Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around October 2026
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 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.
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.
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 | — | 0 | 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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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.