Epic Nursing & Rehabilitation
Epic Nursing & Rehabilitation in Corsicana, TX — inspection on September 4, 2025.
Found 4 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During an interview with the ADM on 09/04/2025 at 2:55pm, ADM that she was notified by the DON that a kitchen staff stated that Resident #4 had possibility drank bleach soap water.
The ADM stated that the only departments that use bleach were dietary and housekeeping.
The ADM stated after the incident, bleach would be securely kept in the offices of the DM and housekeeper supervisor.
The ADM stated that the resident was sent to the ER and her labs were all normal.
The ADM stated there would not be a negative outcome due to the resident not having an adverse effect.
Review of the facility's Safety and Supervision of Residents policy, revised dated July 2017, reflected Policy StatementPolicy Interpretation and ImplementationFacility-Oriented Approach to Safety1.
Our facility-oriented approach to safety addresses risks for group of residents.
Individualized, Resident-Centered Approach to Safety
676295 09/04/2025
Epic Nursing & Rehabilitation 3210 W Hwy 22 Corsicana, TX 75110
The facility failed to have an RN at
This failure could place residents at risk of not receiving adequate care and services of an RN, and decreased quality of life.
Findings included: An observation on 9/3/2025 at 11:22 am of the Daily Nurse Staffing Report posting reflected zero scheduled RN hours.
Further observation on the 9/3/2025 at 11:22 am of the Daily Nurse Staffing Report reflected zero schedule RN hours.
During an interview on 9/3/2025 at 12:15 pm, the DON stated she was not aware that her RN hours could not be used to fulfill the RN staffing hours requirement.
She stated she was not familiar with the average daily census requirement and thought her RN hours in addition to the weekend RNs that worked would cover all the required RN hours.
The DON stated she was responsible for nurse staffing hours but was not aware her hours could not be used to meet the required RN coverage hours.
During an interview on 9/3/2025 at 2:20 pm, the SC stated she had run the RN staffing report and there was no RN coverage for the dates of 8/11 to 8/15/2025, 8/18 to 8/22/2025, 8/25 to 8/28/2025, and 9/1/2025, 9/2/2025.
During an interview on 9/3/2025 at 3:34 pm, the SC stated the RN the facility used for covering RN staffing hours went out on leave 8/11/2025 and was not replaced.
During an interview on 9/3/25 at 4:51 pm, the RNC stated the ADM was responsible for making sure there was RN coverage. RNC stated she was not aware the RN hours could not be the same as the DON hours and was not aware of the average daily census of 60 criteria.
She stated she was aware the facility was using the DON's hours for RN coverage but was not aware that was not allowed.
She stated their average daily census was over 60. RNC stated she had provided RN coverage on 9/3 and 9/4/2025 as she had been in the building.
During an interview on 9/3/2025 at 5:15 pm, the ADM stated she was not aware the facility needed RN coverage hours other than what the DON provided.
The ADM stated it was the DON's responsibility to see that nurse staffing was correct.
She stated she was the interim ADM and did not know if their average daily census was over 60, they needed additional RN coverage hours. In an email on 9/3/2025 at 12:54 pm the ADM was asked to provide proof of RN coverage for 8 hours a day for the last 7 days.
The ADM replied via email on 9/3/2025 at 2:39 pm that the [DON] was in the building on 8/25/2-025 through 8/29/2025.
The ADM was asked via return email on 9/3/2025 at 2:41 pm if there were other RNs in the building for coverage at that time and ADM replied via email on 9/3/2025 at 2:47 pm Unfortunately, no.
Record review of Daily Nurse Staffing sheets for 9/2/2025, 9/3/2025 and 9/4/2025: For shift: 6a-6p, category: RN, total staff scheduled: 0, scheduled hours: 0.
For shift: 6p-6a, category: RN, total staff scheduled: 0 scheduled hours: 0.
Record Review of facility census sheet dated 9/3/2025 reflected the current census was 72 residents.
Review of facility policy Staffing, Sufficient and Competent Nursing, revised August 2022, reflected: Our facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment. 1.Licensed nurses and certified nursing assistants are available 24 hours a day, seven (7) days a week to provide competent resident care services including:a. assuring resident safety;b. attaining or maintaining the highest practicable physical, mental and psychosocial well-being of each resident;c. assessing, evaluating, planning and implementing resident care plans; andd. responding to resident needs.2. A licensed nurse is designated as a charge nurse on each shift.A. A licensed nurse may be a licensed practical nurse (LPN), licensed vocational nurse (L VN), or registered nurse (RN).b. A charge nurse is a licensed nurse with designated responsibilities that may include staff supervision, emergency coordination, provider or physician support and direct resident care.c.
The director of nursing services (DNS) may serve as the charge nurse only when the average daily occupancy of the facility is 60 or fewer residents.3. A registered nurse provides services at least eight (8) hours every 24 hours, seven (7) days a week.
676295 09/04/2025
Epic Nursing & Rehabilitation 3210 W Hwy 22 Corsicana, TX 75110
required time frame.5.
Medication administration times are determined by resident need and benefit,
and preferences, consistent with his or her care plan.6.
Medication errors are documented, reported,
training.7.
Medications are administered within one (I) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders).8. If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication will contact the prescriber, the resident's attending physician or the facility's medical director to discuss the concern.
676295 09/04/2025
Epic Nursing & Rehabilitation 3210 W Hwy 22 Corsicana, TX 75110
During an interview with LVN C on 09/03/2025 at 11:40am, LVN C stated that the ceiling has been like that for a while.
LVN C stated the water stains and black substance were cause by an air condition leak in the ceiling.
LVN C stated that black substance appeared to be mold to her. LVN C stated a negative outcome would be respiratory issues from the mold.
During an interview with the Maintenance Director on 09/03/2025 at 11:45am, Maintenance Director stated that he was aware of the water stains in the ceiling but had not been notified of any black substance in the ceiling.
The Maintenance Director stated the air condition unit in the secure had a leak a few weeks back but that had been fixed.
The Maintenance Director stated he was waiting for the ceiling to completely dry before fixing it.
The Maintenance Director stated that the company requires him to get three estimates before he could proceed to have the work completed.
The Maintenance Director stated that a negative outcome would be the ceiling would look less appealing, and the black substance could be mold.
The Maintenance Director stated if the black substance was mold, then that could cause respiratory issues for the residents on the secure unit.
During an interview with the DON on 09/04/2025 at 2:48pm, the DON stated she was aware that the ceiling had water stains and there was a black substance in the ceiling of the secure unit.
The DON stated that the Maintenance Director had recently fixed air condition leak in the attic on the secure unit.
The DON stated that the water stains and black substance in the ceiling would make the facility look less homelike.
The DON stated that she considered the black substance to be mold.
The DON stated that mold could cause respiratory issues for the residents and staff on the secure unit.
During an interview with the ADM on 09/04/2025 at 2:55pm, the ADM stated she was not aware of any water stains or black substance in the ceiling of the secure unit.
The ADM stated she was aware that air condition on the secure unit had a leak but had been fixed.
The ADM stated that she could not give any negative outcomes due to not knowing what the black substance was.
Review of the facility's Homelike Environment policy, revised dated 2021, reflected Policy StatementResidents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible Policy Interpretation and Implementation1.
Staff provides person-centered care that emphasized the residents' comfort, independence and personal needs and preferences.2.
The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting.
These characteristics include:a.
Clean, sanitary and orderly environment;.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.