Graham Hospital

In the surveyor’s words

From the most serious findings on record at Graham Hospital, in the surveyor’s own words.

• Actual harm, isolatedF686Apr 1, 2026

  Based on observation, interview, and record review the facility failed to implement physician ordered pressure relieving interventions to prevent the development of pressure ulcers and failed to initiate a pressure ulcer care plan as soon as a pressure ulcers were identified for one of one resident (R1) reviewed for pressure ulcers in the sample of 21. These failures resulted in R1 developing a stage two facility acquired pressure ulcer to the right gluteus and a stage four pressure ulcer to the right base of the big toe that required mechanical debridement. The facility's Skin Assessment, Wound Prevention, and Care Policy dated 4/2025 documents, (The facility) shall provide care, treatment, and services to: 1. Identify those at risk for skin breakdown. 2. Promote comfort and mobility. 3. […]

• Actual harm, isolatedF600Mar 17, 2021

  Based on observation, record review and interview, the facility failed to protect a resident from mental abuse by a staff member, for one of two residents (R114) reviewed for abuse, in the sample of 15. This failure resulted in R114 experiencing episodes of crying, distress, fear of staff, and constipation. FINDINGS INCLUDE: The facility policy titled Abuse Prohibition and Reporting dated (revised) 12/20 directs staff, Each resident/resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. It is the policy of (facility) that all patients/residents have the right to be free from all types of abuse, corporal punishment and involuntary seclusion. […]

• No harm, potential for more than minimal, widespreadF657Apr 1, 2026

  Based on interview and record review the facility failed to ensure residents' comprehensive care plans were individualized to reflect each resident's specific needs, conditions, and preferences. This failure affects all 21 residents who reside at the facility. Findings include: The facility's Care Plan Policy revised 3/10/25 documents the individualized care plan is used to outline the care in which the patients shall receive during their stay. A plan of care which defines patient or family outcomes within a pre-established time frame, prompting continuity of care using interventions to meet expected outcomes. The documented plan of care is based on the patient's goals and time frames, settings, and services required to meet those goals. […]

• No harm, potential for more than minimal, widespreadF812Apr 1, 2026

  Based on observation, interview, and record review the facility failed to ensure sanitary conditions were maintained during food preparation and service to prevent cross-contamination and foodborne illness, in accordance with professional standards for food safety. This failure has the potential to affect all 21 residents who reside at the facility.Findings include:The facility's CMS (Centers for Medicare and Medicaid Services) Form 671 dated 3/30/26 and signed by V1 (Administrator) documents 21 residents reside within the facility.On 03/30/2026 at 11:05 AM, V8 (Cook) was observed cleaning main food preparation areas with a wash rag while food on the steam table remained uncovered. […]

• No harm, potential for more than minimal, widespreadF880Apr 1, 2026

  Facility failures resulted in two deficient practices.A. Based on interview and record review, the facility failed to establish and maintain an effective infection prevention and control program by failing to perform surveillance to track and monitor residents and staff illnesses and differentiating between resident facility-acquired and community acquired infections. This failure has the potential to affect all 21 residents residing in the facility.B. Based on observation, interview, and record review the facility failed to implement Enhanced Barrier Precautions while providing incontinent cares for one of 12 residents reviewed for infection control practices in the sample of 21.Findings include:A. […]