F 0842
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in
accordance with accepted professional standards.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview, and record review the facility failed to maintain clinical records that were complete and/or
accurate for 1 of 10 residents (Resident #1) reviewed for clinical records in that:
The RN A did not document Resident # 1 was transferred to the ER on 5.12.25.
This failure could place residents at risk of inaccurate and incomplete clinical records resulting in an
inaccuracy in the care the resident received.
The findings include:
Record review Record review of Resident # 1's Face Sheet revealed she was a [AGE] year-old female
originally admitted to the facility on 4.20.25 and readmitted on 5.20.25. She had diagnoses of fracture of
hip, end stage renal disease (last stage of kidney failure) osteoporosis (porous brittle bone that breaks
easily with spontaneous fractures common), and calciphylaxis (rare and life-threatening syndrome which
involves calcium buildup in the skin and fat tissue leading to clotting and painful lesions).
Record review of admission MDS dated 5.3.25 documented Resident #1 had a BIMS score of 7 (which
indicated moderate cognitive impairment).
Record review of Resident #1's Nursing progress Notes for 5.12.25 stated:
Transfer Notification - Late entry
Effective Date:
5/12/2025 10:38:0
Created By: DON
Created Date :
5/23/2025 11:21:03
Resident was transferred to a hospital on [DATE] 10:38 AM related to AMS
(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
05/23/2025
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 0842
Hypoxia(low oxygen content in the blood)
Level of Harm - Minimal harm
or potential for actual harm
This is intended to serve as notice of an emergency transfer
Residents Affected - Few
Record review of the nurses note dated 5.12.25 indicated Resident #1 returned to the facility with a
diagnoses of urinary tract infection at 1:39 PM on 5.12.25
Resident #1 was nonresponsive and unavailable for an interview at the time of the investigation.
In an interview on 5.22.25 at 2:30 PM, Resident # 1's family member said she was not aware of Resident
#1's transfer to the emergency room on 5.12.25 @ 10:38 AM when she experienced an altered mental
status. She stated she found out the resident had a UTI when she visited the resident at the nursing facility
later that day.
In an interview on 5.23.25 at 11.43 AM RN A stated she thought she did notify Resident #1's family
member
of the transfer on 5.12.25 but if it was not documented, and the family member stated she did not notify her
she could not state with certainty that she did notify her. She stated she failed to follow proper procedure by
not documenting the event when it occurred which could result in an inaccuracy in the care the resident
received.
In an interview on 5.23.25 at 11:50 AM the DON stated she was in the facility and she and another nurse
were present and assisted with the transfer. She stated it was her expectation that resident information was
documented in a resident's record at the time it occurred. She stated if documentation were not made a late
entry could be made at a later date and identified as a late entry with the date and time the event occurred
and the time and date the documentation was created.
Record review of the facility's policy, Documentation not dated, revealed [in part]:
Documentation is the recording of all information, both objective and subjective, in the clinical record of an
individual resident. The facility will maintain complete and accurate documentation for each resident.
The facility will ensure that information is comprehensive and timely and properly signed.
Complete documentation in the electronic health record in a timely manner.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
455968
If continuation sheet
Page 2 of 2
