Epic Nursing & Rehabilitation

Inspectors wroteBased on interview and record review the facility failed to immediately inform the resident, consult with the resident's physician and notify with his or her authority, the resident representative(s) when there was a significant change in the resident's physical, mental, or psychosocial status in either life-threatening condition of clinical complications for one of eight residents (Resident #1) reviewed for resident rights. The facility failed to ensure Resident #1's FM was notified when he hit another resident on 6/25/2026. This failure could place residents at risk of a decreased quality of life and risk of not having their responsible party represent them in medical and care decisions.

Inspectors wroteBased on interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately but not later than 2 hours after the allegation was made, if the events that caused the allegation involved serious bodily injury, to the Administrator of the facility and other officials including to the State Survey Agency in accordance with State and law through established procedures for one of eight (Resident #1) residents reviewed for abuse and neglect. Nursing facility staff failed to report to the Administrator that Resident #1 was observed hitting another resident on 6/25/2026 at 1:30 pm. This failure could place residents at risk of not being protected from abuse, neglect, or exploitation.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming and personal and oral hygiene for 3 of 10 residents (Resident #8, Resident #66, and Resident #70) reviewed for ADL care. The facility failed to ensure Resident #8, Resident #66, and Resident #70 did not have long, and dirty fingernails. This failure could place residents at risk of skin tears, infection, and embarrassment.1. Record review of Resident #8's face sheet, dated 05/26/2026 reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included dysphagia (trouble swallowing), muscle wasting, lack of coordination, unsteadiness on feet, pain, vomiting, hypertension (high blood pressure), and localized edema (swelling). [...]

Inspectors wroteBased on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure CK B wore a hair net on his beard.2. The facility failed to ensure CK B washed his hands when changing tasks.3. The facility failed to ensure DA A washed hands when changing tasks. These deficient practices could place residents at risk for food borne illness. During an observation on initial tour of the kitchen on 05/26/2026 at 9:11 a.m., it was revealed that CK B failed to use a hair net to cover facial hair while preparing puree food. During a kitchen observation on 05/26/2026 at 10:55 a.m., it was revealed that CK B failed to wash hands prior to pureeing ham. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure it formulated, adopted, and enforced policies regarding smoking, smoking areas, and smoking safety for 3 of 5 residents (Residents #15, Resident #35, and Resident #44) reviewed for smoking. 1. The facility failed to complete a smoking assessment for Resident #15. 2. The facility failed to complete a smoking assessment for Resident #35. 3. The facility failed to complete a smoking assessment for Resident#44. This failure placed all residents at risk for serious injury, harm, due to staff not knowing if the resident was safe or needed assistance to smoke.

Inspectors wroteBased on interview and record review the facility failed to ensure assessments accurately reflected the resident's status for 2 of 3 residents (Resident #15, and Resident #67) reviewed for accuracy of assessments. The facility failed to ensure Resident #15's annual MDS, dated [DATE], accurately reflected her smoking status. The facility failed to ensure Resident #67's admission MDS, dated [DATE], accurately reflected his smoking status. These failures could place residents at risk of inadequate supervision due to an inaccurate assessment for smoking status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a baseline care plan for residents that included the instructions needed to provide effective and person-centered care of the residents that meet professional standards of quality care within 48 hours of the resident's admission for 1 (Resident #44) of 4 residents reviewed for care plans. The facility failed to complete a baseline care plan within 48 hours of Resident#44's re-admission date of 05/02/26. This failure could result in residents not receiving prescribed care while in the facility.

Inspectors wroteBased on interviews and record reviews, the facility failed to use services of a Registered Nurse for at least 8 consecutive hours, 7 days a week from 3/30/2026 to 5/7/2026 For one of one nursing facility reviewed for RN coverage. The facility failed to have RN coverage on 3/30/2026, 4/8/2026, 4/13/2026, 4/17/2026, 4/22/2026, 5/1/2026, 5/6/2026, and 5/7/2026. This failure could place residents at risk of not receiving adequate care and services from an RN, and decreased quality of life. During a record review on 5/8/2026 at 5:16 pm with the ADM present, of Daily timecard, period: 3/22/26 to 5/8/26, reflected no time entries for an RN for 3/30/2026, 4/8/2026, 4/13/2026, 4/17/2026, 4/22/2026, 5/1/2026, 5/6/2026, and 5/7/2026. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the residents had the right to be free from abuse and neglect for three residents (Resident #1, Resident #2 and Resident #4) of seven reviewed for abuse. The facility failed to:1) Ensure Resident #1 did not engage in sexual activity with Resident #2 on 9/24/2025.2) Ensure Resident #2 did not engage in inappropriate behavior on 9/18/2025, 9/19/2025 and 9/24/2025.3) Ensure CNA D did not grab Resident #4's wrist forcefully and shake her arm in the presence of therapy staff on 9/3/2025. On 9/26/2025 at 6:40 pm an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 10/3/2025, the facility remained at a level of actual no actual harm at a scope of pattern that is not immediate jeopardy due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the residents had the right to be free from abuse and neglect for three residents (Resident #1, Resident #2 and Resident #4) of seven reviewed for abuse. The facility failed to:1) Ensure Resident #1 did not engage in sexual activity with Resident #2 on 9/24/2025.2) Ensure Resident #2 did not engage in inappropriate behavior on 9/18/2025, 9/19/2025 and 9/24/2025.3) Ensure CNA D did not grab Resident #4's wrist forcefully and shake her arm in the presence of therapy staff on 9/3/2025. On 9/26/2025 at 6:40 pm an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 10/3/2025, the facility remained at a level of actual no actual harm at a scope of pattern that is not immediate jeopardy due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately but not later than 2 hours after the allegation is made if the events that cause the allegation involve abuse or not later than 24 hours if the events that cause the allegation do not involve abuse to the Administrator for 3 of 7 residents (Resident #1, Resident #2, Resident #5) reviewed for Abuse and Neglect.[KS1] [LP2] The facility staff failed to immediately report abuse and neglect to the Administrator when: 1) Resident #1 was observed engaging in sexual activity with Resident #2 on 9/24/2025.2) Resident #2 was observed engaging in inappropriate behavior with Resident #1 on 9/18/2025 and 9/24/2025. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the residents environment remained as free of accident hazards as is possible and ensure each resident received adequate supervision to prevent accidents for 1 of 6 residents (Resident #3) reviewed for accidents and hazards. The facility failed to ensure Resident #3 did not elope from the facility on 09/10/25. The noncompliance was identified as PNC (past noncompliance). The Immediate Jeopardy (IJ) began on 09/10/25 and ended on 09/15/25. The facility had corrected the noncompliance before the survey began. This deficient practice placed residents at risk for falls, injuries, and hospitalization. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs for 3 of 7 residents (Resident #1, Resident #2, Resident #3) reviewed for care plans. The facility failed to update Resident #1's care plan after she was seen in bed with Resident #2 on 9/18/2025[KS1] [LP2] and after a sexual activity incident on 9/24/2025. The facility failed to update Resident #2's care plan after inappropriate behaviors were noted on 9/18/2025, 9/19/2025 and 9/24/2025.[KS3] [LP4] The facility failed to care plan interventions to routinely monitor Resident #3 when an initial elopement assessment was completed 06/03/24[KS5] [LP6] . [...]

Inspectors wroteBased on interview and record review, the facility failed to immediately notify the resident's representative of the change] in the resident's physical, mental, or psychosocial status for one (Resident #1) of seven residents reviewed for resident rights. The facility failed to ensure Resident #1's RP was notified when she was found lying in bed with Resident #2 on 9/18/2025. This failure placed residents at risk of a decreased quality of life and risk of not having their responsible party represent them in medical and care decisions.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents had the right to be free from misappropriation of property and exploitation for 1 of 6 (Resident #5) reviewed for misappropriation and exploitation, in that: The facility failed to ensure Resident #5 was free from exploitation when the BOM took Resident #5's net spend credit card and used the card for personal use. The BOM used Resident #5's credit card and withdrew funds totaling $3700. This failure could place residents at risk of financial hardships and a decrease in resident's quality of life.

Inspectors wroteBased on interview and record review, the facility failed to conduct an initial comprehensive, accurate, standardized reproducible assessment of the resident's functional capacity within 14 days of admission for 1 (Resident #2) of 7 residents reviewed for Comprehensive Assessments being completed timely. 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.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to use services of a Registered Nurse for at least 8 consecutive hours, 7 days a week. The facility failed to have an RN at the facility on 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. This failure could place residents at risk of not receiving adequate care and services of an RN, and decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services which includes the accurate acquiring and administering of medications to meet the needs for 35 out of 72 residents reviewed for pharmacy services, in that:The facility failed to provide morning medications for 35 out of 72 residents on 8/31/2025 resulting in 305 medication errors. This failure could place residents at risk of not receiving the intended therapeutic benefit of the medications and supplements, could result in worsening or exacerbation of chronic medical conditions, and hospitalization.

Inspectors wroteBased on interviews, and record reviews, the facility failed to ensure that residents' environment remained free of accident hazards as was possible for 1 of 6 residents (Residents #4) reviewed for accident prevention. The facility failed to ensure that bleach was not attainable for Resident #4 on 08/26/2025. This failure could place residents at risk for accidents and hazards.

Inspectors wroteBased 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.

Inspectors wroteBased interviews and record reviews, the facility failed to maintain the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week, for 8 days of the 6-month review period, reviewed for RN coverage. The facility failed to ensure the facility maintained the required RN coverage for 8 days between April - June 2024. This failure could place residents at risk of not having their nursing and medical needs met and receiving improper care.

Inspectors wroteBased on observation, interview, and record review the facility failed to store, prepare, distributed, and serve food in accordance with professional standards for food service safety for the facility's only kitchen, reviewed for food and nutrition services. 1. The facility failed to ensure the ice machine in the tray-serving area was cleaned on 02/18/25. 2. The facility failed to ensure the opened packages of food in the dry goods pantry were sealed properly after opening on 02/18/25. 3. The facility failed to ensure the desert was covered until ready to serve on 02/19/25. 4. The facility failed to ensure the kitchen staff wore the appropriate hair covering while food was being prepared in the main kitchen on 02/19/25. These failures could place residents at risk for cross contamination and other air-borne illnesses.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 6 (Resident #71) residents reviewed for Respiratory Care. 1. The facility failed to ensure Resident #71's handheld mouthpiece (device through which medication is inhaled) for his nebulizer (turns liquid medication into a mist) was properly stored when not in use on 02/19/2025. These failures could place the residents at risk for respiratory infection and not having their respiratory needs met.

Inspectors wroteBased on observation, interview, and record review the facility failed to establish and maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two of eight residents (Resident #22 and Resident #38) reviewed for infection control. 1. The facility failed to ensure CNA B changed her gloves and performed hand hygiene while providing incontinent care to Resident #22 on 02/12/2025. 2. The facility failed to ensure LVN B changed her gloves and performed hand hygiene while providing wound care to Resident #38 on 02/20/2025. This failure could place residents at risk of cross-contamination and development of infections.

Inspectors wroteBased on interviews and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 (Resident #1) of 6 residents reviewed for quality of care. The facility failed to document fluid intake for Residents #1 according to physician orders. This failure could place residents at risk of not receiving necessary medical care, and hospitalization.

Inspectors wroteBased on interview and record review the facility failed to, in response to allegations of abuse, neglect, exploitation, or mistreatment, have evidence that all alleged violations were thoroughly investigated and report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the allegation was verified appropriate corrective action was taken for one of three residents (Resident #1) reviewed for abuse and neglect . The facility failed to report, on 02/01/2025, the results of an investigation of an allegation of Abuse and Neglect involving Resident #1 when she had an unwitnessed fall on 01/27/2025. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain personal hygiene for two (Resident #1 and Resident #2) of five residents reviewed for bathing. The facility failed to provide showers to Resident #1 and Resident #2 in compliance with their shower schedules. This deficient practice could place residents at risk of a decline in their sense of well-being and level of satisfaction with life.

Inspectors wroteBased on interviews and record review the facility failed to ensure the comprehensive care plan described the services that were to be furnished to attain or maintain the residents' highest practicable physical, mental, and psychosocial well-being for 1 of 6 residents (Resident #1) reviewed for comprehensive care plans. The facility failed to ensure Resident #1's comprehensive care plan reflected Resident #1's physician's order dated 11/15/2024 diet was regular, puree, and nectar thick liquids. This deficient practice could place residents at risk for receiving improper care and services due to inaccurate care plans.

Inspectors wroteBased on interview and record review, the facility failed to ensure the residents environment remained as free of accident hazards as is possible and ensure each resident received adequate supervision for 2 of 8 residents (Resident #1 and Resident #2) reviewed for accidents and hazards. The facility failed to ensure Resident #1 did not elope from the facility on [DATE]. The facility failed to ensure Resident #2 did not elope from the facility [DATE]. An Immediate Jeopardy (IJ) existed from [DATE] - [DATE]. The IJ was determined to be at past noncompliance as the facility had implemented actions that corrected the deficient practice prior to the beginning of the investigation. This deficient practice placed residents at risk for falls, injuries, dehydration, and hospitalization.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from physical and verbal abuse for 1 of 6 residents (Resident #1) reviewed for abuse. The facility failed to prevent LVN A, on 07/28/24, from physically abusing Resident #1 when she hit Resident #1 in the right arm. These failures could place resident at risk for emotional distress, fear, decreased quality of life and further abuse.

Inspectors wroteBased on interview and record review the facility failed to ensure residents were free from misappropriation and exploitation of property for 1 of 6 residents reviewed for misappropriation of property. (Resident #2) The facility failed to protect Resident #2 from misappropriation/exploitation by allowing CNA C to take money from Resident #2 for CNA C's own well-being and personal expenses, exact date unknown. This failure could place residents who resided in this facility at risk of misappropriation of property.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an allegation of abuse was reported immediately but not later than 24 hours after the allegation was made for 1 of 6 residents (Resident #1) reviewed for reporting. The facility failed to ensure staff immediately reported an allegation to the abuse coordinator when CNAA reported on 07/29/24 to DON that LVN A had hit Resident #1 in the arm on 07/28/24. This failure could affect residents by placing them at risk of abuse if the reportable allegations are not reported timely after they are discovered.

Inspectors wroteBased on interviews and record review the facility failed to ensure assessments accurately reflected the resident's status for 1 of 6 residents (Residents #1) reviewed for resident assessments. The facility failed to ensure Resident #1's quarterly MDS dated [DATE] reflected that Resident #1 had an active diagnosis of dementia. This deficient practice could place residents at-risk for inadequate care due to inaccurate assessments.

Inspectors wroteBased on interview and record review, the facility failed to ensure the medical record contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress, including his/her response to treatments and/or services, and changes in his/her condition for 1of 4 residents (Resident #1) review for resident assessments. The facility failed to ensure Resident #1's face sheet dated 07/18/2024 reflected his current diagnosis of dementia. This deficient practice could place residents at risk for inadequate care due to inaccurate assessments.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain grooming and personal hygiene for 3 of 6 residents (Residents #1, #2 and #3) reviewed for ADL care. The facility failed to ensure Resident #1 was cleaned, groomed, and free from the strong odor or urine; Resident #2 was cleaned, groomed, and free from the strong odor or urine; and, Resident #3 had adequate staff to help stand and ambulate to the bathroom to use the toilet. This failure placed residents at the facility at risk of diminished quality of life.

Inspectors wroteBased on observations, interview, and record review, the facility failed to assess the care required by the resident population considering the types of diseases, conditions, physical and cognitive disabilities, overall acuity, and other pertinent facts that were present within that population when determining staffing requirements for 3 of 6 residents (Residents #1, #2, and #3) reviewed for staffing. The facility failed to schedule nursing staff for resident care based on an evaluation of pertinent information about the residents that may affect the services the facility must provide. This failure placed residents at the facility in risk of having their needs unmet.

Inspectors wroteBased on observation and interview, the facility failed to ensure each resident has a right to secure and confidential personal and medical records for two (2) (WS#1 and WS#2) of seven (7) stationary computer workstations reviewed for resident privacy. The facility failed to ensure Computer Workstation #1 (nurses station) and Workstation #2 (100 hall) were not left open, unattended, and visible to resident medical records. This deficient practice could place residents at-risk of exposure of their personal information to unauthorized individuals.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 4 of 8 residents (Residents #12, #42, #45 and Resident #63) reviewed for accommodation of needs. 1. The facility failed to ensure Resident #12 and Resident #42's call light buttons were located within each residents reach. 2. The facility failed to ensure Resident #45 and Resident #63's call light pull strings, in their individual bathrooms, were free from entanglement and extended the maximum distance from the wall mount to the floor. This failure could place residents at risk of unmet physical needs and psychological anguish.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure assessments accurately reflected the resident's status for 1 of 8 residents (Resident # 14) reviewed for MDS accuracy. The facility failed to ensure Resident #14's Annual MDS Assessment reflected the use of bed rails. This failure could place residents at risk of not receiving the care and services to meet their needs.

Inspectors wroteBased on interview and record review the facility failed to coordinate assessments with the pre-admission screening and resident review (PASARR) program under Medicaid to the maximum extent practicable to avoid duplicative and effort which includes referring all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon significant change in status assessment for 1 of 2 residents (Resident #53) reviewed for PASARR. The facility failed to ensure Resident #53 had an accurate PASRR Level 1 Screening which indicated a diagnosis of mental illness on 03/22/2022. This failure could place residents at risk of not receiving needed individualized care, and specialized services to meet their needs.

Inspectors wroteBased on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 2 of 7 residents (Resident #19 and Resident #72) reviewed for comprehensive care plans. The facility failed to ensure a comprehensive care plan was developed for Resident #19 which included measurable objectives and timetables to meet and implement the residents medical nursing mental and psychological needs . [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrated that was not possible or the resident preferences indicated otherwise for 1 of 8 residents (Resident #4) reviewed for nutrition status maintenance. The facility failed to measure and record Resident #4's body weight, as ordered by the resident's physician, for two consecutive months (November 2023 and December 2023.) This failure could place residents at risk of weight loss, weight gain, nutritional deficit, and adverse health consequences.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that a resident who needed respiratory care, which include tracheostomy care and tracheal suctioning, was provided, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 1 of 7 residents (Resident #13) reviewed for respiratory care. The facility failed to ensure Resident #13's nebulizer masks and tubing were covered. This failure could place residents at risk for respiratory infections.

Inspectors wroteBased on observation, interview and record review the facility failed to provide pharmaceutical services which included procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of resident for 1 of 4 residents (Resident #28) reviewed for pharmacy services. The facility failed to order Resident #28's Coreg (carvedilol) 3.125 mg, (for hypertension), in a timely manner. The failure could place residents at risk of medicinal adverse effects, decreased health status and being hospitalized .

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 6.45%, based on 2 errors out of 31 opportunities, which involved 2 of 4 residents (Residents #28 and Resident #47) observed during medication administration for medication errors. The facility failed to ensure Resident #28 received Coreg (carvedilol) 3.125 mg, (for hypertension) as ordered by the physician. The facility failed to ensure Resident #47 received Tramadol/Acetaminophen 37.5-325, 2 tablets (for chronic pain) as ordered by the physician. These failures could place residents at risk of inadequate therapeutic outcomes.