Inspection Reports for
Epic Assistance Care Home I

The inspection found the facility generally clean and well-maintained with appropriate resident care and documentation. However, three Type B deficiencies were cited related to water temperature exceeding safe limits, lack of current CPR/First Aid certification for two staff members, and improper posting size of the RCFE Complaint poster.

The facility was found to be in full compliance with no deficiencies issued. Observations included proper resident care, safe and clean environment, operational safety equipment, adequate food supplies, and secure storage of medications and toxins.

The complaint investigation was triggered by allegations including questionable death, unauthorized alcohol administration, failure to address and notify changes in resident condition, lack of dignity and supervision, privacy violations, lack of activities, and improper COVID-19 safety protocols. The investigation concluded that all allegations except the COVID-19 safety protocols were unsubstantiated or unfounded. The COVID-19 safety protocols allegation was substantiated due to failure to report positive cases and maintain infected staff on duty without reporting a critical staffing shortage.

The investigation found all allegations except the failure to follow proper COVID-19 safety protocols to be unsubstantiated or unfounded. The resident's death was due to natural causes, no unauthorized alcohol was given, changes in condition were addressed and communicated, residents were treated with dignity and adequately supervised, and privacy and activities were provided appropriately. However, the facility was substantiated for not reporting positive COVID-19 cases and maintaining staff with COVID-19 on active duty without reporting a critical staffing shortage.

The facility was found to be clean, in good repair, and well maintained with adequate safety measures. However, deficiencies were cited related to outdated physician reports for residents with dementia and lack of documented required staff training.

The visit was triggered by a complaint investigation referenced as #22-AS-20230217143103.

Two deficiencies were cited: the fire extinguisher maintenance was outdated by six months, and four out of five physician reports for residents with confirmed dementia diagnoses were outdated by up to two years. Additionally, a technical violation advisory was issued for admitting a resident with a Stage 3 dermal ulcer without an exemption request, and a technical assistance advisory was issued for outdated certificates posted in the facility.

The Licensing Program Analyst observed that the facility had installed a fireplace screen and nightlights in bedrooms, hallways, and kitchen to secure nighttime circulation. All elements verified appeared to be in compliance and the facility was ready to be licensed.

The Licensing Program Analyst observed that required safety measures such as a fireplace screen and nightlights in bedrooms, hallways, and kitchen were in place. All elements verified appeared to be in compliance and the facility was deemed ready to be licensed.

The facility was toured and found generally well maintained with adequate safety features and supplies; however, several items needed correction before licensing, including securing cleaning supplies, installing a screen in front of the fireplace, adding night lights, and securing medications and toxic substances in the staff bedroom.

The applicant/administrator demonstrated understanding of facility operation, admission policies, staffing requirements, restrictive health conditions, general provisions, emergency preparedness, complaints and reporting, and pre-licensing readiness. No deficiencies or violations were noted in the report.