A list of the most recent deficiencies for Epsom Healthcare Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-01 | 2023-06-16 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-02-17 | 2023-04-20 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2023-02-17 | 2023-04-20 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-02-17 | 2023-04-20 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-02-17 | 2023-04-20 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-02-17 | 2023-03-28 | N |
| Post nurse staffing information every day. | Health | 2023-02-17 | 2023-02-22 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2023-02-17 | 2023-02-19 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2023-02-17 | 2023-02-19 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-02-17 | 2023-02-17 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-03-02 | 2022-04-20 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-03-02 | 2022-04-20 | N |
| Have exits that are accessible at all times. | Fire Safety | 2022-03-02 | 2022-04-20 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2022-03-02 | 2022-04-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-03-02 | 2022-04-20 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-03-02 | 2022-04-20 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-03-02 | 2022-04-20 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2022-03-03 | 2022-03-24 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-03-03 | 2022-03-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-03-03 | 2022-03-24 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-01-04 | 2022-02-18 | Y |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2021-03-02 | 2021-04-19 | N |
| Report COVID19 data to residents and families. | Health | 2021-03-04 | 2021-04-05 | N |
