★★ | 0 | 0 |
| Corewell Health Rehabilitation & Nursing Center - | 7 mi | ★★★★★ | 7 | 0 |
| Mission Point Nursing & Physical Rehabilitation Ce | 7.3 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.