Epsom Healthcare Center

In the surveyor’s words

From the most serious findings on record at Epsom Healthcare Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF880Feb 4, 2025

  Based on interview and policy review, it was determined that the facility failed to develop and implement a water management program to prevent the growth of waterborne pathogens in their building with a census of 102 residents. Findings include: Review on 2/3/25 of the facility's water management program, not dated, revealed the following: 1. There was no detailed description and/or diagram of the facility's water system; 2. There was no identification of areas in the water system where legionella and other opportunistic pathogens could grow and spread; 3. Legionella testing was to be done January 2024 and June 2024. Legionella testing was done on January 2024 and there was no second Legionella testing performed in 2024; 4. […]

• No harm, potential for more than minimal, patternF583Mar 12, 2026

  Based on observation, interview and record review, the facility failed to provide privacy of electronic medical records for 2 of 2 units observed (100 and 200 Halls) and during medication administration.Findings include:200 Hall Observation on 3/10/26 at 11:54 a.m. of Staff I (Licensed Nursing Assistant) was documenting on a laptop computer on a bench on [NAME] Wing short hall. Staff I set the computer down on a bench and walked away into a resident room. There was identifiable information observed on the computer screen. Interview on 3/10/26 at approximately 11:56 a.m. with Staff I confirmed the above. Staff I revealed that they had not closed the computer so that they did not have to log in again. Observation on 3/10/26 at 2:05 p.m. […]

• No harm, potential for more than minimal, patternF742Feb 17, 2023

  Based on interview and record review the facility failed to ensure that residents who were diagnosed with a mental disorder or have a history of trauma and/or Post-Traumatic Stress Disorder (PTSD) received appropriate treatment and services for 2 of 3 residents reviewed for behaviors and emotions in a final survey sample of 21 (Resident identifiers are #50 and #75). Findings include: Resident #50 Review on 2/17/23 at approximately 8:40 a.m. of Resident #50's medical record revealed that Resident #50 was admitted to the facility on [DATE] with diagnosis of anxiety, depression, and PTSD. […]

• No harm, potential for more than minimal, patternF883Feb 17, 2023

  Based on interview and record review, it was determined that the facility failed to ensure a resident was provided with education on the risks and benefits of the Pneumococcal vaccination for 5 of 5 residents reviewed for Pneumococcal immunizations (Resident identifiers are #2, #48, #69, #85 and #94). Findings include: Resident #2 Review on 2/17/23 at approximately 10:30 a.m. of Resident #2's medical record revealed their admission to the facility was on 6/17/16. Further review of Resident #2's medical record revealed they had received the Pneumococcal vaccination on 9/15/17. Review on 2/17/23 at approximately 10:45 a.m. […]

• No harm, potential for more than minimal, patternF887Feb 17, 2023

  Based on interview and record review, it was determined that the facility failed to offer and provide education to the risks and benefits of the COVID-19 vaccination for 4 of 5 residents reviewed for COVID-19 immunizations (Resident identifiers are #2, #48, #69 and #94). Findings include: Resident #2 Review on 2/17/23 at approximately 10:30 a.m. of Resident #2's medical record revealed their admission to the facility was on 6/17/16. Further review of Resident #2's medical record revealed they had not received the COVID-19 vaccination, and there was no information regarding the education and offering of the COVID-19 vaccination or declination of the COVID-19 vaccination. Resident #48 Review on 2/17/23 at approximately 10:30 a.m. […]