Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 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.
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 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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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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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.