Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
The Oaks at Byron Center
Byron Center, MI · 60 certified beds · Last Life Safety survey December 3, 2025
CMS Certification Number 235639 · first certified February 2008
Ownership
Operated by TRILOGY HEALTH SERVICES · For profit - Corporation
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within MI
17 citations — more than 65% of the 422 certified nursing homes in MI. Compared within MI rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 16 citations; the earlier surveys in the window averaged 0.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window opens November 2026 — about 2 months from now. This facility’s last Life Safety survey was December 2025. Facilities in MI are typically surveyed 12–14 months after the last one (median 13), measured over 723 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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Emergency preparedness
4 of the 17 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
3 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 17 Life Safety citations above. The Physical Environment Index
How that compares
Compared with the median facility in MI, and nationally. Surveyors differ markedly between states, so the MI figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 17 |
| Median facility in MI | 14 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| September 21, 2023 | 0 |
| October 17, 2024 | 1 |
| December 3, 2025 | 16 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0133 | Install a two-hour-resistant firewall separation. | 1 | 2025-12-03 |
| E-0041 | Implement emergency and standby power systems. | 1 | 2025-12-03 |
| K-0712 | Have simulated fire drills held at unexpected times. | 1 | 2025-12-03 |
| K-0325 | Have properly installed hallway dispensers for alcohol-based hand rub. | 1 | 2025-12-03 |
| K-0511 | Have properly installed electrical wiring and gas equipment. | 1 | 2025-12-03 |
| E-0022 | Establish policies and procedures for sheltering. | 1 | 2025-12-03 |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 1 | 2025-12-03 |
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | 1 | 2025-12-03 |
What the citations cover
- Smoke Deficiencies 6
- Emergency Preparedness Deficiencies 4
- Services Deficiencies 2
- Miscellaneous Deficiencies 2
- Other 3
| Category | Citations |
|---|---|
| Smoke Deficiencies | 6 |
| Emergency Preparedness Deficiencies | 4 |
| Services Deficiencies | 2 |
| Miscellaneous Deficiencies | 2 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 1 |
| Construction Deficiencies | 1 |
| Egress Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
December 3, 2025 — 16 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (January 9, 2026) |
| E-0020 | Establish policies and procedures including evacuation. | Deficient, Provider has date of correction (January 9, 2026) |
| E-0022 | Establish policies and procedures for sheltering. | Deficient, Provider has date of correction (January 9, 2026) |
| E-0041 | Implement emergency and standby power systems. | Deficient, Provider has date of correction (January 9, 2026) |
| K-0133 | Install a two-hour-resistant firewall separation. | Deficient, Provider has date of correction (January 9, 2026) |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (January 9, 2026) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (December 29, 2025) |
| K-0325 | Have properly installed hallway dispensers for alcohol-based hand rub. | Deficient, Provider has date of correction (January 9, 2026) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (January 9, 2026) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (January 9, 2026) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (January 9, 2026) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (January 9, 2026) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (January 9, 2026) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (December 29, 2025) |
| K-0781 | Have restrictions on the use of portable space heaters. | Deficient, Provider has date of correction (December 29, 2025) |
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Deficient, Provider has date of correction (January 9, 2026) |
October 17, 2024 — 1 citation
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (November 8, 2024) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.