Graham Healthcare and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Graham Healthcare and Rehabilitation Center, in the surveyor’s own words.

• Actual harm, isolatedF600May 28, 2026

  Based on record review and staff, Visitor, Police Sergeant, and Nurse Practitioner interviews, the facility failed to protect a cognitively impaired resident's right to be free from staff to resident physical and verbal abuse when Agency Nurse #1 yelled at Resident #1 loudly in a common area of the facility utilizing language that was vulgar and demeaning in a volume that was loud enough for a visitor in a nearby room to hear. Agency Nurse #1 also pushed Resident #1 down into her wheelchair when she attempted to stand up, shook the wheelchair violently, propelled the resident down the hall in her wheelchair in an aggressive manner, and hit Resident #1 in the back with a closed fist multiple times. Resident #1 was crying following the incident and stated to staff that she was afraid. […]

• No harm, potential for more than minimal, patternF757Mar 5, 2026

  Based on record review and interviews with staff and the physician, the facility failed to monitor and document a resident's pulse and blood pressure for a resident who had physician ordered hold parameters for digoxin (a cardiac glycoside used to strengthen heart contractions) and losartan (antihypertensive medication) for 1 of 5 residents reviewed for unnecessary medications (Resident #52).Findings included: Resident #52 was admitted to the facility on [DATE] with diagnoses including paroxysmal atrial fibrillation, congestive heart failure, and hypertension. a. The physician's orders dated 10/16/25 revealed Resident #52 had an order for digoxin 125 micrograms (mcg) by mouth in the evening with a hold parameter if the pulse was below 60. […]

• No harm, potential for more than minimal, patternF644Dec 19, 2024

  Based on record reviews and staff interviews, the facility failed to submit a request for an evaluation of updated Pre-Admission Screening and Resident Review (PASARR) determination for 1 of 3 residents reviewed (Resident #11). The findings included: Resident #11 was originally admitted to the facility on [DATE] with fibromyalgia, osteoarthritis, and Post Traumatic Stress Disorder (PTSD). On 04/10/2024, resident was diagnosed with Major Depressive Disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #11 had moderate cognitive impairment. The MDS further revealed diagnoses on 04/10/2024 of major depressive disorder. Behaviors during the look back period included feeling down, depressed or sleepy. […]

• No harm, potential for more than minimal, patternF761Dec 19, 2024

  Based on observations and staff and Consultant Pharmacist interviews, the facility failed to discard expired medications from 2 of 2 medication rooms (North and South medication rooms), and 1 of 2 medication carts (South medication cart). The facility also failed to date an eye drop after opening in 1 of 2 medication carts (South medication cart). The findings included: 1.a. An observation of the North medication room refrigerator on 12/18/24 at 11:08 AM with Nurse #1 revealed five full bags of Normal Saline 250 milliliters labeled as containing Gentamicin Injection with Resident #4's name. Each bag had a sticker that indicated do not use after with the following dates: 12/9/24, 12/11/24, 12/13/24, 12/15/24, and 12/17/24. […]

• No harm, potential for more than minimal, patternF880Dec 19, 2024

  Based on record reviews, observations, and staff interviews, the facility failed to implement their infection control policy when 3 staff members (Nurse Aides #1, #2, and #3) failed to sanitize their hands in between resident contacts and contact with surfaces in the dining room during meal service. In addition, Nurse #1 failed to don Personal Protective Equipment (PPE) including a gown when providing urinary catheter care and failed to perform hand hygiene before applying gloves and after removing gloves during catheter care for Resident #4. […]