Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Graham Hospital during CMS and state inspections, most recent first.
Failure to implement ordered pressure relief and update the care plan led to facility-acquired pressure injuries. A cognitively intact resident who was dependent for care had a stage II pressure injury to the right gluteus and a stage IV pressure ulcer to the right big toe/foot. The care plan did not include current pressure-relieving interventions, charting showed prolonged sitting without repositioning, and the resident was observed without heel protectors despite orders for turning/repositioning q2h and heel protectors at all times.
Care plans were not individualized to reflect each resident's specific needs, conditions, and preferences. The DON stated he was responsible for initiating and revising care plans for all residents, but the facility's EMR could not customize interventions for individual residents. He confirmed that all 21 residents had care plans based on diagnoses, but individualized interventions were not reflected.
Unsafe Food Handling and Cross-Contamination During Meal Prep: A cook was observed cleaning food prep areas with a wash rag while food on the steam table remained uncovered, then using the same rag to clean a food thermometer and handle food-related items. The cook did not perform hand hygiene or wear gloves, and the Dietary Supervisor and DON confirmed staff are expected to use hand hygiene, gloves, and clean thermometers between uses; the DON also stated the facility had no policy to guide proper food temperature checks.
The facility failed to maintain an effective infection prevention and control program by not tracking resident and staff illnesses or distinguishing facility-acquired from community-acquired infections. The Infection Control Nurse said employee illness was not being tracked, and the resident infection log did not consistently identify infection source or include all illnesses. The facility also failed to use EBP during incontinent care for a resident with an indwelling catheter and wounds, as two CNAs wore gloves but no gowns while providing direct care.
The facility failed to ensure the designated Infection Preventionist completed required IPC training before serving in the role. The Administrator stated there was no certification of completion on file, and the Infection Control Nurse said she had been serving as the Infection Preventionist since July 2025 but had not finished the required modules or received certification. The facility’s CMS Form 671 documented 21 residents in the facility.
A resident with severe cognitive impairment and an indwelling urinary catheter had her drainage bag left uncovered and visible from the room doorway while she sat in a recliner with the door open. The bag was hanging on the side of the bed facing the door and was partially filled with yellow urine. The Administrator stated the bag should be covered with a dignity bag if it could be seen from the room.
Inaccurate MDS coding was found for two residents in Section P. Both residents had physician orders for bilateral upper side rails for positioning and bed mobility, but their MDS assessments coded the side rails as daily restraints. The DON stated the side rails were used for positioning and were not restraints, and the MDS Coordinator confirmed the coding was inappropriate and reported no formal training in Section P coding.
A resident with severe cognitive impairment and stroke-related right-sided deficits had documented ROM limitations and impaired mobility, but the care plan did not include any restorative program to address these needs. The resident was observed with a flaccid right arm and leg, a private caregiver reported staff never performed ROM, and the DON stated the resident received no restoratives or ROM exercises and the facility had no restorative nurse to assess or establish such programs.
Failure to Assess Bed Rail Entrapment Risk: The facility failed to complete a bed rail assessment to identify entrapment risk and failed to document alternatives tried before installing bilateral upper rails for a resident with anxiety/depression, hx of CVA, and generalized weakness. The resident was moderately cognitively impaired, dependent for rolling and transfers, and had quarter side rails in place; the DON confirmed no bed rail assessment or documented alternatives had been completed before the rails were used.
The facility failed to use temperature testing strips for dishwashing, maintain cleanliness of kitchen light covers, and record cool down temperatures for prepared meats, potentially affecting all 22 residents. The Dietary Manager admitted to not using test strips or maintaining cool down logs, and the Director of Plant Operations confirmed the lights were not cleaned by the contracted company.
The facility failed to implement restorative programs for several residents with range of motion limitations due to a lack of a restorative aide. Residents and family members reported not receiving prescribed exercises, and documentation was missing for extended periods. The Director of Nursing confirmed the absence of restorative programs, contributing to the deficiency.
A facility failed to refer a resident for a Level II PASRR evaluation after the resident exhibited new behavioral symptoms and was prescribed Zyprexa for Refractory Depression with Psychotic Symptoms. Despite the facility's policy requiring such referrals for significant changes in condition, no referral was made, and the administrator admitted to not requesting the necessary evaluation.
Failure to Implement Pressure Relief and Update Care Plan
Penalty
Summary
The facility failed to implement physician-ordered pressure relieving interventions for a resident who was cognitively intact, dependent on staff for toileting, rolling left and right, and personal hygiene, and identified as at risk for pressure ulcers. The resident’s most recent MDS documented a stage II facility-acquired pressure ulcer and that the resident was on a turning and repositioning program. The facility’s wound prevention policy required interventions to reduce pressure, maintain skin integrity, and incorporate prevention measures into the plan of care. Record review showed the resident’s care plan, active since 7/20/25, identified high risk for impaired skin integrity but did not include pressure relieving interventions to prevent pressure ulcers or interventions to address the resident’s current pressure ulcers to the right gluteus and right foot. Wound clinic notes documented a stage two pressure injury to the right gluteus with a date acquired of 7/29/25 and a stage four pressure ulcer to the right foot/base of the big toe with a date acquired of 10/20/25. The right foot wound had necrotic tissue and eschar and required open wound debridement. Off-loading orders included a pressure relieving cushion to the wheelchair, turning and repositioning every two hours, and heel protectors at all times. Electronic charting showed the resident remained in the same seated position in a chair for prolonged periods on 3/30/26 and 3/31/26, with no documentation that the resident refused repositioning. During those same timeframes, the resident was observed seated in a padded wheelchair with bilateral heels resting on the footrests and was not wearing heel protector boots. Later, the resident was lying on the right side in bed without heel protectors. The DON stated the resident had a physician’s order to be turned and repositioned every two hours, that turning and repositioning every two hours was the facility’s standard, and that the care plan did not include pressure relieving interventions or current interventions for the wounds. The wound nurse practitioner confirmed the resident had orders for turning and repositioning every two hours and heel protector boots at all times, and confirmed the right gluteus and right big toe wounds were caused by pressure and were facility acquired.
Care Plans Not Individualized
Penalty
Summary
The facility failed to ensure residents' comprehensive care plans were individualized to reflect each resident's specific needs, conditions, and preferences. The facility's Care Plan Policy revised 3/10/25 states the individualized care plan is used to outline the care patients shall receive during their stay, with goals that are realistic, individualized, patient centered, measurable, dated, and reviewed daily. The Patient/Resident Care Plan and Care Conference policy revised September 2025 states residents shall have an individualized care plan. The CMS Form 671 dated 3/30/26 and signed by the Administrator documented 21 residents in the facility. During interview on 4/01/2026, the DON stated he was responsible for initiating and revising care plans for all residents and that he develops comprehensive care plans based on resident diagnoses and revises them as new diagnoses are identified. He further stated he did not have the capability within the facility's EMR system to customize interventions for individual residents and planned to eventually switch to a new system better suited for LTC. The DON confirmed that all 21 residents currently residing in the facility did not have individualized interventions reflected in their care plans.
Unsafe Food Handling and Cross-Contamination During Meal Preparation
Penalty
Summary
Sanitary conditions were not maintained during food preparation and service when a cook was observed cleaning main food preparation areas with a wash rag while food on the steam table remained uncovered. The same wash rag was then placed on the counter and used to clean a food thermometer between temperature checks of food on the steam table. During the observation, the cook also wiped sauce from the lasagna with her fingers onto the same wash rag used to clean the counters and thermometer. When checking hamburger temperatures, the initial holding temperature was 142 F, and the cook stated the hamburgers would be returned to the steamer for reheating. The cook handled the pan using the same contaminated wash rag and placed the rag back on the counter. At no time during the observation did the cook perform hand hygiene or don gloves, and the same wash rag continued to be used for cleaning surfaces and the thermometer throughout food handling activities. The Dietary Supervisor stated staff are expected to perform hand hygiene and wear gloves when handling food, and thermometers should be cleaned between uses with an alcohol swab. The Dietary Director stated that if a wash rag is used for cleaning a thermometer, it should be clean and used for a single purpose only, and confirmed the cook should have performed hand hygiene, worn gloves, and not used the same rag for multiple tasks. The Dietary Director also stated the facility does not have a policy or procedure to guide staff on proper techniques for obtaining food temperatures.
Infection Control Surveillance and Enhanced Barrier Precautions Failures
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program by not performing surveillance to track and monitor resident and staff illnesses and by not differentiating between resident facility-acquired and community-acquired infections. The Infection and Prevention Control Program Plan stated that surveillance of infections, both community acquired and healthcare acquired, would be conducted, and the Infection Prevention Surveillance Policy required review of data sources such as elevated temperatures, respiratory difficulty, wounds, diarrhea, and rash, with collected data recorded and tabulated by site and other factors. However, review of the infection control surveillance logs from January 1, 2026 through March 31, 2026 showed no tracking log of resident illnesses or employee illnesses and no identification of whether resident illnesses were facility-acquired or community acquired. During interview, the Infection Control Nurse stated she had not been tracking employee illness since starting the position in July 2025 and said she had been told not to track employee illnesses because the facility was not allowed to ask why staff called in. She also verified that although an antibiotic tracking log was maintained for residents each month, it did not consistently specify whether an infection was house-acquired or community acquired and did not include a comprehensive record of all resident illnesses other than infections treated with an antibiotic. The facility's Investigation Protocol for Infection Surveillance also stated that the hospital shall investigate infections and determine whether staff are well and have no contagious symptoms present. The facility also failed to implement Enhanced Barrier Precautions while providing incontinent care for a resident who had an order for Enhanced Barrier Precautions, an indwelling urinary catheter, and wounds to the right foot and right gluteus. The resident had a sign on the doorway indicating Enhanced Barrier Precautions. While two CNAs were providing incontinent care to the resident, both wore gloves but did not wear gowns. One CNA stated they did not have time to put on gowns, and the Infection Control Nurse later stated that all employees providing direct care to any resident placed in Enhanced Barrier Precautions should be wearing gowns and gloves while providing direct care.
Infection Preventionist Lacked Required IPC Training
Penalty
Summary
The facility failed to ensure that the designated Infection Preventionist completed specialized Infection Prevention and Control (IPC) training before performing the role. The facility’s Infection and Prevention Control Program Plan, dated March 2024, states that the Infection Control Professional is a registered nurse with knowledge of epidemiology practices, microbiology, and infectious disease who has completed or shall complete a course in infection control approved by the CDC and directs the Infection Control Program. During interview, the Administrator stated that the Infection Control Nurse had not completed IPC training to her knowledge and could not provide a certification of completion. The Infection Control Nurse stated that she had been the Infection Preventionist since July 2025 and had not yet completed the required training, explaining that she had started some infection control modules but did not finish them all and therefore never received a certification of completion. The facility’s CMS Form 671 dated 3/30/26 documented that 21 residents resided in the facility.
Uncovered urinary catheter bag observed in resident room
Penalty
Summary
The facility failed to ensure a resident's indwelling urinary catheter drainage bag was covered to maintain dignity for one resident reviewed for dignity. The resident, who was severely cognitively impaired and had an indwelling catheter, had physician orders for the catheter in place. During observation, the resident was sitting in a recliner in her room with the door open, and her urinary catheter drainage bag was seen hanging on the side of her bed facing the door without a dignity bag covering it. The bag was one fourth full of yellow urine. The Administrator later stated the catheter bag should be covered with a dignity bag if it could be seen from the resident's room and acknowledged uncertainty as to why the resident did not have a privacy bag covering the catheter bag.
Inaccurate MDS Coding for Side Rail Restraints
Penalty
Summary
The facility failed to accurately code the MDS assessments for two residents, R5 and R8, in Section P regarding restraints and alarms. CMS RAI Manual Section P states that assessors must record only devices that meet the definition of a physical restraint or alarm during the seven-day look-back period. R8’s physician order documented bilateral upper side rails for positioning and bed mobility, and her MDS coded the side rails as a daily restraint even though, during interview, she stated she used the side rails to position herself in bed and that they did not restrain her. R5’s physician orders also documented bilateral upper side rails for positioning and bed mobility, yet her MDS likewise coded side rails as a daily restraint. The DON stated that R5 and R8 used side rails for positioning and that the side rails were not being utilized as restraints. The MDS Coordinator stated she had not received formal training regarding coding Section P and confirmed that R5 and R8 did not use side rails as restraints, and that their Section P assessments were inappropriately coded.
Failure to Provide Restorative ROM Program for Resident with Stroke-Related Impairment
Penalty
Summary
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason, was not met for one resident with impaired mobility and ROM limitations. The facility’s Restorative Range of Motion Policy states the program is intended to maintain and improve joint mobility, prevent contractures, pain, and edema, and maintain or improve ROM for extremities with decreased ability and movement. The policy also states a restorative nurse is to conduct the program on a one-to-one basis, and a physician’s order is required for establishing treatment. R6’s MDS documented severe cognitive impairment, functional limitations in ROM to one upper extremity and one lower extremity, dependence on staff for ADLs, and no restorative nursing programs, including ROM programs. The care plan identified CVA with right-sided sensory deficit and impaired mobility, including compromised ability to move, ROM limitation, decreased muscle strength, impaired coordination, imposed restriction of movement, and reluctance to move, but it did not include any restorative programs to address the impaired mobility. During observation, R6’s right arm and right leg were flaccid, and an agency RN stated R6 had a stroke and was unable to move the right arm or right leg. The private caregiver stated staff had never been seen doing ROM with R6, and the DON stated R6 did not receive any restoratives or ROM exercises and that the facility did not have a restorative nurse to assess or establish restorative programs.
Failure to Assess Bed Rail Entrapment Risk
Penalty
Summary
The facility failed to assess and identify entrapment risk associated with the use of side rails and failed to document alternatives to side rails with outcomes before installing side rails for one resident reviewed in a sample of 21. The facility’s Side Rails and Entrapment Policy, dated February 2026, states that individual bed rail evaluations should include data collection, analysis, and determination of potential alternatives to bed rail use, and that residents or representatives should be educated on the risks and benefits when bed rails are deemed necessary and appropriate. The resident had diagnoses including anxiety with depression, history of completed stroke, general weakness, fall downstairs, strain of left elbow, and neck muscle strain. Physician orders dated 3/30/26 documented bilateral upper rails starting 3/16/26 for positioning, bed mobility, getting in and out of bed, and spatial awareness. The MDS dated 3/18/26 documented that the resident was moderately cognitively impaired, required dependent assistance with rolling side to side and transfers, and used side rails daily. The medical record did not include a side rail assessment for entrapment risk or documentation of alternatives tried before side rails were implemented. During observation on 3/30/26, the resident’s bed had bilateral quarter side rails in the upright position, and the DON verified that a bed rail assessment and documented alternatives had not been completed prior to implementation.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to proper food safety protocols in several areas, which could potentially affect all 22 residents. Firstly, the facility did not use temperature testing strips to ensure that dishes reached the required surface temperature during the rinse cycle in the dish machine. The Dietary Manager acknowledged that while the dishwasher is a high-temperature machine, the staff only checked the temperature using the gauge on the machine and had stopped using the test strips, which are essential for verifying the correct surface temperature. Additionally, the facility did not maintain cleanliness in the kitchen, specifically with the hanging light covers over the fryer baskets, which were found to be coated with grease and grime. The Dietary Manager was unsure who was responsible for cleaning these lights, and the Director of Plant Operations confirmed that the contracted cleaning company did not include these lights in their cleaning process. Furthermore, the facility did not complete and record cool down temperatures for prepared meats and leftover items stored in the refrigerator and freezer. The Dietary Manager admitted that they did not keep a cool down log for hot foods, which is a deviation from the facility's policy that requires monitoring and recording of cooling temperatures to ensure food safety.
Failure to Implement Restorative Programs for Residents
Penalty
Summary
The facility failed to develop and implement restorative programming for several residents with limitations in range of motion. Specifically, five residents were identified as not receiving the necessary range of motion exercises as outlined in their care plans. For instance, one resident with impaired mobility due to Parkinsonism and a past hip fracture did not receive the prescribed range of motion exercises for 53 days. Another resident, who is cognitively intact and has impairments in both lower extremities, reported not receiving daily exercises despite the care plan's requirement for twice-daily exercises. The facility's lack of a restorative aide contributed significantly to the deficiency. The Director of Nursing acknowledged that the facility had not had a restorative aide for some time, and the recently hired aide quit during orientation. This staffing issue resulted in the failure to complete restorative programs for residents, as evidenced by the absence of documentation for several residents over extended periods. One resident's care plan did not even include interventions to address their limitations in range of motion, highlighting a gap in care planning. Family members and residents themselves expressed concerns about the lack of restorative exercises. A family member of one resident noted never witnessing staff perform range of motion exercises, while another resident expressed a desire for more exercise to improve mobility. The facility's reliance on the restorative aide job description as the policy for performing restorative programs was insufficient to ensure the necessary care was provided, leading to the identified deficiencies.
Failure to Refer Resident for Level II PASRR Evaluation
Penalty
Summary
The facility failed to refer a resident to the PASRR State Agency for a Level II PASRR evaluation after the resident experienced a significant change in behavioral and psychiatric symptoms. The resident, who was being reviewed for mental illness, began exhibiting new symptoms such as delusions of dust being present on her face, ears, and other objects, which led to her being prescribed Zyprexa for Refractory Depression with Psychotic Symptoms. Despite these changes, the facility did not initiate a Level II PASRR referral as required by their policy. The facility's policy mandates that any resident with a decline or worsening in behavioral health conditions should be referred to the state agency for a Level II PASRR evaluation. However, the resident's medical record showed no evidence of such a referral being made after the onset of new symptoms and the prescription of an anti-psychotic medication. The facility administrator acknowledged the oversight, stating that a Level II PASRR had not been requested for the resident since the new behaviors and medication were introduced.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Canton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sunset Rehabilitation And Health Care | 0.3 mi | — | 3 | 0 |
| Renaissance Care Center | 1.8 mi | — | 1 | 0 |
| Loft Rehab & Nursing Of Canton | 2.7 mi | — | 1 | 0 |
| Clayberg, The | 9.2 mi | — | 0 | 0 |
| Farmington Village Nrsg | 9.6 mi | — | 0 | 0 |
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