Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Graham Oaks Care Center during CMS and state inspections, most recent first.
A resident with multiple comorbidities, including neuromuscular bladder dysfunction, cellulitis, gangrene, and DM, required substantial assistance with ADLs and had documented bowel incontinence. During observed incontinence care, a CNA did not perform hand hygiene before donning gloves, continued care with gloves visibly soiled with feces, retrieved and placed a clean brief, and applied skin protector without changing gloves or washing hands, and then left the room without performing hand hygiene. In interview, the CNA acknowledged not following proper infection control practices and described cross contamination occurring during the care, while facility policy required handwashing and glove changes when gloves became contaminated with feces.
The facility did not notify the State Agency of a change in administrator within the required 30-day period, as the current administrator's information was not updated in TULIP despite her being in the role for several months. Staff and facility postings confirmed her position, but official records remained outdated.
A resident with paraplegia and other complex medical conditions was transferred by an untrained Hospitality Aide using a personal sit-to-stand device, despite the aide's lack of training and the absence of staff competency checks for the equipment. The aide, not authorized to perform transfers, proceeded at the resident's request, leading to a fall and a left knee fracture. The incident revealed that no staff had been trained on the device, and communication lapses between therapy and nursing leadership contributed to the deficiency.
A resident with paraplegia and impaired mobility was transferred using a personal sit-to-stand device by an untrained hospitality aide, resulting in a fall and a left knee fracture. The aide, whose job description did not include transfers and who lacked training on the device, proceeded with the transfer after the resident's request. The facility did not own the device, had no manual for its use, and had not ensured staff competency, leading to the incident.
A resident with multiple complex medical conditions was transferred to the ER for altered mental status and hypoxia, but the RN did not document the transfer at the time of the event. The DON later made a late entry in the record, and the resident's family was not notified promptly. This resulted in incomplete and inaccurate clinical records, contrary to facility policy.
The facility failed to implement comprehensive care plans for three residents, leading to deficiencies in addressing specific needs. A resident's care plan lacked interventions for smokeless tobacco use, another's did not include the use of a trapeze bar for mobility, and a third resident's plan failed to address amputation and fall risk interventions. Observations and staff interviews revealed inconsistencies between care plans and actual practices, potentially impacting resident safety and well-being.
The facility failed to accurately complete MDS assessments for two residents, omitting tobacco use for one and anticoagulant use for another. A resident with severe cognitive impairment was observed using chewing tobacco, which was not documented in his MDS or care plan. Another resident's MDS did not reflect her prescribed anticoagulant medication, despite a physician's order. Staff oversight and lack of thorough documentation review contributed to these deficiencies.
The facility failed to conduct annual Criminal Background Checks for an employee, as required by their policy, potentially placing residents at risk. The oversight was identified during a review of employee files, and the Human Resource Specialist acknowledged the lapse, having only recently assumed the role. The facility's policy mandates these checks within 72 hours of employment and annually, but this was not adhered to for the employee in question.
Failure to Follow Hand Hygiene and Glove-Change Protocol During Incontinence Care
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to incontinence care provided to Resident #1. Resident #1 was an 87-year-old female with neuromuscular dysfunction of the bladder, cellulitis of the right lower limb, a cutaneous abscess of the right upper limb, gangrene, and diabetes mellitus. Her MDS assessment showed she required substantial/maximal assistance with most ADLs, including toileting, and she was occasionally incontinent of bladder and frequently incontinent of bowel. Her care plan documented bowel incontinence with a goal of avoiding complications related to that condition. During observed incontinence care, CNA A did not wash her hands prior to donning gloves and removed a feces-soiled brief from the resident. CNA A wiped the resident from front to back but did not change gloves, continuing to clean the resident with gloves that were visibly soiled with fecal matter. Without changing gloves or performing hand hygiene, CNA A retrieved and placed a clean brief under the resident and applied skin protector while still wearing the soiled gloves, then removed the gloves, picked up trash, and exited the room without performing hand hygiene. In an interview, CNA A acknowledged she should have changed gloves and washed hands before retrieving and placing the clean brief, stated she had not received complete infection control training with return demonstration, and described cross contamination as mixing clean with dirty, which she recognized had occurred during the care. The facility’s infection control policy for female perineal care required staff to wash hands and don clean gloves for perineal care and to change gloves if they became contaminated with feces.
Failure to Notify State Agency of Administrator Change
Penalty
Summary
The facility failed to provide written notice to the State Agency regarding a change in the facility's administrator within the required 30-day period. During an observation, the investigator identified the administrator listed in the TULIP system, but upon interview, the current administrator stated she had assumed the role in March 2025, and her name was not reflected in TULIP. Staff interviews confirmed that the current administrator had been in charge since at least June 2025, and she was the designated abuse coordinator. Facility postings and business cards also identified her as the administrator, but the official state records had not been updated. The administrator acknowledged responsibility for notifying the State Agency of the change but believed the previous administrator would handle the notification. She stated she was aware of the requirement to update TULIP within 30 days but had not done so. No policy regarding this process was provided, and no corporate personnel were available for interview. The deficiency was identified through observation, staff interviews, and review of facility records.
Untrained Staff Performed Improper Transfer Resulting in Resident Injury
Penalty
Summary
The facility failed to protect a resident from neglect by allowing an untrained Hospitality Aide to perform a transfer using the resident's personal sit-to-stand transfer device. The aide was not trained or oriented to use this equipment, and no staff in the facility had received training or competency checks for its use. Despite the Director of Therapy informing the former DON that staff should not use the device and that there was no manual for it, the device remained in the resident's room and was used by staff without proper authorization or training. The resident involved had significant medical needs, including paraplegia, muscle weakness, unsteadiness, osteomyelitis, and thoracic spine pain. Her care plan required assistance with transfers and specified the use of a sit-to-stand device, which was later discontinued after the incident. On the day of the event, the Hospitality Aide, who was not permitted by her job description to perform transfers, responded to the resident's call light after it had been on for about 20 minutes. The aide admitted to not knowing how to use the device but proceeded with the transfer at the resident's request, resulting in the resident falling and sustaining a left knee fracture. Interviews and record reviews confirmed that the Hospitality Aide was not trained for transfer skills until after the incident, and other staff members also lacked training on the device. The administrator was unaware that untrained staff were performing transfers and believed that the prior DON had ensured all necessary training. The Director of Therapy had communicated concerns about the device's use, but these were not acted upon. The incident was captured on video, and subsequent interviews with staff and the resident confirmed the lack of training and improper transfer procedures that led to the resident's injury.
Untrained Staff Use of Resident-Owned Transfer Device Results in Fall and Fracture
Penalty
Summary
A deficiency occurred when a resident with paraplegia, muscle weakness, and impaired lower extremity range of motion was not provided with adequate supervision and assistive devices to prevent accidents. The resident required partial to moderate assistance for transfers and had a care plan indicating the need for staff assistance and the use of a sit-to-stand device, which was later discontinued. The sit-to-stand device used for the resident's transfer was the resident's personal property and not owned by the facility, and there was no manual available for staff training on its use. On the day of the incident, a hospitality aide who was not trained or competency-checked for transfer skills or the use of the sit-to-stand device attempted to transfer the resident to the bathroom. The aide had previously informed the resident of her lack of training, but proceeded with the transfer at the resident's urging. During the transfer, the aide was unable to properly position the resident, and the resident's legs gave out, resulting in a fall and a left knee fracture. The aide was unable to use a gait belt and had difficulty maneuvering the device in the small bathroom. Another aide, also untrained on the device, assisted in lifting the resident from the floor. The hospitality aide's job description did not include performing resident transfers, and the facility's policy required the use of a gait belt for all transfers. The administrator and therapy staff were unaware that untrained staff were using the resident's personal transfer device, and there was no documentation of staff training or competency checks for the equipment. The incident was confirmed through video evidence, staff interviews, and record review, revealing that the lack of proper training, supervision, and equipment ownership led to the resident's injury during the transfer.
Failure to Timely Document Resident Transfer to ER
Penalty
Summary
A deficiency occurred when a registered nurse (RN) failed to document the transfer of a resident to the emergency room (ER) following an episode of altered mental status and hypoxia. The resident, a female with a history of hip fracture, end stage renal disease, osteoporosis, and calciphylaxis, was transferred to the hospital but the event was not recorded in the clinical record at the time it occurred. The late entry documenting the transfer was created by the Director of Nursing (DON) over a week later. Additionally, the resident's family was not notified of the transfer at the time, and only learned of the hospitalization and subsequent diagnosis of urinary tract infection upon visiting the facility later that day. Interviews with the RN and DON confirmed that the proper procedure for timely documentation was not followed. The RN could not confirm that the family was notified, and acknowledged the failure to document the event as it happened. The facility's policy requires that all clinical events be documented in a comprehensive and timely manner, but this was not adhered to in this instance, resulting in incomplete and inaccurate clinical records for the resident.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for three residents, which led to deficiencies in addressing their specific needs. Resident #4's care plan did not include any problem, goal, or intervention related to his use of smokeless tobacco, despite observations of him using chewing tobacco in his room. This oversight indicates a lack of attention to his personal habits and potential health implications. Resident #44's care plan did not address the use of a trapeze bar for bed mobility, even though it was observed in his room and used by the resident. Interviews with staff revealed confusion about the necessity of a physician's order for the trapeze bar and whether it should be included in the care plan. This lack of documentation and clarity could lead to improper use and monitoring of the device, affecting the resident's mobility and safety. Resident #76's care plan failed to address his amputation and the use of a prosthetic leg, and it did not ensure the implementation of a fall mat as an intervention for his fall risk. Observations confirmed the absence of a fall mat in his room, and staff interviews highlighted a disconnect between care plan documentation and actual practice. This deficiency in care planning could result in inadequate support for the resident's mobility and increased risk of falls.
Inaccurate MDS Assessments for Tobacco and Anticoagulant Use
Penalty
Summary
The facility failed to ensure accurate completion of the Minimum Data Set (MDS) assessments for two residents, which could impact the care and services provided. Resident #4's MDS did not reflect his use of smokeless tobacco, despite observations and interviews confirming his use. The resident, a male with severe cognitive impairment, was observed with chewing tobacco on his bedside table, which he confirmed using. The MDS and care plan lacked documentation of this tobacco use, which is a necessary component for accurate resident assessment and care planning. Similarly, Resident #24's MDS failed to document her use of an anticoagulant medication, Pradaxa, prescribed for a cerebral infarction. Despite the physician's order for the medication, the MDS did not indicate its use. The resident, a female with a history of respiratory failure and dementia, was cognitively intact according to her MDS. Interviews with the MDS coordinator and the Director of Nursing (DON) revealed that the oversight was due to staff not thoroughly reviewing documentation, and there was no specific policy for MDS completion beyond following the CMS Resident Assessment Instrument User's Manual.
Failure to Conduct Annual Criminal Background Checks
Penalty
Summary
The facility failed to develop and implement written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents, as well as the misappropriation of resident property. This deficiency was identified during a review of employee files, specifically for Employee C, where it was found that the facility did not complete the required annual Criminal Background Checks. The last check for Employee C was conducted on December 2, 2022, and the oversight was acknowledged by the Human Resource Specialist, who had only been in the position for three weeks and had not yet reviewed all staff files for compliance. Interviews with the Human Resource Specialist and the Administrator revealed that the responsibility for ensuring annual Criminal History checks lies with the Human Resource Specialist. The failure to conduct these checks could potentially place residents at risk for abuse, neglect, and exploitation. The facility's policy, revised in 2017, mandates criminal background checks within 72 hours of employment and annually thereafter. However, this procedure was not followed for Employee C, as confirmed by the Administrator, who acknowledged the lapse in protocol and the potential negative outcomes of not conducting these checks.
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What surveyors actually found near you
We read the 23 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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A prioritized, do-first checklist
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Nursing homes near Graham
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avir At Graham | 1 mi | ★★★★★ | 15 | 0 |
| Olney Rehabilitation And Care Center | 21.9 mi | ★★★★★ | 8 | 0 |
| Avir At Jacksboro | 25.5 mi | ★★★★★ | 12 | 0 |
| Villa Haven Health And Rehabilitation Center | 30 mi | ★★★★★ | 8 | 0 |
| Palo Pinto Nursing Center | 32.3 mi | ★★★★★ | 4 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.