Graham Oaks Care Center
1325 First St · Graham, TX · 76450 · 9405498787
110 certified beds For profit - Limited Liability company Chain: Creative Solutions in Healthcare
Why this verdict
- Carries CMS’s abuse warning icon.
- Inspectors found immediate jeopardy — danger of serious harm or death — in the most recent cycle (2 citations).
- Staffing levels are well below research benchmarks for safe care.
Red flags
CMS abuse warning
CMS flags this facility with its abuse icon: cited for abuse that caused harm in the past year, or potential harm in the past two years.
2 immediate-jeopardy citations in the most recent inspection cycle
Immediate jeopardy is the most serious finding an inspector can make: a situation likely to cause serious injury, harm, or death.
1 abuse-related citation at the actual-harm level
Inspectors cited failures in the abuse-prevention rules (F600–F610) that resulted in actual harm to a resident.
Total nurse staffing below 3.0 hours per resident-day
2.14 reported hours vs the 3.48 minimum CMS's own staffing study recommends.
Weekends run noticeably short-staffed
Weekend staffing is 75% of the overall level. Visit on a Saturday or Sunday before deciding.
If someone you love was harmed at a facility with findings like these, you have options — read this.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 1 of 5 Inspections: 2 of 5 Staffing: 1 of 5 Quality measures: 3 of 5
| Total nurse hours / resident-day | 2.14 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.36 | 0.55–0.75 |
| Weekend hours / resident-day | 1.60 | ≈ weekday level |
| Nursing turnover / year | — | median 45% |
| Fines (3-yr window) | 2 · $34,690 |
Inspection citations (21 in the current record)
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Potential for harm · D March 25, 2026 · found via complaint
Provide and implement an infection prevention and control program.
Corrected March 26, 2026 · Infection Control
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No harm found · C November 8, 2025 · found via complaint
Follow rules about disclosure of ownership requirements and tell the state agency about changes in ownership and/or administrative personnel.
Corrected November 9, 2025 · Administration
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Immediate jeopardy · J October 10, 2025 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected September 3, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Immediate jeopardy · J October 10, 2025 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected September 3, 2025 · Quality of Life and Care
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Potential for harm · D May 23, 2025 · found via complaint
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected June 9, 2025 · Resident Assessment and Care Planning
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Potential for harm · D January 22, 2025 · found via complaint
Ensure each resident receives an accurate assessment.
Corrected January 23, 2025 · Resident Assessment and Care Planning
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Potential for harm · E January 22, 2025 · found via complaint
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected January 23, 2025 · Resident Assessment and Care Planning
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Potential for harm · D October 18, 2024 · found via complaint
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected October 25, 2024 · Freedom from Abuse, Neglect, and Exploitation
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Actual harm · G December 7, 2023
Provide safe, appropriate pain management for a resident who requires such services.
Corrected December 8, 2023 · Quality of Life and Care
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Potential for harm · E December 7, 2023
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected January 5, 2024 · Resident Assessment and Care Planning
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Potential for harm · D December 7, 2023
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected January 5, 2024 · Resident Assessment and Care Planning
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Potential for harm · D December 7, 2023
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected January 5, 2024 · Pharmacy Service
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Potential for harm · D December 7, 2023 · found via complaint
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected January 5, 2024 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D August 9, 2023 · found via complaint
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected August 29, 2023 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D October 25, 2022
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected November 15, 2022 · Resident Assessment and Care Planning
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Potential for harm · E October 25, 2022
Provide safe and appropriate respiratory care for a resident when needed.
Corrected November 15, 2022 · Quality of Life and Care
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Potential for harm · D October 25, 2022
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected November 15, 2022 · Pharmacy Service
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Potential for harm · E October 25, 2022
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected November 15, 2022 · Pharmacy Service
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Potential for harm · E October 25, 2022
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected November 15, 2022 · Pharmacy Service
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Potential for harm · E October 25, 2022
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected November 15, 2022 · Nutrition and Dietary
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Potential for harm · D October 25, 2022
Provide and implement an infection prevention and control program.
Corrected November 15, 2022 · Infection Control
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| October 10, 2025 | Fine | $17,345 |
| October 10, 2025 | Fine | $17,345 |
Better-scoring options nearby
Family & resident reviews — a separate signal, never mixed into the score
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 455968 · certified since October 28, 1991. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.