Decatur Medical Lodge

• Star rating

  The CMS overall star rating changed from 3 of 5 to 2 of 5.

• Star rating

  The CMS health inspection star rating changed from 4 of 5 to 3 of 5.

• Star rating

  The CMS quality measures star rating changed from 3 of 5 to 2 of 5.

• Changed ownership in the last 12 months

  CMS no longer shows a change of ownership in the past 12 months.

CMS lists this as a standard inspection.

• Citation F0628. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

  CMS lists it as corrected on May 30, 2026.

• Citation F0676. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

  CMS lists it as corrected on May 30, 2026.

• Citation F0805. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

  CMS lists it as corrected on May 30, 2026.

  CMS has cited this home for F0805 2 times since 2023.

• Citation F0812. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

  CMS lists it as corrected on May 30, 2026.

  CMS has cited this home for F0812 2 times since 2023.

• Citation F0644. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

  CMS lists it as corrected on May 30, 2026.

• Citation F0689. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS lists it as corrected on May 30, 2026.

  CMS has cited this home for F0689 2 times since 2023.

• Citation F0880. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide and implement an infection prevention and control program.

  CMS lists it as corrected on May 30, 2026.

  CMS has cited this home for F0880 3 times since 2023.

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CMS lists this as a standard inspection.

• Citation E0006. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Conduct risk assessment and an All-Hazards approach.

  CMS lists it as corrected on May 30, 2026.

• Citation E0037. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Establish staff and initial training requirements.

  CMS lists it as corrected on May 30, 2026.

• Citation K0324. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Provide properly protected cooking facilities.

  CMS lists it as corrected on May 30, 2026.

• Citation K0345. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have approved installation, maintenance and testing program for fire alarm systems.

  CMS lists it as corrected on May 30, 2026.

• Citation K0352. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Properly install and monitor supervisory attachments on automatic sprinkler systems.

  CMS lists it as corrected on May 30, 2026.

• Citation K0353. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Inspect, test, and maintain automatic sprinkler systems.

  CMS lists it as corrected on June 3, 2026.

  CMS has cited this home for K0353 2 times since 2023.

• Citation K0522. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have an externally vented heating system.

  CMS lists it as corrected on May 30, 2026.

• Citation K0923. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have proper medical gas storage and administration areas.

  CMS lists it as corrected on May 30, 2026.

  CMS has cited this home for K0923 2 times since 2023.

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• Star rating

  The CMS overall star rating changed from 1 of 5 to 3 of 5. CMS changed how it scores this rating for many homes at once.

• Star rating

  The CMS health inspection star rating changed from 2 of 5 to 4 of 5. CMS changed how it scores this rating for many homes at once.

• Name

  CMS lists a new legal business name for this home.

• Changed ownership in the last 12 months

  CMS records show a change of ownership in the past 12 months.

CMS lists this as a complaint inspection.

• Citation F0804. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

  CMS lists it as corrected on July 25, 2025.

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• Name

  CMS lists a new legal business name for this home.

• Star rating

  The CMS quality measures star rating changed from 2 of 5 to 3 of 5.

CMS lists this as a standard inspection.

• Citation F0761. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

  CMS lists it as corrected on March 7, 2025.

• Citation F0880. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide and implement an infection prevention and control program.

  CMS lists it as corrected on March 7, 2025.

• Citation F0656. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

  CMS lists it as corrected on March 7, 2025.

• Citation F0693. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

  CMS lists it as corrected on March 7, 2025.

• Citation F0700. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.

  CMS lists it as corrected on March 7, 2025.

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CMS lists this as a standard inspection.

• Citation K0916. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Have a battery powered remote alarm panel in a location accessible by operating personnel.

  CMS lists it as corrected on March 20, 2025.

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• Star rating

  The CMS health inspection star rating changed from 1 of 5 to 2 of 5.

• Star rating

  The CMS quality measures star rating changed from 3 of 5 to 2 of 5.

CMS lists this as a complaint inspection.

• Citation F0695. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide safe and appropriate respiratory care for a resident when needed.

  CMS lists it as corrected on June 10, 2024.

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CMS lists this as a complaint inspection.

• Citation F0580. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

  CMS lists it as corrected on May 13, 2024.

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• Fine

  CMS changed the fine from August 29, 2023 from $22,335 to $14,518.

• Star rating

  The CMS quality measures star rating changed from 2 of 5 to 3 of 5.

• Staffing

  Total nurse staffing reported to CMS went from 3.5 to 3.1 hours per resident per day.

CMS lists this as a standard inspection.

• Citation F0812. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

  CMS lists it as corrected on January 15, 2024.

• Citation F0925. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

  CMS lists it as corrected on January 15, 2024.

• Citation F0805. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

  CMS lists it as corrected on January 15, 2024.

• Citation F0814. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Dispose of garbage and refuse properly.

  CMS lists it as corrected on January 15, 2024.

• Citation F0880. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide and implement an infection prevention and control program.

  CMS lists it as corrected on January 15, 2024.

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CMS lists this as a standard inspection.

• Citation K0741. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

  CMS lists it as corrected on January 20, 2024.

• Citation K0353. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Inspect, test, and maintain automatic sprinkler systems.

  CMS lists it as corrected on January 20, 2024.

• Citation K0355. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Properly select, install, inspect, or maintain portable fire extinguishes.

  CMS lists it as corrected on January 20, 2024.

• Citation K0363. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Install corridor and hallway doors that block smoke.

  CMS lists it as corrected on January 20, 2024.

• Citation K0923. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Have proper medical gas storage and administration areas.

  CMS lists it as corrected on January 20, 2024.

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CMS lists this as a complaint inspection.

• Citation F0755. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

  CMS lists it as corrected on December 9, 2023.

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CMS lists this as a complaint inspection.

Severity J is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.

152 of 1,177 Texas homes (13%) got a citation at the immediate jeopardy level in 2023.

• Citation F0689. Severity J: immediate jeopardy, isolated.

  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS lists it as corrected on August 28, 2023.

• Citation F0584. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

  CMS lists it as corrected on October 31, 2023.

• Citation F0607. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Develop and implement policies and procedures to prevent abuse, neglect, and theft.

  CMS lists it as corrected on October 12, 2023.

• Citation F0609. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

  CMS lists it as corrected on October 12, 2023.

• Citation F0809. Severity C: potential for minimal harm, widespread.

  The rule CMS cited: Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.

  CMS lists it as corrected on November 10, 2023.

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