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Complaint Investigation

Graham Oaks Care Center

October 10, 2025 · Graham, TX · 1325 First St
Citations 2
CMS Rating 1/5
Beds 110
Provider ID 455968
Healthcare Facility
Graham Oaks Care Center
Graham, TX  ·  View full profile →
Inspection Summary

Graham Oaks Care Center in Graham, TX — inspection on October 10, 2025.

Found 2 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF0600
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Immediate Jeopardy

During an Interview with the Administrator on 10/10/25 at 8:00 AM stated she only had 1 hospitality aide left in the building as of 10/9/25.

She stated everyone else had completed training and skills checks and were ready to test.

She stated scheduling was in process with herself and the new DON monitoring compliance During an Interview with Resident #1 on 10/9/25 at 4:00 PM she stated she had not been transferred by staff other than CNAs, and LVN, and that no Hospitality Aides had transferred her since the incident.

She stated they always use 2 people to transfer.

She stated she was transferred by the Hoyer lift and that her family member was asked by the administrator to remove the sit to stand device from the building.

During an Interview with the current DON and the RNC on 10/9/25 at 4:10 PM both stated all Hospitality aides were checked off on transfer skills as of 9/19/25.

Interviews with 7 Nurses' Aides (B, D, E, F, G, H, I, J) and one Hospitality Aide K on 10/9/25 between 9:00 and 10:00 AM were able to state their job description and duties they were allowed to perform.

They stated they would go to the Kardex in the point of care to make sure what kind of care they needed.

Hospitality Aide K stated she was told by the administrator that she cannot work on the floor until she passes her Texas Nurse's Aide Training requirement online and supervised clinical with competency checks.

During Interviews with resident numbers 1,3,4,5,6,7 and 8 on 10/9/25 between 11:00 AM and 1:00 PM all stated that that they were transferred appropriately and had no transfer related incidents.

Residents #1, #7 and #4 stated that were transferred by a Hoyer lift by two people, and never just by one person.

Residents stated they could tell if a resident was a Hospitality Aide or CNA or a Nurse's Aide by looking at their employee's name badge.

They stated Hospitality aides were not allowed to transfer residents.

Record reviews of skills checklist and CNA online training revealed certificates of training and skills check lists for Nurses' Aides B, E, F, G, H, I, J and one Hospitality Aide K were in their employee files and dated before entrance.

During Interviews on 10/9/25 between 11:00 and 1:00 PM Nurses' Aides B, D, E, F, G, H, I, J and one Hospitality Aide K stated they signed a nurse's aide job description stating their duties and name tags were updated to reflect their current job duties.

Record review of Resident #1's care plan reflected that she was a Hoyer lift as of 9/3/25.

Record review of Resident #'s 1, 2, 3, 4, 5, 6, and 7's care plan and Kardex reflected accuracy.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

10/10/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Graham Oaks Care Center

1325 First St Graham, TX 76450

SUMMARY STATEMENT OF DEFICIENCIES

During an Interview with the current DON and the RNC on 10/9/25 at 4:10 PM both stated all Hospitality aides were checked off on transfer skills as of 9/19/25.

Interviews with 7 Nurses' Aides (B, D, E, F, G, H, I, J) and one Hospitality Aide K on 10/9/25 between 9:00 and 10:00 AM were able to state their job description and duties they were allowed to perform.

They stated they would go to the Kardex in the point of care to make sure what kind of care they needed.

Hospitality Aide K stated she was told by the administrator that she cannot work on the floor until she passes her Texas Nurse's Aide Training requirement online and supervised clinical with competency checks.

During Interviews with resident numbers 1,3,4,5,6,7 and 8 on 10/9/25 between 11:00 AM and 1:00 PM all stated that that they were transferred appropriately and had no transfer related incidents.

Residents #1, #7 and #4 stated that were transferred by a Hoyer lift by two people, and never just by one person.

Residents stated they could tell if a resident was a Hospitality Aide or CNA or a Nurse's Aide by looking at their employee's name badge.

They stated Hospitality aides were not allowed to transfer residents.

Record reviews of skills checklist and CNA online training revealed certificates of training and skills check lists for Nurses' Aides B, E, F, G, H, I, J and one Hospitality Aide K were in their employee files and dated before entrance.

During Interviews on 10/9/25 between 11:00 and 1:00 PM Nurses' Aides B, D, E, F, G, H, I, J and one Hospitality Aide K stated they signed a nurse's aide job description stating their duties and name tags were updated to reflect their current job duties.

Record review of Resident #1's care plan reflected that she was a Hoyer lift as of 9/3/25.

Record review of Resident #'s 1, 2, 3, 4, 5, 6, and 7's care plan and Kardex reflected accuracy.

Facility ID:

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Graham, TX, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Graham Oaks Care Center or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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