Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Epsom Healthcare Center during CMS and state inspections, most recent first.
Failure to Protect EMR Privacy: Staff were observed leaving laptops open with resident identifiable information visible on 100 and 200 Halls, including while stepping away from the computer. During med pass, an RN and an LPN partially closed laptop screens and left the carts or computers out of sight while resident health information remained on the screen. Facility policy requires staff to lock the screen or use the walk-away button when away from the computer.
Missed care plan meetings and no resident invitation documented. A resident who was his/her own decision maker was not invited to attend routine interdisciplinary care plan meetings, and the most recent care conference showed no attendance or declination documentation. The resident had quarterly comprehensive MDS assessments, but no care plan meetings were documented after later assessments, and the SS staff confirmed the meetings were missed.
The facility failed to follow professional standards for medication administration and weight monitoring. An LPN discontinued Eliquis for a resident without a new order, and another resident missed Pyridostigmine doses without documented hold parameters or provider notification. The facility also did not re-weigh residents after a large weight gain and a large weight loss, including a resident with severe protein-calorie malnutrition.
A resident with autonomic hypotension and medication induced hypertension had an order for Pyridostigmine 30 mg BID, but multiple doses were not given because the medication was reported unavailable. The record showed no documentation that the provider was notified when the medication was unavailable, and an LPN confirmed the doses should have been administered because the medication was in the facility. An APRN was unaware the resident had missed doses or whether the medication was available.
A resident’s consultant pharmacist MRR recommended changing lisinopril to losartan, and an APRN agreed and signed the recommendation, but the order was not updated in the resident’s chart. The resident’s physician orders still showed lisinopril with no change, and the APRN confirmed the EHR was not updated to reflect the recommended order change.
A resident’s self-administered inhalers and nasal spray were repeatedly observed unsecured on the bedside table and dresser instead of being kept in a locked storage area, despite care plan and physician orders allowing bedside storage. An LPN confirmed the meds were not locked, and another LPN noted there was a resident on the unit with a history of wandering into other residents’ rooms.
Kitchen equipment was found unclean in the main kitchen and a second-floor kitchenette. A fryolator had yellow-brown debris, cloudy dark oil with visible crumbs, and grease-like grime on the basket and tank area, while a microwave had dried food particles on the interior surfaces. The FSD confirmed both observations, and the fryolator cleaning log showed it had been cleaned every two weeks despite manufacturer instructions calling for daily maintenance and cleaning.
Failure to follow EBP PPE requirements was identified for two residents. One resident had EBP orders due to open wounds and a pressure injury, and staff were observed assisting with dressing and transfers while wearing gloves but no gown despite signage requiring both for high-contact care. Another resident with a history of ESBL and an EBP care plan was observed during linen care and dressing assistance with gloves only, and the LNA confirmed the gown was not worn.
The facility failed to implement a comprehensive water management program to prevent waterborne pathogens, affecting 102 residents. Key staff were unable to describe the water system or identify risk areas, and the required Legionella testing was incomplete. This lack of understanding and oversight led to deficiencies in pathogen control.
The facility failed to follow the seven rights of medication administration for two residents. A Medication Nursing Assistant administered an incorrect dose of Calcium to a resident, while an LPN did not check the apical pulse before administering Metoprolol to another resident, contrary to the physician's order and facility policy.
The facility failed to revise care plans for two residents. One resident's care plan lacked interventions for monitoring adverse drug reactions for an anticoagulant medication, and another resident's care plan did not include an intervention to encourage going to bed if they fall asleep in their wheelchair. These deficiencies were confirmed by the DON and an LPN, respectively.
A registered nurse failed to instruct a resident to rinse their mouth after using a corticosteroid inhaler, contrary to physician's orders and manufacturer warnings, increasing the risk of infection. The DON confirmed the findings.
Failure to Protect Electronic Medical Record Privacy
Penalty
Summary
The facility failed to provide privacy of electronic medical records for residents on 100 and 200 Halls and during medication administration. On 200 Hall, a Licensed Nursing Assistant was observed documenting on a laptop computer placed on a bench on the short hall and then walking away into a resident room while identifiable information remained visible on the screen. The same computer was later observed open on the bench with a blank screen, but resident identifiable information could be seen when the keyboard was touched, and no staff were nearby. On 100 Hall, a laptop computer was observed open on a movable computer stand near a bench with resident identifiable information visible when the keyboard was touched, and no nursing staff were nearby. During medication administration on the East Hall and North Hall, a Registered Nurse and a Licensed Practical Nurse were observed partially closing laptop screens and walking away from the medication cart or leaving the computer out of sight while resident health information remained visible on the screen. Staff confirmed these observations, and facility staff stated that policy requires staff to lock the screen or use the walk-away button when stepping away from the computer.
Missed interdisciplinary care plan meetings and no resident invitation documented
Penalty
Summary
The facility failed to hold routine interdisciplinary care plan meetings and failed to include the resident in the care planning process for one resident reviewed for care planning. Resident #27 stated in interview that he/she had not been invited to attend care plan meetings. Record review showed quarterly comprehensive MDS assessments completed on 8/13/25, 11/5/25, and 1/22/26, and the resident was identified as his/her own decision maker. The Care Conference Report showed the most recent care plan meeting was held on 8/19/25, with Resident #27 not listed as attending and no documentation that he/she had been invited. There were no documented care plan meetings after the 11/5/25 and 1/22/26 MDS assessments. Staff L confirmed that the most recent care plan meeting was on 8/19/25, that Resident #27 was not documented as attending or declining, and that the facility missed care plan meetings for the later quarterly comprehensive MDS assessments. The facility policy stated that the resident and/or legal representative are encouraged to attend and participate in assessment and person-centered care plan development, and that the social services director or designee is responsible for notifying the resident/representative and maintaining records of such notices.
Medication Administration and Weight Monitoring Failures
Penalty
Summary
The facility failed to follow professional standards related to medication administration for Resident #8 and Resident #24. For Resident #8, a progress note documented that the nurse practitioner wanted Eliquis decreased from 5 mg twice daily to 5 mg once daily, but the medication was discontinued after the morning dose on 2/26/26 without a new physician order to restart it. The March 2026 MAR showed no Eliquis order from 3/1/26 through 3/11/26, even though later physician and NP notes stated to continue Eliquis for chronic atrial fibrillation. Staff E confirmed the resident should have been on Eliquis 5 mg daily, and Staff D confirmed the verbal order was not entered and the medication was discontinued instead. For Resident #24, the MAR showed Pyridostigmine Bromide 30 mg twice daily ordered for orthostatic hypertension, but the medication was not administered on multiple dates because of "condition" or elevated blood pressure comments. One entry had no documentation of what the condition was, and the order did not include parameters to hold the medication. Staff D confirmed the medication was not given as ordered and that there were no hold parameters, and also confirmed there was no documentation that the provider had been notified when the medication was not administered. Staff E stated they were not aware the resident had missed the medication on those dates. The facility also failed to follow its weight policy for Resident #5 and Resident #65. Resident #5 had a documented weight increase from 135.4 lbs. to 148 lbs. in 7 days, but no re-weigh was done to verify the accuracy of the weight and the dietician was not notified. Resident #65 had a documented weight loss from 123.8 lbs. to 108 lbs. in 11 days, with no documentation verifying the accuracy of the weight loss and no re-weigh recorded after 3/8/26. Resident #65 was admitted with severe protein-calorie malnutrition and had nutritional interventions in place, including therapeutic diet, snacks between meals, Megace, and house supplements twice daily.
Missed Pyridostigmine Doses for Resident With Autonomic Hypotension
Penalty
Summary
The facility failed to provide routine medications to meet the needs of one resident reviewed for choices, Resident #24. An outside cardiology progress note dated 2/26/26 documented a recommendation to consider starting Pyridostigmine 30 mg twice daily for autonomic hypotension with medication induced hypertension. A physician's order was entered for Pyridostigmine Bromide 30 mg twice daily with a start date of 2/27/26, but the medication was not administered on 2/27/26, 2/28/26, 3/2/26, 3/3/26, 3/6/26, and 3/7/26 because it was not available. The record contained no documentation that the provider was notified on 2/27/26 or 2/28/26 that the medication was unavailable. The facility pharmacy delivery form showed the medication was delivered on 2/28/26 at 10:44 p.m., and an LPN confirmed the medication should have been administered on the missed dates because it was available in the facility. An APRN stated he/she was not aware the resident had missed the doses or whether the medication was available at the facility.
Failure to Act on Pharmacist Medication Review Recommendation
Penalty
Summary
The facility failed to act on a provider-approved pharmacy medication regimen review recommendation for Resident #95. On 2/16/26, the consultant pharmacist completed a Medication Regimen Review and recommended that the prescriber consider changing lisinopril to losartan. Staff E, an APRN, agreed with the recommendation and signed the form, but the resident’s physician orders still showed no change to lisinopril on 3/12/26. During interview, Staff E confirmed agreement with the recommendation but stated that the electronic health record was not updated to reflect the recommended order change. The facility policy stated that written or electronic pharmacy findings and recommendations are given to the attending physician, DON, medical director, and others as appropriate to ensure the findings are acted upon.
Unsecured Self-Administered Medications in Resident Room
Penalty
Summary
The facility failed to ensure self-administered medications were properly secured for Resident #53. On 3/10/26, observation in the resident’s room found three prescription medication boxes with pharmacy labels on the bedside table and not secured in a locked storage area. The medications observed were Breztri inhaler, Albuterol Sulfate inhaler, and Ipratropium Bromide nasal spray. At that time, Resident #53 was in bed sleeping. Review of the resident’s care plan showed that the inhalers and nasal spray could be kept in the resident’s room, and the active physician orders also indicated that these medications could be kept at bedside. However, on 3/11/26, the Breztri inhaler and Ipratropium Bromide nasal spray were again observed on the bedside table and the Albuterol Sulfate inhaler was on top of the bedside dresser, still not secured in a locked storage area. An LPN confirmed the medications were not locked. On 3/12/26, an LPN stated there was a resident on the unit with a history of wandering into other residents’ rooms, and the medications were again observed unsecured in Resident #53’s room while the resident was not present.
Kitchen Equipment Not Kept Clean
Penalty
Summary
The facility failed to ensure kitchen equipment was clean for 1 of 1 kitchen and 1 of 2 kitchenette observed. During a kitchen tour, a fryolator was observed with yellow-brown, food-like debris on the top surface, cloudy dark oil with visible crumbs inside, and a thick layer of yellow-brown, grease-like grime on the upper portion of the fryolator, including the basket and the top area of the tank. Staff G, the Food Service Director, confirmed the observation and stated the fryolator had last been cleaned two weeks earlier and was cleaned every two weeks. In the second floor kitchenette, a microwave was observed with multiple dried food particles scattered across the interior surfaces, including the bottom, side walls, and top interior area. Staff G confirmed the condition of the microwave. Review of the fryolator cleaning log showed it was last cleaned on 2/28/26, and the manufacturer’s instructions stated that daily preventative maintenance and daily cleaning, including filtering the oil and removing loose debris, were required. The FDA 2022 Food Code was also reviewed and stated that equipment food-contact surfaces and utensils shall be clean to sight and touch and that cooking equipment food-contact surfaces shall be kept free of encrusted grease deposits and other soil accumulations.
Failure to Follow EBP PPE Requirements
Penalty
Summary
The facility failed to follow its infection control policy for Enhanced Barrier Precautions (EBP) for 2 of 4 residents reviewed. Resident #65 had a care plan and physician order for EBP due to open wounds, and the record also showed a pressure injury to the right scapula that was present on admission. On 3/10/2026, an EBP sign outside the resident’s room indicated that gloves and a gown were required for high-contact care activities such as dressing and transfers, but Staff M, a Certified Occupational Therapy Assistant, was observed assisting the resident with dressing while wearing gloves and no gown. Staff M confirmed not wearing a gown during the dressing assistance. On 3/11/2026, Staff M was again observed in Resident #65’s room assisting the resident while seated in a wheelchair, wearing gloves and no gown. Staff M confirmed assisting with dressing and transferring from bed to wheelchair without a gown. Resident #90 had a care plan intervention for EBP and a history of ESBL. On 3/11/2026, an EBP sign outside the resident’s room indicated gloves and gown were required for high-contact activities including dressing, toileting, and changing linens. Staff N, a Licensed Nursing Assistant, was observed changing blue soak pads on the resident’s bed while wearing gloves and no gown, then going into the bathroom and appearing to assist the resident. Staff N later confirmed assisting Resident #90 with dressing in the bathroom while not wearing a gown.
Deficient Water Management Program for Pathogen Control
Penalty
Summary
The facility failed to develop and implement a comprehensive water management program to prevent the growth of waterborne pathogens, affecting a census of 102 residents. The review of the facility's undated water management program revealed several deficiencies, including the absence of a detailed description or diagram of the water system, and a lack of identification of areas where Legionella and other opportunistic pathogens could grow and spread. Additionally, the facility did not conduct the required second Legionella testing in 2024, and there were no control measures or procedures for monitoring and intervening when control limits were not met. Interviews with key staff members, including the Director of Maintenance and Environmental Services, the Director of Nursing, the Infection Preventionist, and the Administrator, confirmed these findings. Staff members were unable to describe the facility's water system or identify areas at risk for pathogen growth. They also could not explain the measures in place to minimize the risk of Legionella and other pathogens, indicating a lack of understanding and oversight of the water management program. This lack of knowledge and implementation contributed to the facility's failure to adequately manage and control waterborne pathogens.
Medication Administration Errors for Two Residents
Penalty
Summary
The facility failed to adhere to the seven rights of medication administration for two residents. For Resident #6, Staff E, a Medication Nursing Assistant, administered 375 mg of Calcium Extra Strength instead of the prescribed 200 mg chewable Calcium. This discrepancy was confirmed during an interview with Staff E, who acknowledged the error in medication dosage. For Resident #37, Staff F, an LPN, did not follow the physician's order to check the apical pulse before administering Metoprolol Succinate 100 mg extended release. Instead, Staff F used a pulse oximeter to measure the resident's pulse, which did not comply with the facility's policy on Apical Pulse Monitoring. The policy requires the use of a stethoscope to determine the apical pulse, and the medication should be held if the apical pulse is less than 60. Staff F confirmed during an interview that they did not check the apical pulse as required.
Failure to Revise Care Plans for Residents
Penalty
Summary
The facility failed to revise care plans for two residents, leading to deficiencies in their care. For Resident #63, the medical record showed a provider order for Eliquis, an anticoagulant, starting on 12/22/23 for atrial fibrillation. However, the care plan did not include interventions for monitoring adverse drug reactions related to the anticoagulant medication. This was confirmed by the Director of Nursing during an interview on 3/7/24. The facility's policy on Anticoagulant Medications, dated 9/1/22, requires assessment for any signs or symptoms of adverse drug reactions, which was not followed in this case. For Resident #31, a nurse's note dated 3/4/24 indicated that the resident fell asleep in their wheelchair and fell forward to the floor on 2/27/24. The note stated that the care plan was updated to include an intervention to encourage the resident to go to bed if they fall asleep in their wheelchair. However, a review of the care plan on 3/6/24 revealed that this intervention was not included, and the care plan for falls was last updated on 1/18/24. This discrepancy was confirmed by an LPN during an interview on 3/7/24. The facility's policy on Comprehensive Care Planning, dated 9/1/22, mandates ongoing assessments and revisions of care plans as residents' conditions change, which was not adhered to in this instance.
Failure to Follow Medication Administration Standards
Penalty
Summary
The facility failed to follow professional medication administration standards for a resident. During an observation, a registered nurse did not instruct the resident to rinse their mouth after inhaling a corticosteroid medicine, despite the physician's orders specifying this instruction. The review of the physician's orders and the manufacturer's warnings indicated that rinsing the mouth after use is necessary to reduce the risk of Candida albicans infections. The Director of Nursing confirmed these findings during an interview.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Epsom
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Havenwood-heritage Heights | 7.7 mi | ★★★★★ | 6 | 0 |
| Harris Hill Center, Genesis Healthcare | 9.1 mi | ★★★★★ | 11 | 0 |
| Presidential Oaks | 10 mi | ★★★★★ | 9 | 0 |
| Pleasant View Center | 10.4 mi | — | 9 | 0 |
| Hackett Hill Healthcare Center | 14.8 mi | ★★★★★ | 5 | 0 |
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