Below 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 Medical Lodge during CMS and state inspections, most recent first.
Failure to Provide Written Transfer or Discharge Notices: The facility did not provide written transfer/discharge notices, reasons for the move, or appeal rights to two residents or their representatives when they were sent to the ER, and it did not send copies to the LTC Ombudsman. Both residents had severe cognitive impairment and required substantial to maximal assistance. Interviews with the SW, DON, and Administrator confirmed the facility relied on verbal notification and telephone calls instead of written notices.
Improper positioning during meals: Two residents with severe cognitive impairment and mechanically altered diets were observed being fed in unsafe positions. One CNA fed a resident while reclined in a geri-chair, and another fed a resident while her head and neck were bent to the side; both CNAs acknowledged the positions were not appropriate, and an ADON confirmed the residents were supposed to be upright for meals.
Pureed Meal Contained Corn Husk: A resident with severe cognitive impairment, stroke, seizure disorder, and malnutrition was ordered a pureed diet, but the meal served contained shredded corn husk in the pureed tamales. The surveyor found the tamales were not edible, the Dietary Manager confirmed the husk was present, CNA reported removing pieces that were sticking out before feeding the resident, and the staff member who prepared the food said she was too hurried to taste it.
Improper Food Storage and Handwashing Sink Waste Receptacle Use: A facility kitchen review found the waste receptacle at handwashing sink #1 contained items other than disposable paper towels, including gloves, a plastic lid, and a straw. In dry storage and the walk-in freezer, multiple food items were left improperly labeled, unsealed, or exposed to air, and dented cans were observed among stored food items. The Dietary Manager stated that non-original packaging required product names, freezer items needed open and use-by dates, and dented cans belonged in a designated area.
A resident with PTSD, anxiety disorder, depression, and moderately impaired cognition was not referred for PASARR Level II review after a significant change in status assessment. The MDS Coordinator said the resident’s PASARR Level 1 was negative but incorrect based on the diagnosis, and no PASARR Level II screening or PASARR evaluation was found in the record.
Wheelchair Not Maintained in Good Repair: A resident with severe cognitive impairment, hemiplegia, ESRD, and seizure disorder was observed seated in a wheelchair missing the right armrest cushion and with a cracked, worn left armrest exposing the filling. The resident had scabs on both forearms and said he wanted armrests on both sides; the resident representative also requested repair. Staff said equipment issues were to be reported electronically, but the Maintenance Manager was not aware of any needed repair for the wheelchair.
Failure to perform hand hygiene during incontinence care occurred when a CNA cleaned a resident, removed the soiled brief, changed gloves, and then placed a clean brief without cleaning her hands. The resident had severely impaired cognition, heart failure, and non-Alzheimer's dementia, and required extensive assistance with toilet use. The CNA acknowledged she was supposed to perform hand hygiene after changing gloves, and the DON confirmed staff were trained to do so and that the facility policy requires hand hygiene after glove removal.
Two residents experienced repeated issues with cold and unappetizing meals, missing condiments, and delayed meal service. Staff and resident interviews, as well as council meeting notes, confirmed ongoing problems with food temperature, taste, and order accuracy. Operational issues in the kitchen, including equipment malfunction and disorganized meal tickets, contributed to the deficiency.
A medication cart in the facility was left unlocked and unattended, containing various medications such as insulins and albuterol inhalers. LVN B admitted to forgetting to lock the cart, which was against the facility's policy. The ADON confirmed that LVN B had been trained on medication safety, and the DON emphasized the importance of keeping carts locked to prevent unauthorized access.
Two residents in a facility were not provided with proper infection control measures. A CNA failed to wear a gown while providing perineal care to a resident with a Foley catheter, and an LVN did not wear a gown while administering medications via G-tube to another resident. Both residents were on Enhanced Barrier Precautions, requiring PPE during high-contact care. These lapses in protocol posed risks of infection transmission.
The facility failed to document the use of bed rails and grab bars in the care plans of two residents, despite their observed use. Both residents had significant mobility and cognitive impairments, requiring substantial assistance. Interviews with staff revealed a lack of proper documentation and communication regarding the use of these aids, contrary to facility policy.
A facility failed to ensure proper G-tube medication administration for a resident, as LVN B did not obtain physician orders for water flushes and used a syringe and plunger instead of gravity flow. The resident, dependent on enteral nutrition due to swallowing difficulties, did not receive care per facility policy, leading to a deficiency.
A facility failed to assess the risks and benefits of bed rails and obtain informed consent for a resident with multiple health conditions, including Parkinson's and Alzheimer's. The resident required substantial assistance for daily activities, yet grab bars were installed without proper documentation or consent. Staff interviews revealed a lack of adherence to policies regarding the assessment and documentation of bed rail use.
A resident with COPD did not receive proper respiratory care as the facility failed to date the oxygen tubing, contrary to their policy. The tubing was supposed to be changed and dated weekly by the night nurse, but this was not done, posing a risk of infection. Interviews with ADONs confirmed the oversight, highlighting a lapse in following the facility's oxygen administration policy.
A resident experienced a fall while transferring from a wheelchair to a bed, but the nurse on duty failed to notify the physician and family, as required by facility policy. The resident, who was on anticoagulant therapy, did not report immediate pain, and the incident was not documented or reported to management. This oversight placed the resident at risk for delayed medical intervention.
Failure to Provide Written Transfer or Discharge Notices
Penalty
Summary
The facility failed to notify two residents and/or their representatives in writing of transfer or discharge, the reasons for the move, and their right to appeal, and it also failed to send a copy of the notice to the Office of the State Long-Term Care Ombudsman. The deficiency involved Resident #14 and Resident #109, both of whom were reviewed for discharge planning and were sent to the emergency room without evidence of the required written notice being provided. Resident #14 was a female admitted to the facility with diagnoses including cognitive communication deficit, dysphagia, atherosclerotic heart disease, and acute embolism and thrombosis of the right peroneal vein. Her MDS reflected a BIMS score of 03/15, indicating severe cognitive impairment, and she required substantial to maximal assistance with care. A progress note documented that she was sent to the ER due to stomach pain, inability to open her eyes, and an elevated anion gap. There was no evidence that a transfer or discharge notice had been provided to Resident #14, her responsible party, or the LTC Ombudsman. Resident #109 was a female admitted to the facility with diagnoses including unspecified atrial fibrillation, dementia, muscle weakness, essential hypertension, and atherosclerotic heart disease. Her MDS also reflected a BIMS score of 03/15, indicating severe cognitive impairment, and she required substantial to maximal assistance with care. A progress note documented that she was sent to the ER due to altered level of consciousness and general weakness. There was no evidence that a transfer or discharge notice had been provided to Resident #109, her responsible party, or the LTC Ombudsman. Interviews with the Social Worker, DON, and Administrator confirmed that the facility did not provide written transfer or discharge notices when residents were sent to the emergency room and instead notified responsible parties by telephone.
Improper positioning during meals
Penalty
Summary
The facility failed to ensure that two residents were positioned appropriately for eating and drinking. Resident #96 had severe cognitive impairment, a history of stroke, non-Alzheimer’s dementia, Parkinson’s disease, and was on a mechanically altered diet. During observation, CNA A fed the resident pureed food while she was reclined in a geri-chair. CNA A stated she was feeding the resident in a reclined position because the family wanted the chair to remain reclined, and ADON C said the resident was supposed to be fed in a reclined position for that reason. ADON C also stated that the reclined position to eat could cause aspiration and choking. The resident’s family representative later stated she never told staff to recline the resident to eat and expected the facility to know to sit the resident upright. Resident #34 also had severe cognitive impairment, a history of stroke, heart failure, non-Alzheimer’s disease, and was on a mechanically altered diet. During observation, CNA E fed the resident while her neck and head were bent over to the left side, and CNA E held the drinking glass while the resident drank fluids. CNA E stated the resident would normally lean over to eat and drink and that this did place her at risk for choking, and she said she had not been trained to position the resident to eat. ADON Z stated the resident was not supposed to lean over to her left side to eat. The facility policy stated residents shall receive assistance with meals in a manner that meets the individual needs of the resident.
Pureed Meal Contained Corn Husk
Penalty
Summary
The facility failed to ensure a pureed meal was prepared in a form designed to meet the individual needs of Resident #63. Resident #63 was an elderly female admitted to the facility with a BIMS score of 6, indicating severely impaired cognitive skills, and diagnoses including stroke, seizure disorder, and malnutrition. Her orders reflected a pureed texture, regular consistency diet, and her care plan identified a nutritional problem and risk for malnutrition with interventions to provide and serve the diet as ordered. During a sample tray observation, the pureed meal served included tamales, stewed tomatoes, charro beans, rolls, Spanish rice, and a sopapilla. The surveyor found shredded corn husk in the pureed tamales, and the tamales were not edible because the husk could not be chewed and had to be spit out. The Dietary Manager confirmed the husk was present in the food. CNA G stated she fed Resident #63 the pureed tamales and had to pull out pieces that were sticking out before giving the resident the pureed portions. The DON stated she did not see the lunch trays, and the Dietary Manager said the pureed food was supposed to be tasted every meal but she did not taste the lunch meal. [NAME] F, who prepared the pureed tamales, said she had been trained to puree food but did not taste the food at lunch because she was in too much of a hurry.
Improper Food Storage and Handwashing Sink Waste Receptacle Use
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards in its only kitchen reviewed for food safety. During observation of handwashing sink #1, the garbage receptacle contained items other than disposable paper towels, including disposable gloves, a plastic lid, and a straw. The Dietary Manager stated that the receptacle at the sink is used for paper towels and that trash should not be thrown in it. In the dry storage room, food items were observed improperly stored and exposed to air, including zipper storage bags of round buns that were open, lacked a name, and had dates listed as opened and use by dates; one bag contained buns past the use by date. Also observed were canned food items with dents, including a can of tomato soup dented on the top seal and a can of mixed vegetables dented on the lower left side. In the walk-in freezer, zipper storage bags containing bread or cheese sticks and a brown bag inside a zipped bag were observed without names on the packages. The Dietary Manager stated that food items not in original packaging should be labeled with the product name, that freezer items required an open date and use by date, and that dented cans were to be placed in the designated dented can area in her office.
Failure to Refer Resident for PASARR Level II Review
Penalty
Summary
The facility failed to refer one resident for PASARR Level II resident review after a significant change in status assessment. Resident #2’s annual MDS assessment showed a BIMS score of 11, indicating moderately impaired cognitive skills, and his diagnoses included PTSD, anxiety disorder, and depression. His care plan identified him as at risk for a mood problem related to PTSD and included behavioral health consults as needed. Although his PASARR Level 1 screening dated 12/26/24 reflected no mental disorders, the resident’s clinical record did not contain a PASARR Level 2 screening or a PASARR evaluation. During interview, the resident stated he did not receive PASARR services. The MDS Coordinator stated the resident was a veteran and did not qualify for PASARR services, but also acknowledged the resident had a negative PASARR Level 1 that was not correct based on his diagnosis. She said she missed the diagnosis and did not submit a new PASARR Level 1 screening, and stated that a negative PASARR Level 1 screening could cause residents to miss PASARR services.
Wheelchair Not Maintained in Good Repair
Penalty
Summary
The facility failed to ensure Resident #13’s manual wheelchair was maintained in good repair. Resident #13 was a male with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, end stage renal disease, and unspecified convulsions. His MDS reflected a BIMS score of 05, indicating severe cognitive impairment, and he required a wheelchair with complete dependence for toileting and showering. His care plan also identified skin-picking behavior and risk for pressure ulcers. During observation, Resident #13 was seated in his wheelchair in the dining room and the wheelchair was missing the right-hand armrest cushion. The left armrest was cracked, had open areas exposing the cushion filling underneath, and appeared to be missing some of the cushion filling. Resident #13 had several scabs on both forearms and stated he was not sure where they came from and that he would like armrests on both sides of his wheelchair. His resident representative also stated she wanted the wheelchair repaired and believed the missing armrest could be uncomfortable and possibly cause scratches or bruising. Staff interviews confirmed that wheelchair repair issues were to be reported through an electronic interface, and the Maintenance Manager stated he was not aware of any repairs needed for Resident #13’s wheelchair.
Failure to Perform Hand Hygiene During Incontinence Care
Penalty
Summary
Provide and implement an infection prevention and control program was deficient when CNA I did not perform hand hygiene during incontinence care for Resident #86. Resident #86 was an [AGE]-year-old female admitted to the facility on [DATE], with a BIMS score of 7 indicating severely impaired cognitive skills. Her diagnoses included heart failure and non-Alzheimer's dementia. Her care plan documented an ADL self-care performance deficit related to muscle weakness and stated that she required extensive assistance from one staff member with toilet use. During an observation on 04/27/26 at 10:00 AM, CNA I was preparing to provide incontinence care, cleaned the resident, removed the soiled brief, changed gloves, and did not perform hand hygiene before placing a clean brief on the resident. In interview, CNA I stated she was supposed to perform hand hygiene when she changed gloves and said she did not do so during this care. The DON stated staff were supposed to perform hand hygiene when they changed gloves and had been trained to do it. The facility policy stated hand hygiene is the primary means to prevent the spread of infections and directs staff to use alcohol-based hand rub or soap and water after removing gloves.
Failure to Provide Palatable and Appropriately Tempered Meals
Penalty
Summary
The facility failed to ensure that food and drink provided to residents were palatable, attractive, and served at a safe and appetizing temperature. Observations revealed that residents experienced significant delays in meal service, with some residents waiting up to 43 minutes after the first tray was served to receive their meals. During this time, food items such as tomato soup were repeatedly served cold, and condiments were often missing from trays. One resident reported that his soup was cold on multiple occasions, even after staff attempted to reheat it, and ultimately declined further attempts to provide a hot meal. Another resident expressed dissatisfaction with the timeliness and quality of his meals, stating that food was often cold and condiments were not provided. Record reviews and interviews indicated that these issues were not isolated incidents. Resident council meeting notes documented ongoing complaints about food temperature, taste, and missing items, with residents reporting cold meals and incorrect orders. Staff interviews confirmed that the kitchen experienced operational issues, such as a malfunctioning microwave, which contributed to the inability to serve hot food. The dietary manager and kitchen supervisor acknowledged that meal tickets were disorganized and that equipment problems hindered their ability to provide meals at the appropriate temperature. Further review of care plans and assessments showed that the affected residents had specific dietary needs and required supervision or assistance with eating. Despite these needs, the facility did not consistently monitor or document food temperatures, as evidenced by missing entries in the food temperature log. The lack of timely and appropriate meal service, combined with repeated resident complaints and staff acknowledgment of the problems, demonstrated a failure to provide meals that met the required standards for palatability, appearance, and temperature.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments, as observed with Nurse medication cart #1. On the specified date, the medication cart was left unlocked, unattended, and out of the view of LVN B outside a resident's room. The cart contained various medications, including insulins, prescription pills, over-the-counter medications, and inhalers with albuterol. During the observation period, three staff members walked past the unlocked and unattended cart. In an interview, LVN B admitted to forgetting to lock the medication cart when it was unattended, acknowledging that the cart should never be left unlocked as it poses a risk of unauthorized access to medications. The ADON confirmed that LVN B, an agency nurse, had been in-serviced on medication safety and storage, and had verbalized understanding of these protocols. The DON reiterated the expectation that all medication carts should be locked when not in use to prevent unauthorized access. The facility's policy on medication storage, revised in April 2019, mandates that unlocked medication carts should not be left unattended.
Infection Control Lapses in PPE Usage
Penalty
Summary
The facility failed to maintain proper infection prevention and control measures for two residents, leading to potential risks of communicable disease transmission. One incident involved a CNA who did not wear a gown while providing perineal care to a resident with a Foley catheter, despite the resident being on Enhanced Barrier Precautions (EBP). The CNA admitted to forgetting to don the gown, acknowledging the risk of infection spread due to this oversight. The resident's care plan required the use of gown and gloves during high-contact care, which was not adhered to during this incident. Another incident involved an LVN who failed to wear a gown while administering medications and tube feeding via a G-tube to a resident on EBP. The LVN attributed the oversight to nervousness from being observed, which led to not following the infection control precautions. The resident required EBP due to the presence of a G-tube, and the care plan specified the use of PPE during high-contact care activities. The LVN's failure to wear PPE posed a risk of contamination and infection exposure to the resident. Both incidents highlight lapses in following the facility's infection control protocols, which are designed to prevent the transmission of infections among residents and staff. The facility's policies require the use of PPE during high-contact care for residents with indwelling medical devices, such as Foley catheters and G-tubes. These deficiencies were identified through observations and interviews with the involved staff and facility management.
Failure to Document Use of Mobility Aids in Care Plans
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for two residents, specifically regarding the use of bed rails, grab bars, or mobility bars. For Resident #4, the care plan did not document the use of grab/mobility bars, despite observations showing a grab/mobility bar raised on the left side of the bed. Resident #4 had multiple diagnoses, including Parkinson's Disease, Alzheimer's Disease, and Type 2 Diabetes Mellitus, and required substantial assistance for various activities of daily living. The absence of documentation in the care plan regarding the use of these bars posed a risk of not meeting the resident's individual needs and ensuring continuity of care. Similarly, Resident #19's care plan lacked documentation of the use of a grab/transfer bar, which was observed in the resident's room. Resident #19 had a history of hemiplegia, chronic obstructive pulmonary disease, and other mobility-related issues, requiring substantial assistance for daily activities. The resident confirmed using the grab/transfer bar for personal care and repositioning, yet this was not reflected in the care plan. This oversight could lead to inadequate care and services for the resident. Interviews with facility staff, including a CNA, the DON, and an LVN, revealed a lack of proper documentation and communication regarding the use of grab/transfer bars. The facility's policy required a safety assessment, consent, and care plan documentation for the use of such equipment, which was not followed in these cases. The failure to update the care plans as per the facility's policy and guidelines contributed to the deficiency, potentially compromising the safety and care of the residents involved.
Deficiency in G-Tube Medication Administration
Penalty
Summary
The facility failed to ensure that a resident receiving enteral nutrition was provided with appropriate treatment and services to prevent complications. Specifically, LVN B did not obtain physician orders for water flushes before and after medication administration via the G-tube for Resident #81. Additionally, LVN B did not adhere to the facility policy of holding tube feeding for 30 minutes after medication administration. Instead, LVN B immediately resumed the feeding after administering medications. LVN B also administered medications and water using a syringe and plunger, rather than allowing them to flow gently by gravity, as per facility protocol. This method of administration could potentially cause damage to the G-tube and lead to complications. During an interview, LVN B, a travel nurse, admitted to using the syringe and plunger method as it was how she had been trained, and she was not aware of the specific facility protocols. The resident involved, a female with a history of cerebral infarction, difficulty speaking, and swallowing, was dependent on staff for all activities of daily living and required a feeding tube for nutrition. The facility's policies and procedures for enteral nutrition and medication administration were not followed, leading to the deficiency. Interviews with the ADON and DON revealed that LVN B had been in-serviced on G-tube procedures, but the nurse did not adhere to the protocols during the observed incident.
Failure to Assess and Obtain Consent for Bed Rails
Penalty
Summary
The facility failed to properly assess the risks and benefits of bed rails and grab bars for a resident, identified as Resident #4, and did not obtain informed consent prior to their installation. This deficiency was identified through observations, interviews, and record reviews. The facility did not have evidence of informed consent or an assessment of the resident for the risk of entrapment associated with the use of bed rails or grab bars. Resident #4, a male with multiple diagnoses including Parkinson's Disease, Alzheimer's Disease, and Type 2 Diabetes Mellitus, was noted to have moderate cognitive impairment and required substantial assistance for various activities of daily living. Despite these conditions, there was no signed consent form or documented verbal permission for the use of enabler bars in his medical record. Observations revealed that grab/mobility bars were installed on the resident's bed without proper documentation or consent. Interviews with facility staff, including CNAs, LVNs, and the DON, highlighted a lack of adherence to the facility's policies regarding the assessment and documentation of bed rail use. Staff members acknowledged the importance of checking for orders and obtaining consent for bed rails or grab bars, but the necessary steps were not followed in this case. The facility's policies require a comprehensive assessment and informed consent before the use of such devices, which was not adhered to for Resident #4.
Failure to Date Oxygen Tubing for Resident with COPD
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident with chronic obstructive pulmonary disease (COPD) by not ensuring that the resident's oxygen tubing was dated. This oversight was identified during an observation where the resident was found lying in bed with a nasal cannula connected to an oxygen concentrator, and the tubing was not dated. The facility's policy required that oxygen tubing be changed and dated weekly by the night nurse, a task that was not completed in this instance. Interviews with two Assistant Directors of Nursing (ADONs) confirmed that the responsibility for dating the oxygen tubing fell to the Sunday night nurse, and the task was supposed to be verified using a room round sheet. The failure to date the tubing posed a risk of infection and respiratory complications for the resident, as undated tubing could harbor bacteria. The facility's policy on oxygen administration required documentation of the date and time when oxygen setup or adjustments were performed, which was not adhered to in this case.
Failure to Notify Physician and Family After Resident Fall
Penalty
Summary
The facility failed to immediately inform a resident, the resident's physician, and the resident's family member about an accident involving the resident that resulted in a fall. The incident involved a female resident who was cognitively intact and had a history of rheumatoid arthritis, atrial fibrillation, and was on anticoagulant therapy. On the day of the incident, the resident fell in her room while transferring herself from a wheelchair to the bed, resulting in her landing on her bottom. Despite the fall, the resident did not report immediate pain, and the nurse on duty, LVN A, did not notify the physician or the resident's family about the fall. The report highlights that LVN A did not document the fall in the resident's medical records or notify the physician and family, as required by the facility's policy. The nurse mistakenly believed that the incident did not constitute a fall because the resident lowered herself to the ground. Consequently, the necessary assessments, such as neuro checks, were not performed, and the incident was not reported to the facility's management. The Assistant Director of Nursing (ADON) and the Administrator both confirmed that the nurse should have followed the facility's protocol for falls, which includes notifying the physician, family, and management, and conducting a thorough assessment of the resident. The facility's policy on falls requires that any fall, whether witnessed or unwitnessed, be documented and reported immediately to ensure timely medical intervention and to prevent further complications. The failure to adhere to this policy placed the resident at risk for delayed physician intervention and potential adverse effects due to her medical condition and anticoagulant therapy. The report underscores the importance of following established protocols to ensure resident safety and effective communication with all parties involved.
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What surveyors actually found near you
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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) |
|---|---|---|---|---|
| The Hills Nursing & Rehabilitation | 0.7 mi | ★★★★★ | 13 | 0 |
| Heritage Place Of Decatur | 1.7 mi | ★★★★★ | 10 | 0 |
| Bridgeport Medical Lodge | 9 mi | ★★★★★ | 5 | 1 |
| Springtown Park Rehabilitation And Care Center | 18.3 mi | ★★★★★ | 4 | 0 |
| Longmeadow Healthcare Center | 20 mi | ★★★★★ | 0 | 0 |
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