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,
resident);Interventions:Anticipate behavior(s) and redirect when in close proximity to others that
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;
676295 10/03/2025
Epic Nursing & Rehabilitation 3210 W Hwy 22 Corsicana, TX 75110
exploitation in the DON's office.
The DM stated taking a resident's magazine would be exploitation.
jeopardy to resident health or 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. safety 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
systems
676295 10/03/2025
Epic Nursing & Rehabilitation 3210 W Hwy 22 Corsicana, TX 75110
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”.
676295 10/03/2025
Epic Nursing & Rehabilitation 3210 W Hwy 22 Corsicana, TX 75110
financial policies, ethical standards, and proper fund management procedures.
This training was
jeopardy to resident health or Person(s) Responsible: Administrator and/or Designee Completion Date: 10/01/25 Action safety (Prevention): Education provided to Nursing Staff by the Director of Nursing on:1.
Resident Kardex that will contain the updated care plans and interventions following behavioral events.
Staff will be
Assistant Director of Nursing. 2.
Testing and verbal confirmation are utilized to assess knowledge retention.3.
Annual training via Relias regarding resident's rights, theft, misappropriation and abuse.
All Facility staff, new hire and agency will complete prior to working their next shift.
Knowledge will be verified via test and verbal discussion with affirmative feedback.
Person(s) Responsible: Administrator and/or Designee Completion Date: 10/1/25 Action (Monitoring): 1--During daily meeting, Director of Nursing, Assistant Director of Nursing, and/or Designee will review all progress notes and event reports to ensure effective care plans/interventions are in place following any resident-to-resident or other inappropriate behavior.
Will be reviewed during daily meeting x 30 days and then weekly thereafter. 2-Weekly and as needed reconciliation of resident trust fund by the Business Office Manager/Regional Business Office Manager.
This will be ongoing.
Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, and/or Designee Completion Date: 10/1/25 Action (QAPI): Medical Director informed of this plan at the Ad Hoc QAPI. At this time no other recommendations have been made.
Person(s) Responsible: Administrator Completion Date: 10/1/2025 The surveyor monitored the POR as follows: Record Review of abuse, neglect, exploitation Inservice completed by 10/03/25 Record Review of copy of cashier's check totaling in the amount of $3700 paid out to Resident #5's RP. An interview with CNA F on 10/03/25 at 12:00pm stated she 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 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.
676295 10/03/2025
Epic Nursing & Rehabilitation 3210 W Hwy 22 Corsicana, TX 75110
took Resident #5's credit card and used it for her personal use.
The ADM stated it was expected for
jeopardy to resident health or next day.Review of facility policy Abuse, Neglect, Exploitation or Misappropriation - Reporting and safety Investigating, revised September 2022, reflected: Reporting Allegations to the Administrator and Authorities1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of
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.
676295 10/03/2025
Epic Nursing & Rehabilitation 3210 W Hwy 22 Corsicana, TX 75110
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.
676295 10/03/2025
Epic Nursing & Rehabilitation 3210 W Hwy 22 Corsicana, TX 75110
interdisciplinary team (IDT).4.
The resident, the resident's family and/or the resident's legal
676295 10/03/2025
Epic Nursing & Rehabilitation 3210 W Hwy 22 Corsicana, TX 75110
jeopardy to resident health or safety - Review of Elopement book and Inservice on where the book is located was completed on 09/10/25.
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 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
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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.