Graham Oaks Care Center

Inspectors wroteBased on interviews and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 5 of 7 residents (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #6) reviewed for care plans. The facility failed to ensure the staff developed the comprehensive care plan goals and interventions from the comprehensive assessment for Resident #1, Resident #2, Resident #3, Resident #4, and Resident #6. The facility failed to ensure the comprehensive care plans for Resident #1, Resident #2, and Resident #4 described the resident's preference and potential for future discharge. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the environment was as free of accident hazards as is possible and each resident receives adequate supervision to prevent accidents for 1 of 77 resident rooms observed (Resident #8) reviewed for accidents and hazards. Facility staff failed to remove an extension cord from Resident #8's room. This deficient practice could place resident at risk of a fire hazard or tripping.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable disease and infections for one (Resident #1) of three residents reviewed for infection control practices. CNA A failed to perform proper hand hygiene including changing gloves while providing incontinence care to Resident #1 on 03/25/26. This failure could place residents at risk for the spread of infection.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide written notice to the State Agency responsible for licensing the facility at the time of change, for a change in the facility's administrator for 1 of 1 facility. The facility failed to notify the State Agency of a change in the facilities administrator within 30 days. This failure could result in the lack of knowledge and inability to connect with the appropriate leadership of the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were free from abuse and neglect for one (Resident #1) of 8 residents reviewed for neglect. On 9/2/25 the facility allowed Hospitality Aide A to perform a transfer on Resident #1 and failed to ensure she was trained and permitted per her job description to use Resident #1's personal medical transfer equipment to perform a transfer. No staff in the facility had been trained in the use of Resident #1's personal medical transfer equipment, and the Director of Therapy had asked the former DON to ensure her staff did not use the device. The transfer resulted in a fall during which Resident #1 received a fracture in her left knee. The noncompliance was identified as PNC. The IJ began on 9/2/25 and ended on 9/3/25. The facility had corrected the noncompliance before the survey began. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure 1 (Resident #1) of 8 residents reviewed for accident hazards were free from accident hazards in their environment. The facility failed to ensure Resident # 1's received adequate supervision and assistive devices to prevent accidents. The lift used by facility staff was not an adequate assistive device since there was no manual for proper staff training and the device was the personal property of Resident #1. This resulted in a fall during a transfer in which Resident #1 received a fracture on her left knee on 9/3/25. The noncompliance was identified as PNC. The IJ began on 9/2/25 and ended on 9/3/25. The facility had corrected the noncompliance before the survey began. This failure placed residents at risk for serious injuries, a decline in the resident's condition, hospitalization, or death.

Inspectors wroteBased on interview, and record review the facility failed to maintain clinical records that were complete and/or accurate for 1 of 10 residents (Resident #1) reviewed for clinical records in that: The RN A did not document Resident # 1 was transferred to the ER on 5.12.25. This failure could place residents at risk of inaccurate and incomplete clinical records resulting in an inaccuracy in the care the resident received.

Inspectors wroteBased on observation , interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to meet the resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 3 of 24 residents (Resident #4, Resident #44 and Resident #76) reviewed for comprehensive person-centered care plans. 1. The facility failed to ensure Resident #4's comprehensive care plan was person centered and measurable when addressing Resident #4's Tobacco use. 2. The facility failed to ensure Resident #44's comprehensive care plan contained the resident's use of Trapeze bar (medical device used to help patient move and positions themselves in bed) for bed mobility. 3. [...]

Inspectors wroteBased on observation , interview and record review the facility failed to ensure the assessments accurately reflected the resident status for 2 of 11 residents (Residents #4 and #24) reviewed for assessments . 1. The Facility failed to ensure Resident #4's MDS was accurately completed with the residents tobacco use. 2. The facility failed to ensure Resident #24's MDS was accurately completed with Resident #24's anticoagulant. These failures could place residents at risk by decreasing the accurate information available to determine the care and services needed for each resident.

Inspectors wroteBased on interview and record review the facility failed to develop and implement written policies and procedures prohibited and prevented abuse, neglect, and exploitation, of residents and misappropriation of resident property for 1 of 4 employee files (Employee C) reviewed for abuse protocol. The facility failed to complete annual Criminal Background Checks for Employee C. This failure could place residents at risk for abuse, neglect, and exploitation.

Inspectors wroteBased on interview and record review, the facility failed to ensure that pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 3 (Resident # 55) residents reviewed for quality of care. The facility failed to ensure Resident #55's pain was managed at a level that did not interfere with the resident's sleep or day to day activities This deficient practice could place residents at risk of pain, discomfort, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a baseline care plan within 48 hours for 2 of 5 residents (Residents #39 and #56) whose record were reviewed for recent admission to the facility, in that: 1. Resident #39 was admitted to the facility on [DATE] and a baseline care plan had not been developed within 48 hours of his admission. 2. Resident #56 was admitted to the facility on [DATE] and a baseline care plan had not been developed within 48 hours of her admission. This failure placed the residents at risk for not receiving care and services to meet their needs and to promote their physical and mental health and well-being within their new living environment.

Inspectors wroteBased on interview and record review the facility failed to implement their written policies and procedures to prohibit abuse, neglect, exploitation, and misappropriation of resident property for 1 of 8 employee files (Employee C) reviewed for abuse protocol. The facility did not complete reference checks on Employee C, with a hire date of 11/27/2023, prior to employment at the facility. This failure could place residents at risk for abuse, neglect, and exploitation.

Inspectors wroteBased on interview, and record review, the facility failed to update the comprehensive care plan after the assessment for 1 of 6 residents (Resident #'s 53) reviewed for plan of care revision. The facility failed to include in the care plan, nutritional interventions for a significant weight loss for Resident #53 after the 11/26/2023 Comprehensive MDS . This failure could place the residents at risk of staff and providers not having the most current information for the Resident's plan of care.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents who have not used psychotropic drugs are not given these drugs unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record and gradual dose reductions were attempted for 1 of 5 residents (Resident #56) whose records were reviewed for unnecessary medications. Resident #56 was admitted to the facility on [DATE]. Her admission orders included an order for the antipsychotic medication Zyprexa 5 mg for a diagnosis of depression, with a start date on 04/18/2023. She did not have a diagnosis or indication of use for antipsychotic medication. The facility's failure placed the resident at risk for adverse side effects from receiving antipsychotic medication that was not indicated for use.