The Oaks at Byron Center

In the surveyor’s words

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

• Actual harm, isolatedF686Jul 14, 2022

  Based on observation, interview and record review, the facility failed to provide care to prevent the development and/or worsening of pressure ulcers, consistent with professional standards of practice in 2 of 3 residents (Resident #46 and #50) reviewed for pressure injuries, resulting in the development of a pressure ulcer for Resident #46, and the potential for infection and overall deterioration in health status for all residents at risk for deterioration in skin integrity. Findings include: Resident #46 Review of a Face Sheet revealed Resident #46 was originally admitted to the facility with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, widespreadF880Dec 3, 2025

  Based on observation, interview and record review, the facility failed to 1.) Provide Personal Protective Equipment (PPE) in the soiled utility rooms and resident rooms that were on transmission-based precautions (TBP) and enhanced barrier precautions (EBP) for Resident #67, #3, #29, and #53; 2.) [NAME] (put on) PPE when providing care for residents in EBP for Resident #5, #67, and #74; 3.) Clean and properly store nebulizer equipment for Resident #10; 4.) Ensure an active Water Management Plan specifically tailored to the facility. These deficient practices resulted in the potential for cross contamination and the spread of disease to all residents that reside in the facility. […]

• No harm, potential for more than minimal, widespreadF812Oct 17, 2024

  Based on observation, interview, and record review, the facility failed to prepare food in accordance with professional standards for food service safety. This deficient practice has the potential to result in food borne illness among all residents that consume food in the kitchen. Findings include: During a tour of the facility, at 8:40 AM on 10/16/24, an interview with Food Service Director (FSD) F, found that hand washing should take place for 20 seconds. During an observation of lunch service, starting at 12:14 PM on 10/16/24, it was observed that [NAME] EE, was on the serving line going through the process of making and plating alternates and puree menu items. At this time, it was observed that [NAME] EE would occasionally use his apron for wiping his gloves off as they got soiled. […]

• No harm, potential for more than minimal, widespreadF812Jul 14, 2022

  Based on observation, interview, and record review the facility failed to ensure food items were discarded after the use by date and ensure kitchen equipment was maintained in a sanitary manner with the potential to affect those consuming food or fluids from the kitchen out of the facility census of 53 resulting in the potential for food-borne illness or physical contamination of food. Findings include: Food Dating: During an observation and interview on [DATE] 07:22 AM, in the walk-in refrigerator in the kitchen a container labeled cranberry sauce had an opened on/prepared date of [DATE] and discard date of [DATE]. […]

• No harm, potential for more than minimal, widespreadF812Apr 14, 2021

  Based on observation, interview, and record review, the facility failed to monitor and maintain the dish machine and clean food-contact surfaces, resulting in the potential spread of infectious diseases. These deficient practices affect all 55 residents in the facility. Findings include: On 4/12/21 at 11:17 AM, during an inspection of the kitchen, Dietary Staff DD was observed to be running dishes through the dish machine. Dietary Staff DD was asked by the Surveyor to use a non-reversable color changing test strip (160 degrees), to test the dish machine to ensure the proper sanitizing temperature was being achieved. The test strip did not change colors, indicating the sanitizing rinse cycle was not resulting in the dish ware reaching 160 degrees. […]