Byron Health Center

In the surveyor’s words

From the most serious findings on record at Byron Health Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jun 18, 2025

  Based on interview and record review the facility failed to ensure adequate supervision was in place to prevent residents from leaving the facility unsupervised for 1 of 3 residents reviewed (Resident B). Resident B was unsupervised, walked approximately 3 miles across heavily traveled streets. Resident B's unsupervised wandering could result in death. The Immediate Jeopardy began on 6/15/25 when the facility failed to prevent Resident B from leaving the facility unsupervised. The Executive Director (ED) and Assistant Administrator were notified of the Immediate Jeopardy on June 17, 2025, at 12:34 PM. […]

• No harm, potential for more than minimal, widespreadF812Mar 31, 2026

  Based on observation, interview and record review, the facility failed to ensure proper labeling, storage, and sanitation were maintained in the kitchen. 103 of 103 residents who resided in the facility and received food from the kitchen.Findings include:During an initial observation of the kitchen on 3/25/2026 at 9:12 AM, the following items in the walk-in freezer were observed to be open to air, undated and did not contain an expiration date: one bag of frozen chips and one box of cinnamon rolls.In the refrigerator, a container of beef base was observed to be open, without a lid and did not contain an open date or expiration date.In dry storage, the following items were observed to be open, undated and did not contain an expiration date: elbow macaroni removed from its original packaging… […]

• No harm, potential for more than minimal, widespreadF867Mar 31, 2026

  Based on observation, record review, and interview the facility failed to have effective implementation of interventions to maintain kitchen sanitation for 103 of 103 residents residing in the facility ate food prepared in the kitchen.Findings include: A review of survey results, dated 5/19/25, indicated the facility was cited for F812. The citation included maintaining sanitation, open food items, labeling of food, and food open being dated.During an observation, on 03/25/2026 at 9:12 AM, in the kitchen there was a bag of frozen chips and cinnamon rolls in freezer open to air no open dates. Beef base without an open date, elbow macaroni in clear bin without a date, white bread, whole wheat bread, hamburger buns, and sub buns without dates. Dill weed seasoning without a lid, open to air. […]

• No harm, potential for more than minimal, patternF812May 19, 2025

  Based on observation, interview and record review the facility failed to ensure kitchen sanitation was maintained, opened food items were labeled and dated, and baking trays were thoroughly air dried. 95 of 96 residents residing in the building were served food prepared in the kitchen. Findings include: During an observation on [DATE] at 9:07 AM, A container of ice cream was observed in the walk-in freezer. The dietary manager (DM) opened the container and dip marks where ice cream had been removed were observed. No open date was observed on the container. A large, covered cart was observed in the back of the walk-in cooler with a discard date of [DATE]. The DM lifted the cart cover revealing individual pieces of cake on plates and bowls of fruit. […]

• No harm, potential for more than minimal, patternF805Sep 1, 2022

  Based on observation, interview, and record review, the facility failed to ensure recipes were followed when preparing pureed foods for 17 of 17 residents reviewed. (Resident 77, Resident 75, Resident 28, Resident 33, Resident 35, Resident 70, Resident 20, Resident 2, Resident 55, Resident 62, Resident 56, Resident 74, Resident 65, Resident 38, Resident 44, Resident 57, and Resident 1). In an interview on 8/30/22 3:22 PM, the administrator and dietary manager indicated 17 residents received pureed diets from the facility kitchen. Resident 77's record was reviewed on 9/1/22 1:40PM. […]