Health inspection·October 18, 2024

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to develop and implement written policies and procedures prohibited and prevented abuse, neglect, and exploitation, of residents and misappropriation of resident property for 1 of 4 employee files (Employee C) reviewed for abuse protocol. Residents Affected - Few The facility failed to complete annual Criminal Background Checks for Employee C. This failure could place residents at risk for abuse, neglect, and exploitation. Findings include: In a record review of Employee C's personnel file reflected the facility did not complete annual Criminal History checks. The last check completed was date 12/2/22. In an interview on 10/16/24 at 4:45 PM, the Human Resource Specialist said the annual Criminal History checks for Employee C were not completed. He said it was the responsibility of the Human Resource Specialist to ensure reference checks were completed and documented during annual review. He said Criminal History checks helped prevent abuse . Human Resource Specialist stated he has worked for facility for only 3 weeks and has not completed reviews of all staff to see if background checks and training are up to date. Human Resource Specialist stated the former HRS must have missed the annual background check for Employee C. In an interview on 10/17/24 at 5:15 PM, the Administrator said Human Resources should be completing employee reference checks prior to employment and annually. The Administrator said Employee C's Criminal History was not checked or documented. The Administrator said a potential negative outcome of not checking employee Criminal History annually was to ensure the facility did not employ a person whose criminal history did not put the safety for the resident in jeopardy. A Criminal Background check was conducted for Employee C on 10/16/24, Employee C was employable. Record review of the facility's policy Criminal Background Checks , dated as revised 11/17/2017, reflected the following [in part]: Policy: It is the policy of the company to conduct criminal background checks of all applicants within 72 hours of employment . and complete annual Criminal History checks, Procedure: 6. The Criminal History Coordinator will be responsible for obtaining reference checks and licensure verification/registries prior to employment and annually. Written documentation of reference (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 455968 Printed: 05/15/2026 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 455968 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2024 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)