Average — CMS composite of the measures below.
The next survey window likely opens around March 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 Decatur Center For Nursing And Healing Llc during CMS and state inspections, most recent first.
Improper Dumpster and Refuse Disposal: The dumpster area was observed covered with food debris and trash on the platform and in adjacent grass areas, and a gray trash container was overflowing and uncovered. The FSD and KM confirmed the findings, and staff interviews showed uncertainty about who was responsible for keeping the area clean and how often the waste vendor emptied the dumpster.
PTAC air filters in two rooms were observed with significant gray, fuzzy particulate matter, and the Maintenance Director confirmed the filters needed cleaning. The facility also had inconsistent linen availability for resident care, with residents and a family member reporting shortages of towels, washcloths, sheets, gowns, and under pads, and staff describing delayed linen delivery, limited cart supplies, and nonfunctioning dryers that slowed processing.
Unsafe Environmental Hazards and Lack of Interim Protection: Surveyors observed a broken handrail with exposed, jagged edges outside the elevator area and a loose, rusted heater cover with sharp edges in the first-floor central shower room. The Maintenance Director and Administrator acknowledged the hazards had not been repaired or otherwise mitigated, and the DON stated interim safety measures should have been in place until repairs were completed.
Staff failed to follow the facility’s hand hygiene policy during wound care waste disposal. An RN and an LPN were observed wearing soiled gloves in the hallway after completing wound care, with the RN leaving the resident room without hand hygiene and the LPN using gloved hands to open the biohazard room door. Both staff acknowledged the practice was not appropriate, and the IP and DON confirmed gloves should be removed and hand hygiene performed before entering common areas.
The facility did not adhere to its policy on garbage disposal, as observed with overflowing dumpsters and a missing lid on the dumpster outside the kitchen. The sliding door was also left open and difficult to close. The Dietary Manager had informed the Maintenance Director about the missing lid, but the Administrator was unaware until the survey. The Maintenance Director had contacted the county regarding the issue two weeks earlier.
The facility failed to cover, label, and date an open bag of cabbage in a walk-in cooler, as required by their policy. The Dietary Manager and an employee acknowledged the oversight, noting it was likely left open after salad preparation. This deficiency potentially affected 121 of 123 residents receiving an oral diet from the kitchen.
A facility failed to accurately document a fall in a resident's MDS assessment. The resident, with multiple health issues, fell while moving from a chair to a bed, resulting in a finger strain. Although the incident was recorded in progress notes and a fall report, it was not reflected in the MDS. The MDS Assessment Nurse confirmed the oversight during an interview.
A resident experienced late administration of scheduled medications, specifically gabapentin, which was consistently given outside the facility's policy of a 60-minute window. The resident reported that the delays affected her neuropathy, and interviews with the DON and an LPN confirmed the policy but did not acknowledge any issues with timing.
A resident with multiple health conditions did not receive the required number of showers per the facility's schedule. The resident's care plan required extensive assistance for bathing, but they only received one shower per week initially, missing a scheduled shower. The DON confirmed the oversight in the shower schedule.
Improper Dumpster and Refuse Disposal
Penalty
Summary
Garbage and refuse were not properly disposed of at the dumpster site, and the facility failed to ensure garbage and refuse receptacle containers were covered and that the dumpster area remained clean and free of debris. Review of the facility policy titled "Disposal of Garbage and Refuse" showed that refuse and dumpsters were to be kept outside the facility with tightly fitting lids, doors, or covers, and that containers were to be kept covered when not being loaded. The policy also stated the surrounding area was to be kept clean so that debris and insect/rodent attractions were minimized, and that garbage should not accumulate or be left outside the dumpster. During observation with the FSD and KM, the dumpster and dumpster platform at the rear of the facility were covered with food debris and trash, with debris present on the platform and in the grass areas adjacent to the dumpster platform near the fence. A gray trash container was overflowing with trash and was not covered. These observations were confirmed by both the FSD and KM. Interviews further showed that the FSD and KM could not state with certainty which department was responsible for maintaining the area for cleanliness or how often the dumpster was emptied by the sanitation/waste vendor. The Administrator stated cleanliness of the grounds and dumpster area was a joint interdisciplinary responsibility of Maintenance and Environmental Service staff, while the Maintenance Director and Environmental Services Director each described routine monitoring of the dumpster area by their respective staff.
Soiled PTAC Filters and Inconsistent Linen Availability
Penalty
Summary
The facility failed to maintain the environment in a safe, sanitary, and functional condition when PTAC air filters in two rooms on Team A Hall were observed with a significant amount of gray, fuzzy particulate matter. Survey observations on multiple dates showed the filters remained soiled, and the Maintenance Director confirmed that the filters required cleaning. The Maintenance Director stated that filters were expected to be checked daily and cleaned weekly, and then directed a Maintenance Assistant to clean all air filters on the first floor. During the cleaning, the Maintenance Assistant removed particulate matter with a duster and disposed of the debris into a trash can located in a public restroom on the hallway. The facility also did not consistently make clean linens available for resident care. Review of resident assessments showed that R39 had a BIMS score of 15, R8 had a BIMS score of 10, R101 had a BIMS score of 14, R89 had a BIMS score of 13, and R90 had a BIMS score of 10. Interviews with residents and a family member described repeated shortages of towels, washcloths, sheets, gowns, and under pads. R101 stated she could not wash her face each morning because there were not enough towels and washcloths. R89 reported staff often had to leave the room to search for supplies and sometimes could not locate a gown. R72's family member stated essential items were frequently unavailable and that he had purchased these items for R72 because of the lack of supplies. Additional observations and staff interviews showed linen carts with very limited supplies, including one cart with approximately three bed sheets and another with only one towel. A resident council meeting also included concerns about shortages of towels, washcloths, and gowns, and R90 reported waiting overnight to receive these items. Staff stated linen was typically delivered between 11:00 AM and 12:00 PM, while CNA FF reported supplies were often not available at the start of the 7:00 AM shift and were not delivered until about 12:00 PM, creating a gap of up to five hours. The Environmental Supervisor stated two of three dryers were not functioning, which delayed processing and distribution of linen.
Unsafe Environmental Hazards and Lack of Interim Protection
Penalty
Summary
The facility failed to ensure the environment remained free of accident hazards and did not maintain environmental surfaces in a safe condition. Surveyors observed a broken handrail on the second floor outside the elevator area that had exposed, jagged, sharp edges and remained in the same condition during a later observation. The Maintenance Director acknowledged the damaged handrail and stated it had not been repaired or otherwise mitigated. The Administrator stated replacement handrails had been delivered but were not installed, and confirmed that safety measures should have been implemented until the replacement handrail could be installed. Surveyors also observed the first-floor central bath shower room with rust on the door frame and on a heater cover. The heater cover was loose, secured only by the top screw, moved when touched, and had sharp, rusted edges. The LPN Unit Manager confirmed these conditions posed a safety hazard because residents were transported into and out of the shower room and could come into contact with the rusted, sharp surfaces. The DON stated environmental hazards must be repaired in a timely manner and that interim safety measures must be implemented until repairs were completed. The Maintenance Director confirmed the damaged door frame and heater cover and stated a work order had been submitted that day for repairs.
Failure to Perform Hand Hygiene and Remove Soiled Gloves Before Leaving Resident Room
Penalty
Summary
The facility failed to ensure staff followed infection control practices during the handling and disposal of contaminated wound care waste. Review of the facility’s Hand Hygiene policy stated that staff must perform hand hygiene when indicated and that gloves do not replace hand hygiene; hand hygiene is required before donning gloves and immediately after removing them. During an observation on 03/31/2026 at 1:28 PM, the Skin Management Specialist/Regional Nurse and an LPN completed wound care and then disposed of wound care waste. The Regional Nurse removed the left glove but kept the right glove on and exited the resident room into the hallway without performing hand hygiene, while still wearing the soiled glove. The LPN was also wearing soiled gloves in the hallway and used gloved hands to open the door to the biohazard room. Both staff members later confirmed they wore gloves in the hallway and did not perform hand hygiene before leaving the resident room. The Infection Preventionist and DON stated staff were expected to remove gloves and perform hand hygiene before exiting resident rooms and entering common areas.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to ensure proper disposal of garbage and refuse as required by their policy. Observations revealed that the facility's garbage dumpsters were overflowing with garbage bags, and the dumpster outside the kitchen was missing a lid with the sliding door left open. The Dietary Manager noted that the sliding door was difficult to close and confirmed that the lid had been missing for some time, having already notified the Maintenance Director. The Administrator was unaware of the missing lid until informed during the survey, while the Maintenance Director acknowledged awareness of the issue and stated he had contacted the county about it two weeks prior.
Failure to Properly Store and Label Food in Walk-In Cooler
Penalty
Summary
The facility failed to ensure that opened food stored in one walk-in cooler was covered, labeled, and dated, as required by their policy titled Food Receiving and Storage. During an observation, it was noted that an open bag of cabbage in the walk-in cooler had no open date or label. The Dietary Manager (DM) acknowledged the oversight, suggesting it was left open from salad preparation, although the cabbage did not match the premade salads. An employee (EE) later confirmed that the cabbage was used for slaw and speculated that staff mistakenly left it open after preparing salads for residents who preferred them. The EE admitted to seeing the open, unlabeled bag firsthand. This deficiency had the potential to affect 121 of 123 residents who received an oral diet from the kitchen, as the facility's policy mandates that all foods stored in the refrigerator or freezer must be covered, labeled, and dated to ensure safety and compliance with professional standards.
Inaccurate MDS Assessment for Resident Fall
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for a resident reviewed for falls. The resident, who was admitted with multiple diagnoses including type II diabetes mellitus, sepsis, morbid obesity, and a pressure ulcer, experienced a fall while attempting to move from a chair to a bed. This incident was documented in the resident's progress notes and a fall incident report, indicating a left index finger strain and subsequent medical interventions. However, the MDS assessment did not reflect this fall, as Section J, which records falls since admission, was marked 'no'. During an interview, the MDS Assessment Nurse acknowledged the oversight, confirming that the fall was not captured in the MDS due to an error.
Medication Administration Timing Deficiency
Penalty
Summary
The facility failed to administer scheduled medications within the required 60-minute window for a resident, identified as R13, who was reviewed for medication administration. The facility's policy on Medication Administration, dated January 2023, mandates that medications should be administered within 60 minutes before or after the scheduled time unless otherwise ordered by a physician. However, the Medication Administration Audit Report for R13 documented multiple instances where gabapentin, prescribed for neuropathy, was administered significantly outside the prescribed time frame. For example, on several occasions, the 9:00 am dose was administered as late as 11:34 am, and the 5:00 pm dose was given as late as 7:49 pm. Interviews with the resident, R13, and the Director of Nursing (DON) revealed discrepancies in the administration times. R13 reported that her medications were consistently late, which affected her neuropathy. The DON acknowledged the two-hour window for medication administration but did not recall any concerns about late medications. The Licensed Practical Nurse (LPN) also confirmed the one-hour window policy. Despite these policies, the facility failed to adhere to the medication administration schedule, leading to the deficiency noted in the report.
Failure to Provide Scheduled Showers for Resident
Penalty
Summary
The facility failed to provide the required number of showers for a resident, identified as R12, who was admitted with multiple diagnoses including type II diabetes mellitus, sepsis, morbid obesity, and a pressure ulcer. R12's care plan indicated the need for extensive assistance by one staff member during bathing. The facility's shower schedule mandated two showers per week, but R12 only received one shower during the first few weeks of admission. Specifically, R12 did not receive a shower on the scheduled date of 7/24/2024. Interviews with R12 and the Director of Nursing confirmed the deficiency, with the DON acknowledging that the shower schedule should have ensured R12 received the appropriate number of showers based on their room and bed placement.
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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 Decatur
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Harborview Decatur | 0.2 mi | ★★★★★ | 0 | 0 |
| Parkside At Budd Terrace Operating Company Llc | 2.9 mi | ★★★★★ | 22 | 0 |
| Crossings At East Lake Of Journey Llc, The | 3 mi | ★★★★★ | 8 | 0 |
| A.g. Rhodes Home Wesley Woods | 3.1 mi | ★★★★★ | 5 | 0 |
| Pruitthealth - Virginia Park | 3.6 mi | ★★★★★ | 0 | 0 |
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