Average — CMS composite of the measures below.
The next survey window likely opens around October 2026
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 Heritage Place Of Decatur during CMS and state inspections, most recent first.
A contracted LPC entered isolation rooms of three cognitively intact residents with confirmed COVID-19 while wearing only a cloth face mask and not donning the required PPE that was available outside each room, despite posted signs at the facility entrance and on room doors indicating COVID-19 precautions and PPE requirements. Each resident had an acute COVID-19 care plan specifying infection control measures and PPE use during care, along with room isolation. The LPC later stated he had noticed but not thoroughly read the signs and had not been directly informed by staff of the outbreak or PPE expectations, while facility leadership stated that vendors were expected to follow the same infection prevention and isolation policies as staff.
Food Storage and Kitchen Sanitation Failures: The facility’s kitchen had a deep fryer layered with grease and food debris, along with multiple unlabeled, undated, or unsealed food items in the refrigerator and freezer. Staff also found thawed and refrozen cookie dough, frozen chicken without labels, a red frozen substance with a knife in it, and defrosted breaded cauliflower left on the floor. Interviews confirmed that food should be sealed, labeled, dated, stored correctly, and that kitchen equipment should be cleaned after each meal.
Advance Directive Not Placed in Clinical Record: A resident with respiratory failure and severe cognitive impairment had an OOHDNR order, but the document was not uploaded to the clinical record. The MDS and care plan still reflected full code status, while the SW, ADON, and DON gave differing accounts of how the DNR was communicated and why it was not filed in the chart.
A facility failed to maintain comfortable room temperatures for three residents. One resident sat in a wheelchair wrapped in a blanket, another wore a thick jacket with a heavy blanket, and a third was covered with multiple blankets in bed. Room temperatures were measured at 69 to 70 degrees F while the thermostat was set to 72 degrees F and cooling. Residents reported being very cold at night, needing extra blankets or a winter coat, and staff said they were not allowed to adjust the thermostats.
The facility failed to coordinate PASRR Level 1 screenings for two residents with documented mental illness diagnoses. One resident had schizophrenia, bipolar disorder, anxiety, and major depressive disorder, yet her PASRR Level 1 screening indicated no mental illness; the MDS Coordinator stated a new screening should have been completed. Another resident had anxiety, depression, and bipolar disorder, but her PASRR Level 1 screening incorrectly marked no evidence of mental illness; the MDS Nurse stated this should have been corrected so a PASRR Level II evaluation could occur.
Incomplete Care Plan for Psychosocial Needs: A resident admitted with anxiety, depression, psychotic disorder, and schizophrenia had a care plan that addressed anti-psychotic meds but did not specifically include the schizophrenia diagnosis with goals and interventions. The MDS Coordinator said care plans were her responsibility and the DON stated accurate care plans were needed to ensure residents received appropriate care and their needs were met.
Hand hygiene was not performed between glove changes during wound care for a resident with a left heel pressure ulcer. An RN removed dirty gloves and put on new gloves without sanitizing his hands, then repeated the same action after cleansing the wound before applying the dressing. The resident had severe cognitive impairment and was receiving ordered daily wound care for the heel wound. Interviews with the RN, ADON, and DON confirmed hand hygiene was required before wound care, during glove changes, and after the procedure.
The facility failed to provide a private space for a resident council meeting, which was held in the front lobby, compromising privacy as staff and community members passed through. A resident expressed discomfort discussing issues due to interruptions. The Activity Director, new to the role, acknowledged the need for privacy, and the Administrator confirmed meetings should be private, as per facility policy.
The facility did not follow the breakfast menu as eggs were unavailable, impacting meal accuracy. Residents were informed of the shortage during breakfast, and an observation confirmed the absence of eggs in the kitchen. The Dietary Manager, responsible for food orders, acknowledged the shortage, which was rectified later that morning with a delivery.
A facility failed to maintain a washing machine, leading to a linen shortage. A resident reported sleeping on towels due to a lack of clean sheets, and the Laundry Aide confirmed the machine had been out of service for months. The Maintenance Specialist was waiting for parts from overseas, and the Administrator provided funds for laundromat use but had not contacted Corporate about replacing the machine.
A resident with severe cognitive impairment and multiple diagnoses was admitted with an indwelling catheter, but the facility failed to document physician orders for its use and maintenance. Interviews with staff revealed that the admitting nurse did not input the necessary orders into the EHR, and the facility lacked a policy for verifying such orders, leading to potential risks of infection and improper care.
A facility failed to update a resident's care plan to reflect new diet orders, despite the resident's complex medical conditions. The care plan inaccurately listed a discontinued diet, and staff interviews revealed a lack of adherence to policy for updating care plans with dietary changes.
The facility failed to appoint a qualified Director of Food and Nutrition Services, as the Dietary Manager did not meet the necessary qualifications, such as certification or relevant experience. The manager had only completed a basic food handler course and was unable to pursue further training due to staffing shortages. This deficiency could increase the risk of foodborne illness and inadequate nutrition for residents.
Vendor Noncompliance With COVID-19 Isolation PPE Requirements
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective Infection Prevention and Control Program when a contracted Licensed Professional Counselor (LPC) did not use appropriate PPE while visiting residents on COVID-19 isolation precautions. Three residents had active care plans for COVID-19 infection that included interventions such as ensuring infection control measures and PPE use during care, staying in their rooms, and limiting contact with others. Each of these residents was on isolation precautions for confirmed COVID-19, and their rooms were designated isolation rooms with posted signage indicating required PPE and precautions. Resident #1 was an older female with intact cognition and active diagnoses including Alzheimer’s disease, depression, seizure disorder, and respiratory distress. Her care plan for acute COVID-19 infection specified infection control measures and PPE use during care, along with room isolation. Resident #2 was an older female with intact cognition and active diagnoses including hypertension, viral hepatitis, bipolar disorder, and asthma; her COVID-19 care plan also required infection control measures, PPE use, and remaining in her room as much as possible. Resident #3 was an older male with intact cognition and active diagnoses including hypertension, anemia, diabetes mellitus, bipolar disorder, and asthma, and his COVID-19 care plan similarly required infection control measures, PPE use, and room isolation. On the survey date, a sign at the facility entrance alerted all visitors that there had been a COVID-19 case in the last 14 days and that masks were required. Each isolation room door also had signage specifying appropriate PPE and precautions. Despite this, the LPC entered the isolation hallway and visited two residents in a shared isolation room and then another resident in a separate isolation room while wearing only a cloth face mask and without donning any of the PPE available outside each room. In interview, the LPC acknowledged seeing the signs at the front door and on resident doors but stated he did not read them thoroughly and had not been informed by staff of the COVID-19 outbreak or PPE requirements. The Administrator and DON stated that vendors were expected to follow the facility’s infection control policy and isolation precautions the same as staff, and that vendors not following these precautions could place residents at risk of infection.
Food Storage and Kitchen Sanitation Failures
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional food safety standards in its only kitchen. During observation, the deep fryer was found layered in grease with food spills and food particles. The kitchen also contained a case of unopened defrosted breaded cauliflower on the floor, and the weekend cook stated it had been taken out of the freezer on another shift, left on the floor, defrosted, and then forgotten instead of being discarded. Refrigerator observations showed multiple food items that were not properly labeled, dated, or stored. These included a plastic container of pineapple slices with no label or date, three packages of cheese in sealed plastic bags with no label or date, ham in a sealed plastic bag with no label or date, and a clear bag of lettuce that was unsealed and had no label or date. An unopened ham was also found lying in the opened case of petite tomatoes, which the cook stated could have caused cross contamination. Freezer observations showed cookie dough that had been thawed and refrozen, with freezer shelf lines visible, and it was in a clear plastic bag that was not sealed properly and had no label or date. A sealed plastic bag of frozen chicken was also unlabeled and undated. In addition, a large plastic bucket containing a red frozen substance with a large knife sticking out of it was found in the freezer with no label or date. Interviews with kitchen staff and the Dietary Manager confirmed that food items should be sealed, labeled, dated, and stored correctly, that thawed food should not be refrozen, and that equipment such as the deep fryer should be cleaned after each meal.
Advance Directive Not Placed in Clinical Record
Penalty
Summary
The facility failed to implement its advance directives policy by not obtaining and placing Resident #9’s out-of-hospital DNR order in the clinical record. Resident #9 was an [AGE]-year-old female admitted on [DATE] with diagnoses including respiratory failure and severe cognitive impairment, with a BIMS score of 5. Her quarterly MDS reflected her as a full code, and her care plan also listed full code interventions, including initiating BLS CPR if she was without a heartbeat or not breathing. Record review showed a physician order for an OOHDNR with a start date of [DATE], but the document was not uploaded to the resident’s clinical record. The Social Worker stated she and the nurses were responsible for ensuring residents’ advance directives were in place and said she had not been told the resident had become a DNR. The ADON stated the family later elected DNR status after a hospital stay and that a family member said the OOHDNR had been given to a nurse, but the facility asked for another copy because they could not identify which nurse received it. The DON stated the family emailed her a copy of the DNR and that she forgot to upload it to the resident’s clinical record.
Cold Resident Rooms and Inadequate Temperature Control
Penalty
Summary
The facility failed to provide comfortable and safe temperature levels in the rooms of Residents #11, #15, and #38. During observations, Resident #38 was sitting in a wheelchair with a blanket wrapped around him, Resident #15 was sitting in a recliner wearing a thick jacket with a heavy blanket over her, and Resident #11 was in bed covered with multiple blankets. The thermostat in Hall A was observed set to 72 degrees F and cooling, while ambient temperature checks showed Resident #38's room at 70 degrees F, Resident #15's room at 69 degrees F, and Resident #11's room at 70 degrees F. During interviews, Resident #38 stated his hands got so cold at night that he could not stand to touch himself anywhere. Resident #15 stated she had to wear her down jacket all the time because her room was always too cold and that she slept with a heavy comforter because of the cold. Resident #11 stated the facility got very cold at night and she had to keep asking staff for another blanket, sometimes having 3 to 4 blankets on her by morning; she also said staff told her they were not allowed to turn up the heat. The Maintenance Director stated staff had complained the facility was too warm in the morning, so he turned the thermostat down from 74 degrees to 72 degrees and tried to keep temperatures between 70 and 75 degrees, while also stating the standard was 71 to 81 degrees and that residents needing extra blankets or winter coats to stay warm was not acceptable. The DON stated staff were busy and sometimes did not notice that less active residents could be cold, and the Regional Nurse Consultant stated the facility addressed room temperatures but did not have a policy about room temperatures or a homelike environment.
Failure to Coordinate PASRR Level 1 Screenings for Residents With Mental Illness Diagnoses
Penalty
Summary
The facility failed to coordinate assessments with the PASRR program for 2 of 5 residents reviewed for PASRR Level 1 screenings. For Resident #6, record review showed diagnoses of schizophrenia, bipolar disorder, anxiety disorder, and major depressive disorder, and the care plan listed schizophrenia, bipolar disorder, and depression with medications in use. Her PASRR Level 1 Screening dated 12/09/21 indicated she did not have mental illness, and the MDS Coordinator stated the resident was admitted with a negative Level I PASRR screening despite a diagnosis of schizophrenia. The MDS Coordinator stated a new Level I should have been completed because of the resident's mental illness diagnoses and that an inaccurate Level I could prevent the resident from possibly receiving PASRR special services. For Resident #29, record review showed diagnoses of anxiety disorder, depression, and bipolar disorder, with intact cognition and a BIMS score of 15. Her PASRR Level 1 Screening dated 11/07/22 had NO marked for the question asking whether there was evidence or an indicator of mental illness. The MDS Nurse stated she was responsible for completing and reviewing PASRR Level 1 screenings and did not realize the mental illness question had been marked incorrectly. She stated Resident #29 should have had another PASRR Level 1 Screening so the resident could have had a PASRR Level II evaluation. The facility's PASRR policy stated it was the policy to obtain a PL1 screening form from the referring entity prior to admission and submit it timely per PASRR regulatory timeframes.
Incomplete Care Plan for Psychosocial Needs
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #11 that included measurable objectives and time frames to meet the resident’s medical, nursing, mental, and psychosocial needs identified in the comprehensive assessment. Resident #11 was an [AGE] year-old female admitted on [DATE] with diagnoses including anxiety disorder, depression, psychotic disorder, and schizophrenia. Her admission MDS, dated [DATE], reflected intact cognition with a BIMS score of 15. Record review of the resident’s care plan, dated 08/16/25, showed that it addressed the resident’s use of anti-psychotic medications related to schizophrenia, but it did not specifically address her diagnosis of schizophrenia with goals and interventions. During interviews, the MDS Coordinator stated she was responsible for ensuring care plans were complete and up to date and learned of new issues to add during the facility’s Standards of Care meetings. The DON stated accurate care plans were necessary to ensure each resident received appropriate care and their needs were being met.
Hand Hygiene Not Performed Between Glove Changes During Wound Care
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program when RN D did not sanitize his hands between glove changes during wound care for a resident with a left heel pressure ulcer. The resident was an [AGE]-year-old female admitted on [DATE] with respiratory failure, a BIMS score of 5 indicating severe cognitive impairment, and a care plan that identified her as at risk for pressure ulcers/injuries. Her September 2025 physician orders directed staff to clean the left heel wound with wound cleanser, pat dry, apply a thin layer of Iodosorb to gauze, place it on the open wound, and cover with a dry dressing daily and as needed. During observation of wound care, RN D and CNA E were both wearing gowns and gloves while the CNA held the resident’s foot. RN D removed the old dressing, took off dirty gloves, and put on new gloves without sanitizing his hands. He then cleansed the wound, removed his dirty gloves again, and applied new gloves without sanitizing his hands before applying the new dressing. RN D sanitized his hands only after the wound care was completed. Interviews with RN D, the ADON, and the DON confirmed that hand hygiene should be performed before wound care, after removing gloves, before putting on new gloves, and after the treatment was completed. The facility’s wound care checklist also stated that hands should be washed or sanitized during glove changes throughout the dressing procedure.
Failure to Provide Private Meeting Space for Resident Council
Penalty
Summary
The facility failed to provide a private meeting space for the residents' monthly group meeting, affecting 12 residents who were part of the resident council. The meeting was held in the front lobby, near the front door and the Administrator's office, where multiple staff and community members passed through, compromising the privacy of the meeting. One resident expressed discomfort in discussing issues due to the interruptions and lack of privacy. The Activity Director, who had recently assumed the role, was responsible for organizing the resident council meetings. She acknowledged that the meeting should have been held in a private area and noted that the residents had voted to hold the meeting in the lobby. Despite posting signs indicating a meeting was in progress, the location did not ensure privacy. The Administrator confirmed that the meetings were supposed to be private and stated that no complaints had been received about the lack of privacy. The facility's policy, dated 12/13/16, indicated that private space should be provided for resident council meetings.
Failure to Follow Breakfast Menu Due to Egg Shortage
Penalty
Summary
The facility failed to adhere to the breakfast menu on 08/07/24, which included a choice of juice, hot or cold cereal, fresh pasteurized eggs, bacon or sausage, breakfast bread, margarine/jelly, milk, and coffee. During a confidential resident group meeting, residents reported they were informed that eggs were unavailable for breakfast due to the kitchen running out of eggs. An observation of the kitchen confirmed the absence of eggs, although a delivery was made later that morning. The Dietary Manager, responsible for ordering food, acknowledged the shortage, stating that the kitchen had run out of eggs the previous day. The facility's dietary services policy emphasizes the importance of preparing food to maximize flavor, appearance, and nutritional value.
Laundry Equipment Failure Leads to Linen Shortage
Penalty
Summary
The facility failed to maintain a laundry washing machine (Washer A) in operating condition, which could place residents at risk of not having clean linen for their beds. This issue was highlighted by an interview with a resident who reported having to sleep on bath towels due to a lack of clean sheets. The resident, who is also the President of the Resident Counsel, mentioned that several residents experienced delays in receiving their clothing from the laundry and noted a shortage of linen, particularly on weekends. The Laundry Aide confirmed that Washer A had been out of service for at least two months, leaving only one functioning washer. The Maintenance Specialist stated that the washing machine had been out of service since April 2024 due to two inlet valves that were on order from overseas. Despite repeated inquiries, the supplier had not provided a delivery date for the parts. The Administrator was aware of the situation and provided funds for laundry staff to use a local laundromat when necessary, but had not communicated with Corporate about replacing the machine due to the delay in obtaining parts.
Lack of Physician Orders for Indwelling Catheter
Penalty
Summary
The facility failed to ensure that a resident had a physician's order for an indwelling catheter upon admission. The resident, a female with severe cognitive impairment and multiple diagnoses including vascular dementia and urinary retention, was admitted with an indwelling catheter. However, there were no physician orders documented for the catheter's use, treatment, or maintenance. This oversight was identified during a review of the resident's records, which showed no orders for the catheter despite its presence and use. Interviews with facility staff, including an LVN, the ADON, and the DON, revealed that it was the admitting nurse's responsibility to input the catheter order into the electronic health record (EHR). The staff acknowledged that the absence of such orders could lead to risks such as infection or improper catheter care. The facility also lacked a policy addressing the input and verification of physician orders for catheters, which contributed to the deficiency. Despite regular in-service training on infection prevention and catheter care, the failure to ensure proper documentation of physician orders for the catheter was evident.
Failure to Update Resident Care Plan with New Diet Orders
Penalty
Summary
The facility failed to ensure that each resident's person-centered comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment. Specifically, for one resident, the care plan was not updated to reflect new diet orders. The resident, a male with multiple diagnoses including end-stage renal disease, diabetes mellitus, and congestive heart failure, had a care plan that did not reflect his current dietary needs. The care plan still indicated a low concentrated sweets diet, which had been discontinued, and did not include the updated regular diet with mechanical soft texture and regular consistency. Interviews with facility staff, including the MDS Coordinator and the Director of Nursing (DON), revealed that care plans should be reviewed quarterly and updated with any changes in diet or orders. However, the MDS Coordinator admitted that she does not handle acute clinical care plans and that it is her responsibility to ensure care plans are accurate. The DON confirmed that care plans should be updated with any dietary or order changes and that it is her responsibility to ensure they reflect current orders. Despite recent in-service training on care plans, the facility's policy and procedure for care planning were not followed, leading to the deficiency.
Lack of Qualified Director in Food and Nutrition Services
Penalty
Summary
The facility failed to designate a qualified individual to serve as the Director of Food and Nutrition Services. The Dietary Manager, who was reviewed for qualifications, did not meet the necessary criteria, which include being a certified dietary manager or certified food service manager, having a similar national certification for food service management and safety, holding an associate's or higher degree in food service management or hospitality, or having two or more years of experience in the position of food and nutrition services in a nursing facility along with a completed course of study in food safety management. The Dietary Manager had only completed a Food Handler Essentials Course and lacked the appropriate certification, education, or qualifications required for the role. During an interview, the Dietary Manager revealed that she had been employed at the facility for approximately three months and had not started taking any dietary manager classes due to being short-staffed, which required her to work as a cook. She confirmed that there was no personnel in the kitchen who was a trained and certified Food Protection Manager. Additionally, the facility's Registered Dietitian worked only eight full-time hours during the month of July 2024. This lack of qualified personnel in the food and nutrition services department could place residents at increased risk of foodborne illness and inadequate nutrition.
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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 | 1.3 mi | ★★★★★ | 13 | 0 |
| Decatur Medical Lodge | 1.7 mi | ★★★★★ | 15 | 0 |
| Bridgeport Medical Lodge | 9.4 mi | ★★★★★ | 5 | 1 |
| Springtown Park Rehabilitation And Care Center | 20 mi | ★★★★★ | 4 | 0 |
| Longmeadow Healthcare Center | 20.6 mi | ★★★★★ | 0 | 0 |
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