Graham Oaks Care Center

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

with 10 staff members Hospitality Aides A, B, C, K, E, D, F, G, H, I, J (formerly titled Hospitality aides but now classified as Nurses' Aides) between 2:00 PM and 4:00 PM on 10/9/25 reflected that they all attended

a training skills lab on 9/3/25 and competed competency checks on 9/11/25. They stated hey were trained

on Abuse and Neglect, Safe Transfers, an checked off on the Hoyer lift. Hospitality Aides A, B, C, K, E, D, F, G, H, I and J stated they were not allowed to operate the hydraulic controls and must transfer a mechanical lift with 2 people. Observed Hospitality Aide B and CNA 1 perform a Hoyer lift on 10/4/25 at 1:30 PM using 2 people on Resident #4 and proper procedure and all all-safety rules were followed, and no incidents were noted. Correction #8Reviewed QAPI minutes for meeting last held 10.3.25. Reviewed PIP dated 9/3/25 for incident. Meeting attended by medical director. Signed on 10/3/25. Correction # 9Interview with the Medical Director on 10/6/25 at 4:00 PM verified that he had been notified of the incident and the PIP on 9/3/25.

Correction #10 Reviewed monitoring by the facility of ADL assistance initiated on 9/3/25 revealed that the monitoring was complete and current with evidence of monitoring from 9/3/25 to 10/9/25. Monitoring continues daily at the time of exit. 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.

Event ID:

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/10/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Graham Oaks Care Center

1325 First St Graham, TX 76450

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

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.

Event ID:

Facility ID:

If continuation sheet