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 DON on 09/04/2025 at 2:48pm, DON stated that the kitchen staff stated she was not aware if Resident #4 had drank from the cup with bleach soap water.
The DON stated that Resident #4 was given water per the bleach label instructions.
The DON stated Resident #4 was sent to the ER per the NP.
The DON stated that the paperwork from the hospital did not reflect Resident had drank the bleach soap water and her lab were all normal.
The DON stated there would not be a negative outcome due to the hospital lab work showing Resident #4 did not have toxic chemicals in her system.
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
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
09/04/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Epic Nursing & Rehabilitation
3210 W Hwy 22 Corsicana, TX 75110
SUMMARY STATEMENT OF DEFICIENCIES
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.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
09/04/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Epic Nursing & Rehabilitation
3210 W Hwy 22 Corsicana, TX 75110
SUMMARY STATEMENT OF DEFICIENCIES
Review of facility policy Administering Medications, revised April 2019, reflected: Medications are administered in a safe and timely manner, and as prescribed. 1.
Only persons licensed or permitted by this state to prepare, administer and document the administration of medications may do so.2.
The director of nursing services supervises and directs all personnel who administer medications and/or have related functions.3.
Staffing schedules are arranged to ensure that medications are administered without unnecessary interruptions.4.
Medications are administered in accordance with prescriber orders, including any required time frame.5.
Medication administration times are determined by resident need and benefit, not staff convenience.
Factors that are considered include:a. enhancing optimal therapeutic effect of the medication;b. preventing potential medication or food interactions; andc. honoring resident choices and preferences, consistent with his or her care plan.6.
Medication errors are documented, reported, and reviewed by the QAPI committee to inform process changes and or the need for additional staff 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.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
09/04/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Epic Nursing & Rehabilitation
3210 W Hwy 22 Corsicana, TX 75110
SUMMARY STATEMENT OF DEFICIENCIES
Based on observation, interview, and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for 1 of 5 halls reviewed for environment.
The facility did not address moisture damage and discoloration in the ceiling on the hallway in the secure unit.
This failure could place residents at risk of not living in a safe, functional, sanitary, and comfortable environment.The findings included: During on observation on 09/03/2025 at 11:37am, the ceiling in the hallway in the secure unit had water stains and a black substance in the ceiling.
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;.
Facility ID: