Epic Nursing & Rehabilitation
Epic Nursing & Rehabilitation in Corsicana, TX — inspection on October 3, 2025.
Found 8 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
Review of Resident #2's care plan, dated 09/26/2025 reflected the following focus: I have episodes of adverse behavior(s): Sexually inappropriate behavior (has held hands and attempted to kiss others, shows preference to one resident);Interventions:Anticipate behavior(s) and redirect when in close proximity to others that mightinvoke aggression.Ensure family/MD/aware of behaviors and/or any increase in behaviors noted.Ensure staff is aware of physical/sexual behaviors and interventions.Redirect/remove when approaching/being approached by particular female residentMonitor and chart behaviors q shift and report to MD.Resident will be placed one to one until IDT determines one to one is no longer inneed.
During an interview on 9/26/2025 at 3:10 pm, LVN C stated she found Resident #1 and Resident #2 lying in bed together on 9/18/2025.
She stated the residents were lying side by side on top of the covers, fully clothed and Resident #2 had his hand on Resident #1's leg.
She stated Resident #2 wasn't trying to engage in anything.
She stated she had no suspicion of ANE because she did not see him try to grab at nothing or try to touch [Resident #1] in an inappropriate way - he did not seem malicious or vicious at that time[ .
She stated she was easily able to redirect him from the situation and denied seeing Resident #1 and Resident #2 in bed together prior to that.
She stated she did not] report the incident as ANE because they weren't naked and didn't have their hands in each other's pants - nothing like that going on, they were fully clothed and weren't trying to do anything. LVN C stated she notified the DON but did not remember if she called either resident's RP.
During an interview on 9/27/2025 at 12:00 pm, the ADM stated she was not aware of the incident last week on 9/18/2025 between Resident #1 and Resident #2 when they were found on the bed together.
She stated it was her expectation that staff would report it immediately to her and notify the RPs of both residents.
She was unaware that the RP's had not been notified.
During an interview on 9/27/2025 at 1:39 pm, the FM for Resident #1 stated he was notified about an incident of sexual behavior that occurred on 9/24/2025 but never received a call about a previous incident on 9/18/2025. He stated when he was contacted by the facility on 9/24/2025 there was no indication there were any previous incident between [Resident #1} and {Resident #2] or any other male residents.
The FM stated he was Resident #1's POA and it was very upsetting that they had not notified him about the incident on 9/18/2025.
Review of facility Policy Resident Rights, dated February 2021, reflected: 1.
Federal and state laws guarantee certain basic rights to all residents of this facility.
These rights include tl1e resident's right to:a. a dignified existence;b. be treated with respect, kindness, and dignity;c. be free from abuse, neglect, misappropriation of property, and exploitation;k. appoint a legal representative of his or her choice, in accordance with state law;o. be notified of his or her medical condition and of any changes in his or her condition;p. be informed of, and participate in, his or her care planning and treatment;
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
10/03/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Epic Nursing & Rehabilitation
3210 W Hwy 22 Corsicana, TX 75110
SUMMARY STATEMENT OF DEFICIENCIES
jeopardy to resident health or safety
completed her abuse, neglect, exploitation inservice this morning and was giving a test after completion.
CNA F was able to provide types of abuse physical, sexual, financial, and gave examples such as stealing a resident's money. CNA F knew to report immediately if ever witnessed to the ADM. An interview with RN G on 10/03/25 at 12:15pm stated she was given in-service this morning over abuse, neglect, and exploitation. RN G knew to contact the ADM immediately if ever witnessed. RN G knew types of abuse such as taking funds, sexual abuse, and talking bad to residents. RN G knew the signs of abuse/neglect, gave examples of not changing the residents and not caring for them. An interview with CNA H on 10/03/25 at 1:42pm stated as soon as she walked in the door this morning she was provided the abuse, neglect, exploitation training along with a test. CNA H gave examples of abuse /neglect such as yelling at a resident, ignoring call light, sexual, mental, and stealing money from a resident. CNA H stated she was aware last week sometime that a resident had something stolen. An interview with MA I on 10/03/25 at 2:03pm stated she received her in-service on by 10/3/25 over abuse, neglect, and exploitation. MA I was able to give the types of abuse such as physical, mental, and financial. MA I was able to give an example of financial abuse by stealing or borrowing. MA I was able to give signs of abuse/neglect examples such as not changing residents, not feeding, or caring for them. An interview with HK J on 10/03/25 at 2:36pm stated that she received the in-service over abuse, neglect, and exploitation today. HK J knows to report to the ADM if she ever witnessed any abuse or neglect. HK J was able to give examples of abuse /neglect such as resident-to-resident aggression, verbal abuse, not wanting to help a resident, exploitation (stealing money).
An interview with the DM on 10/02/25 at 2:53pm stated that she just had her in-service over exploitation in the DON's office.
The DM stated taking a resident's magazine would be exploitation.
The DM know to report immediately to the AM if she witnessed any abuse or neglect. An interview with the DA on 10/02/25 at 3:07pm stated she was in the DON's office just a while ago for in-service.
The DA know who to report abuse, neglect, and exploitation to the ADM immediately.
While the IJ was removed on 10/03/25 at 5:12pm, the facility remained out of compliance at a level of no actual harm at a scope of pattern because the facility's need to evaluate the effectiveness of the corrective systems
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
10/03/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Epic Nursing & Rehabilitation
3210 W Hwy 22 Corsicana, TX 75110
SUMMARY STATEMENT OF DEFICIENCIES
Review of facility's investigation dated 09/18/25 reflected a thorough investigation was completed, and the allegation of misappropriation was confirmed.
Review of facility's policy, dated April 2021, titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program reflected: Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation.
This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms.
The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives:
- Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including,
but not necessarily limited to: a. facility staff. b. other residents. c. consultants. d. volunteers. e. staff from other agencies. f. family members. g. legal representatives. h. friends. i. visitors; and/or j. any other individual.
Develop and implement policies and protocols to prevent and identify theft, exploitation, or misappropriation of property”.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
10/03/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Epic Nursing & Rehabilitation
3210 W Hwy 22 Corsicana, TX 75110
SUMMARY STATEMENT OF DEFICIENCIES
jeopardy to resident health or safety
residents and not caring for them. An interview with CNA H on 10/03/25 at 1:42pm stated as soon as she walked in the door this morning she was provided the abuse, neglect, exploitation training along with a test.
CNA H gave examples of abuse /neglect such as yelling at a resident, ignoring call light, sexual, mental, and stealing money from a resident. CNA H stated she was aware last week sometime that a resident had something stolen. An interview with I on 10/03/25 at 2:03pm stated she received her in-service on by 10/3/25 over abuse, neglect, and exploitation. MA I was able to give the types of abuse such as physical, mental, and financial. MA I was able to give an example of financial abuse by stealing or borrowing. MA I was able to give signs of abuse/neglect examples such as not changing residents, not feeding, or caring for them. An interview with HK J on 10/03/25 at 2:36pm stated that she received the in-service over abuse, neglect, and exploitation today. HK J knows to report to the ADM if she ever witnessed any abuse or neglect. HK J was able to give examples of abuse /neglect such as resident-to-resident aggression, verbal abuse, not wanting to help a resident, exploitation (stealing money). An interview with the DM on 10/02/25 at 2:53pm stated that she just had her inservice over exploitation in the DON's office.
The DM stated taking a resident's magazine would be exploitation.
The DM know to report immediately to the AM if she witnessed any abuse or neglect. An interview with the DA on 10/02/25 at 3:07pm stated she was in the DON's office just a while ago for in-service.
The DA know who to report abuse, neglect, and exploitation to the ADM immediately.
While the IJ was removed on 10/03/25 at 5:12pm, the facility remained out of compliance at a level of no actual harm at a scope of pattern because the facility's need to evaluate the effectiveness of the corrective systems.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
10/03/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Epic Nursing & Rehabilitation
3210 W Hwy 22 Corsicana, TX 75110
SUMMARY STATEMENT OF DEFICIENCIES
jeopardy to resident health or safety
impairment.
Record review of Resident #5's care plan, dated 09/29/25, revealed Resident #5 was care planned for visually impaired and requires secure storage of personal items/medications in a lock box to ensure safety and prevent misuse or loss.An attempted interview with the BOM was made 10/02/25 at 4:30pm, 10/03/25 at 11:49am, and 10/03/25 at 3:37pm.
Voice message was left and the BOM did not return call prior to facility exit 10/03/25.In an interview with the Marketing Director on 10/01/25 at 10:44am she stated that the BOM confessed to her on 9/16/25 around 6:00 PM that she took Resident #5's credit card and used it for her personal use.
The Marketing Director stated the BOM stated that she had used $2000 and then stated $3000.
The Marketing Director told the BOM that once she used the card she could not stop.
The Marketing Director stated the BOM gave her the office key and stated she was not coming back to work because the police would be there.
The Marketing Director stated she did not immediately report the incident to the ADM because she was still trying to process what the BOM just told her.
The Marketing Director stated she reported to the ADM around 9:00am on 9/17/25.
The Marketing Director stated it was expected for her to report to the abuse coordinator immediately after the BOM told her.In an interview with the ADM on 10/03/25 at 12:40pm she stated the Marketing Director did not contact her until the next day (could not recall the exact time, around 10:30am), after the BOM told her that she took Resident #5's credit card and used it for her personal use.
The ADM stated it was expected for the Marketing Director to report to her immediately once she found out about the incident and not the next day.Review of facility policy Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, revised September 2022, reflected: Reporting Allegations to the Administrator and Authorities1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law and HHSC reporting guidelines.2.
The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies:a.
The state licensing/certification agency responsible for surveying/licensing the facility;b.
The local/state ombudsman;c.
The resident's representative;d.
Adult protective services (where state law provides jurisdiction in long-term care);e.
Law enforcement officials;f.
The resident's attending physician; andg.
The facility medical director.3.
Immediately is defined as:a. within 2 hours of an allegation involving abuse or result in serious bodily injury; orb. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
10/03/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Epic Nursing & Rehabilitation
3210 W Hwy 22 Corsicana, TX 75110
SUMMARY STATEMENT OF DEFICIENCIES
The facility failed to complete a comprehensive assessment for Resident #2 within 14 days of admission.
This failure placed newly admitted residents at risk of not having care and treatment needs assessed to ensure necessary care and services were provided to meet these needs.
Findings included: Review of Resident #2's face sheet dated 9/26/2025 reflected an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including Dementia (group of brain disorders that cause progressive cognitive decline), Parkinson's disease (progressive neurological disorder that affects movement, balance and coordination), hypotension (low blood pressure), anxiety disorder and Benign Prostatic Hyperplasia (BPH - enlarged prostate gland).
Review of Resident #2's MDS screen in the EMR on 9/26/2025 and 10/3/2025 reflected there was no MDS assessment.
During an interview on 10/3/2025 at 4:17 pm, the MDS Coordinator stated Resident #2 did not have an MDS assessment done yet.
She stated she was running late in getting assessments done.
She further stated the facility has 14 days from admission to complete MDS assessments and Resident #2's did not get done.
She stated she was the one responsible for making sure they got done.
She stated she initially thought Resident #2 was respite because he was admitted on hospice services.
During an interview on 10/3/2025 at 4:30 pm, the ADM stated she was unaware the MDS assessments were late and not getting done and unaware that Resident #2 did not have any MDS assessments done since his admission.
She stated the MDS coordinator reported up to regional MDS staff but that at the local level the MDS coordinator reported directly to the ADM.
She stated her expectation was that the MDS coordinator will complete MDS assessments on time per the facility policy.
Review of Facility Policy Comprehensive Assessments with revision date February 2025 reflected: Comprehensive assessments are conducted to assist in developing person-centered care plans.1.
Comprehensive assessments are conducted in accordance with criteria and time frames established in the Resident Assessment Instrument (RAI) User Manual.2. admission Assessment -The admission assessment is a comprehensive assessment for a new resident and, under some circumstances, a returning resident that must be completed by the end of day 14, counting the date of admission to the nursing home as day 1 if:a. this is the resident's first time in this facility, ORb. the resident has been admitted to this facility and was discharged return not anticipated, ORc. the resident has been admitted to this facility and was discharged return anticipated and did not return within 30 days of discharge.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
10/03/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Epic Nursing & Rehabilitation
3210 W Hwy 22 Corsicana, TX 75110
SUMMARY STATEMENT OF DEFICIENCIES
Review of Facility Policy Care Planning - Interdisciplinary Team with revision date 12/2024, reflected: The interdisciplinary team is responsible for the development of resident care plans.1.
Resident care plans are developed according to the timeframes and criteria established by S483.21.2.
Comprehensive, person-centered care plans are based on resident assessments and developed by an interdisciplinary team (IDT).4.
The resident, the resident's family and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
10/03/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Epic Nursing & Rehabilitation
3210 W Hwy 22 Corsicana, TX 75110
SUMMARY STATEMENT OF DEFICIENCIES
- Review of Inservice on missing resident policy and protocol to follow was completed on 09/10/25.
jeopardy to resident health or safety
- Review of Elopement book and Inservice on where the book is located was completed on 09/10/25.
- Review of Signage on door in front door and any door staff exit through to make sure residents are not able to exit facility was observed on 09/10/25.
- Review of Care plans updated on all residents that are an elopement risk was completed on 09/10/25.
- Review of Assessment on Resident #3, Reviewed Resident #3's updated care plan, moved to the secure unit on 09/10/25. - Review of Staff statements/witness statements about the elopement incident was completed on 09/11/25. - Review of Root cause analysis was completed on the elopement was completed by DON on 09/11/25 - Review of Complete incident report on the elopement was completed on 09/15/25
Facility ID: