Graham Oaks Care Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600Oct 10, 2025

  Based 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. […]

• Immediate jeopardy, isolatedF689Oct 10, 2025

  Based 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. […]

• Actual harm, isolatedF697Dec 7, 2023

  Based 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. […]

• No harm, potential for more than minimal, patternF656Jun 14, 2026

  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. […]

• No harm, potential for more than minimal, patternF656Jan 22, 2025

  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. […]