Byron Health Center

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 and placed in a plastic container, two bags of bread with approximately 10 slices each, one bag with 11 hamburger buns, two bags with one submarine bun each and one bag of whole wheat bread with three slices.On the countertop in the kitchen, the following items were observed to be open, tied in a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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. These were similar issues compared to the recertification survey dated 5/19/25 with F812 being cited 2 years in a row. In an interview, on 3/31/26 at 9:59am, the Executive Director (ED) indicated herself and the Assistant Executive Director did various observations of the kitchens and kitchenettes…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure cervical collars were provided and maintained for 2 of 2 residents reviewed (Resident 2, and Resident 20). Findings include:1) In an observation, on 03/25/2026 at 10:04 AM, Resident 2 was observed lying in bed with no cervical collar in place around her neck. In an observation, on 03/27/2026 at 10:43 AM, Resident 2 was observed lying in bed with no cervical collar in place around her neck. In an observation, on 3/30/2026 at 11:15 AM, a soft cervical collar was observed on the bedside stand next to Resident 2's bed. Resident 2's record was reviewed on 03/25/2026 12:27 PM. Diagnoses included cerebral infarction due to unspecified occlusion or stenosis of right middle cerebral artery, and hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. A current significant change Minimum Data Set (MDS) assessment, dated 1/21/2026, indicated Resident 2 had a Basic Interview for Mental Status (BIMS) score of 9 (moderate cognitive impairment). A review of physician orders, dated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview the facility failed to ensure neurological assessments were completed after falls for 3 of 8 residents reviewed. (Resident 6, Resident 13, and Resident 29)Findings include: Resident 6's record review began on 3/25/26 at 1:36pm. Diagnosis included epilepsy, dementia, and diabetes. In an interview, on 03/26/2026 at 1:46 PM, Licensed Practical Nurse 8 (LPN), explained the procedure for unwitnessed fall follow through. LPN 8 explained staff assess the resident for any injuries, attempt to figure out the cause of the fall, start neurological assessments, then did neuros every 15mins afterward x4, then neurological assessment (neuros) every hour x4, and then neuros every shift x 72 hours. The nurse would contact the provider and family. The nurse was to do a skin assessment, post fall assessment, dehydration assessment, and document findings in a progress note. In an interview, on 03/27/2026 at 11:12 AM, DIrector of Nursing (DON) indicated neuros were to be done after an unwitnessed fall every 15 minutes for the first hour, then hourly x4, and then…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a verbalization of suicidal ideation was investigated for 1 of 1 resident reviewed (Resident 77).Findings include:Resident 77's record was reviewed on 03/25/2026 at 11:25 AM. Diagnoses included Alzheimer's disease, anxiety, and depression.A current admission Minimum Data Set (MDS) assessment, dated 1/27/2026, indicated Resident 77 had a Basic Interview for Mental Status (BIMS) score of 4 (cognitively impaired).Resident 77's current care plan, dated 4/26/26, titled depression with history of suicidal ideation, indicated Resident 77 had a problem of depression. Interventions included redirecting Resident 77 when making comments related to suicidal ideation and notifying a supervisor immediately when suicidal comments were made.A progress note, dated 3/9/2026, at 4:24 PM, indicated Resident 77 told Volunteer 4 she had nothing to live for and wanted to kill herself. No additional progress notes regarding suicidal ideation were available for review.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to ensure appropriate infection control practices related to the storage of resident care equipment for 1 of 2 residents reviewed (Resident 79).Findings include:During an observation on 3/25/2026 at 10:11 AM, the following was observed: Resident 79 was sitting in a recliner in his room and had a portable urinal bottle with yellow liquid inside hanging by the handle on the trash bin, dated 3/19/2026.During an observation on 3/26/2026 at 1:27 PM, the following was observed: Resident 79 was sitting in a recliner in his room and had a portable urinal bottle with yellow liquid inside hanging by the handle on the trash bin.During an observation on 3/27/2026 at 12:47 PM, the following was observed: Resident 79 was sitting in a recliner in his room and had a portable urinal bottle with yellow liquid inside hanging by the handle on the trash bin. A glove, plastic drinking cup, piece of folded paper and three paper towels were observed in the trash can.During an observation on 3/27/2026 at 1:15 PM, the following was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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 5/13/25 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 5/11/25. The DM lifted the cart cover revealing individual pieces of cake on plates and bowls of fruit. The fruit and cake were not individually covered and appeared dry. A large bin labeled flour was observed with a scoop lying in the flour supply. A large bin labeled sugar was observed with a scoop lying in the sugar supply. Four chef salads were observed on plates covered with plastic wrap inside the reach-in cooler. No date was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview the facility failed to ensure dignity was maintained for 1 of 1 resident reviewed. (Resident 10) Findings include: During an observation, on 5/15/25 at 7:26AM, Licensed Practical Nurse (LPN) 6 administered medications to Resident 10. The medications were administered in a common area while Resident 10 was sitting eating breakfast at dining table. The medications administered included Trulicity, a subcutaneous injection of a hypoglycemic agent. The Trulicity injection was administered in Resident 10's right upper quadrant of his abdomen after Resident 10 pulled up his shirt revealing his abdomen. In an interview, on 5/15/25 at 9:56AM, LPN 6 indicated she normally would stop giving medications and assist in serving breakfast rather than administering medications during breakfast. In an interview, on 5/15/25 at 10:10AM, Registered Nurse (RN) 5 indicated nurses were not permitted to give medications in the common area during breakfast due to dignity issues as well as residents were to enjoy their meal without interruptions. Resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure privacy of electronic and paper medical information for 1 of 20 residents reviewed. (Resident 80) Findings include: During an observation, on 5/14/25 at 10:30 AM, a computer screen on top of a medicine cart was open with Resident 80's name, picture, medication list and other personal health information visible on the screen. A paper worksheet was lying on top of the medicine cart displaying vital signs and other health information for residents on the unit. The medicine cart was observed in a hallway leading to the common areas of the unit where staff and residents were observed passing by. During an observation, on 5/14/25 at 12:31 PM, Registered Nurse (RN) 5 was observed seated next to Resident 80 in the dining room assisting her with lunch. RN 5 rose from her chair, walked to the medicine cart, activated the lock and returned to her seat. The computer on top of the medicine cart was open to Resident 80's medication list and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview the facility failed to ensure a bed hold policy was given prior to discharge to 2 of 3 residents reviewed. (Resident 35 and Resident 47) Findings include: 1) Resident 35's record review began on 5/13/25 at 10:33AM. Resident 35's diagnoses included kidney failure, respiratory failure, and pneumonitis due to inhalation of food and vomit. On 10/8/24 Resident 35 was sent to the hospital. There was no documentation to indicate a bed hold had been explained to her or the family in the medical record. The facility was unable to show proof a bed hold was given prior to discharge. 2) Resident 47's record review began on 05/14/25 at 1:34 PM. Resident 47's diagnoses included respiratory failure, dysphagia, and altered mental status. Resident 47 was sent to the hospital on 3/8/25 there was no documentation to indicate a bed hold had been explained to him or his family in the medical record. The facility was unable to provide proof a bed hold was given prior to discharge. In an interview, on 05/16/25 at 12:27 PM, the Director of Nursing (DON) indicated a bed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review the facility failed to ensure assessments were accurately recorded for 2 of 2 residents reviewed. (Resident 1, Resident 35) Findings include: During an observation on 05/16/2025 at 1:38 PM the following was observed: the Director of Nursing approached Resident 1 to check pupils. Upon shining a flashlight in the left eye, the pupil appeared dilated, round and nonreactive to light; the right pupil appeared round, non-dilated, and reacted to light. Resident 1's record was reviewed on 05/14/2025 at 12:53 PM. Diagnoses included 6th abducent nerve palsy (affects the ability to turn the eye outward), 3rd oculomotor nerve palsy (affects the ability for eye to look straight ahead, also effects the pupils ability to constrict to light leaving the pupil dilated), and blepharoconjunctivitis (inflammation of the eyelid and conjunctiva (mucus membrane of eye)). A review of Resident 1's current quarterly MDS indicated their BIMS (Basic Interview for Mental Status) score was 5 (severe cognitive impairment). A review of Resident 1's current care plan…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure oxygen tubing was appropriately applied and stored when not in use for 1 of 2 residents reviewed. (Resident 28) Findings include: During an observation on 5/13/25 at 12:04 PM oxygen tubing was lying across Resident 28's bed unbagged. The bedside oxygen concentrator was turned on, releasing oxygen while Resident 28 was in the dining room. During an interview on 5/13/25 at 12:05 PM, Licensed Practical Nurse (LPN) 2 indicated bedside oxygen should be turned off when not in use and oxygen tubing should be bagged when not in use. LPN 2 indicated she was unable to find a bag in Resident 28's room to place her oxygen tubing in. During an observation on 05/15/25 10:19 AM, Resident 28 was observed lying on her right side in bed with her chin tucked to her chest, breathing in a labored manner. She was not wearing the oxygen. Resident 28's oxygen tubing was about 2.5 feet away from the resident lying neatly coiled, unbagged on a bedside table.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review the facility failed to ensure fall prevention interventions were followed for 1 of 4 resident reviewed (Resident B). Findings include: A facility reported incident file was provided by the Executive Director on 2/21/25 at 10:15 AM. The file included the following: The file, dated 2/4/25, indicated around 6:40 PM, Certified Nurse Aide (CNA) 5 assisted Resident B in the shower. Resident B was in the shower chair, started to foam at the mouth and turned blue. CNA 5 ran out of the room, left the resident alone in the shower chair, and got help. Upon return, CNA 5 and Qualified Medication Aide (QMA) 4 found Resident B on the floor of the shower. CNA 5's statement, undated, indicated while she assisted Resident B with a shower, Resident B foamed at the mouth. CNA 5 indicated she ran to get the nurse and upon return found Resident B on the floor of the shower. CNA 5's statement also indicated she did not witness the fall as she had ran to get the nurse and then came back. CNA 5 indicated she had left Resident B alone in the shower chair. QMA 4's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to ensure residents were free from mental and physical abuse by staff for 1 of 3 resident's reviewed (Resident D). The deficient practice was corrected on 2/1/24 prior to the start of the survey and was therefore past non-compliance. Findings include: A Indiana IDOH (Indiana Department of Health) incident report, dated 1/30/24 at 7:00 p.m., indicated the Administrator had viewed the facility camera, located on the male secured unit, for investigation of a staff members reported injury. The camera footage indicated at 5:04 a.m., QMA 2 walked into the nurse office followed by Resident D in his wheelchair. The resident was next seen on the floor outside the nurse office followed by his wheelchair coming out after him. He got back into his wheelchair and left the area. QMA 2 was observed to follow Resident D and removed the backpack off the back of his chair. A struggle between the 2 ensued and QMA 2 swung the backpack at the resident. QMA 4 came into view and ran towards the area where QMA 2 and the Resident were…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.