Graham Oaks Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. The facility failed to ensure the comprehensive care plans for Resident #1, Resident #2, and Resident #4 documented a desire to return to the community was assessed. This failure could place the residents…

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 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.The findings include: Record review of Resident #8's face sheet dated 04/07/26 revealed an [AGE] year-old female admitted to facility 09/23/25 with diagnoses including Chronic Obstructive Pulmonary Disease (lung disease) and Dementia (decline in cognitive function). Record review of Resident #8's MDS assessment dated [DATE] revealed the BIMS score was 7 of 15 reflective of severe cognitive impairment. Resident #8 ambulatory with wheelchair and partial assistance with transfers. Record review of Resident #8's Comprehensive Care Plan dated 04/01/26 the resident has…

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 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.Findings included: Record Review of Resident #1's face sheet dated 03//25/26, revealed an 87- year- old female admitted to the facility on [DATE] with diagnoses including neuromuscular dysfunction of bladder ( a condition that affects bladder function due to nervous system problems), Cellulitis of right lower limb (a common bacterial infection that occurs when it enters a crack or break in the skin), cutaneous abscess of right upper limb (a pus-filled…

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 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. The findings include: Record review Record review of Resident # 1's Face Sheet revealed she was a [AGE] year-old female originally admitted to the facility on 4.20.25 and readmitted on 5.20.25. She had diagnoses of fracture of hip, end stage renal disease (last stage of kidney failure) osteoporosis (porous brittle bone that breaks easily with spontaneous fractures common), and calciphylaxis (rare and life-threatening syndrome which involves calcium buildup in the skin and fat tissue leading to clotting and painful lesions). Record review of admission MDS dated 5.3.25 documented Resident #1 had 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. The facility failed to ensure Resident # 76's comprehensive care plan contained Resident #76's amputation . 4. The facility failed to ensure Resident #76's use of a fall…

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 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. The findings include: 1. Record review of Resident # 4's face sheet, dated 1/22/2025, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #4 had diagnoses which included Rhabdomyolysis (rare muscle injury where your muscles break down), high blood pressure and congestive heart failure. Record review of Resident #4's Annual MDS, dated [DATE], revealed Section C- Cognitive Patterns BIMS score of 5, which…

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 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. Findings include: In a record review of Employee C's personnel file reflected the facility did not complete annual Criminal History checks. The last check completed was date 12/2/22. In an interview on 10/16/24 at 4:45 PM, the Human Resource Specialist said the annual Criminal History checks for Employee C were not completed. He said it was the responsibility of the Human Resource Specialist to ensure reference checks were completed and documented during annual review. He said Criminal History checks helped prevent abuse . Human Resource Specialist stated he has worked for facility for only 3 weeks and has not completed reviews of…

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 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. The findings included: 1. Resident #39 Review of Resident #39's admission Record, dated 12/07/2023, revealed an [AGE] year-old male admitted to the facility on [DATE]. The resident's diagnoses included: Type 2 diabetes mellitus with foot ulcer; hyperlipidemia (high cholesterol); hypertension (high blood pressure);…

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 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. Findings included: In a record review of Employee C's personnel file revealed the facility did not complete reference checks with a hire date of 11/27/2023 prior to employment. In an interview on 12/07/23 at 11:30 AM, the Human Resource Specialist said the reference checks for Employee C were not completed. He said it was the responsibility of the Human Resource Coordinator to ensure reference checks are completed and documented prior to hire. He said reference checks helps prevent abuse. In an interview on 12/07/23 at 1:54 PM, the Administrator said Human Resources should be completing employee reference checks prior…

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 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. Findings included: Record review of Resident #53's electronic health record revealed a [AGE] year-old male with a, re-admission date 11/21/2023, Diagnoses: dysphagia (difficulty swallowing), essential (primary) hypertension (high blood pressure), Alzheimer's disease (progressive memory loss), atrial fibrillation (the hearts upper chambers beat out of sequence with the lower chambers which can lead to poor blood flow, blood clots and stroke), anxiety disorder (feelings of worry and fear that interfere with daily…

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 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. The findings included: Review of Resident #56's admission Record, dated 12/07/2023, revealed a [AGE] year-old female admitted to the facility on [DATE]. The resident's diagnoses included: iron deficiency…

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 report the results of investigations of allegations of abuse in accordance with State law, including to the State Survey Agency, within 5 working days of the incident for 4 (Resident #2, Resident #3, Resident #7and Resident #12) of 10 residents reviewed for abuse. The facility failed to report the investigations findings of abuse when Resident #3 attempted to remove Resident #2 from dinner table resulting Resident #2 receiving nail marks on her arm from Resident #3. The facility failed to report the investigation findings of abuse when Resident #12 slapped Resident #7 in the face while both residents were passing in the hall. This failure could place residents at risk for abuse. Findings include: Resident #2 Record review of Resident #2's, , MDS dated [DATE] indicated the resident was an [AGE] year-old female with a BIMS of 3 (severely cognitively impaired). The residents Medical Diagnoses were Dementia (a decline in cognitive abilities), and Psychotic…

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.