Inspection visit
Inspection
13 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 13 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0565
Honor the resident's right to organize and participate in resident/family groups in the facility.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview, and record review the facility failed to provide a private meeting space for
the residents' monthly group meeting for 12 of 12 confidential residents reviewed for resident council.
Residents Affected - Some
The facility failed to provide a private space for resident group meetings.
This failure could place residents, who attended resident group meetings, at risk of not being able to voice
concerns due to a lack of privacy.
Findings included:
Observation and interview on 08/07/24 beginning at 10:05 AM, during a confidential resident group meeting
with 12 residents, revealed the meeting was held in the front lobby of the facility near the front door and the
Administrator's office door. During this meeting, there were two signs posted. However, multiple staff walked
through the space as well as people from the community. One resident stated she did not feel comfortable
talking about issues due to staff and administration interrupting the meeting as well as when they have their
monthly meetings.
Interview on 08/08/24 at 03:54 PM, the Activity Director revealed she became the AD on 08/05/24. She
stated she was responsible for organizing the resident council meetings. She stated the resident council
meeting should be held in a private area. She said she asked the residents where they would like to hold
the meeting on 08/07/24. She stated the Resident Council President told her a vote was taken, and the
residents voted to have the meeting in the lobby which was near the front door and the Administrator's door.
The Activity Director stated before the meeting began on 08/07/24, she posted two signs that read,
Resident Council Meeting in Process and This is Where They Chose to Have It. The Activity Director stated
she posted the signs in spots near the residents' group meeting. The Activity Director said the next resident
council meeting would be held in an area that allowed for the residents' privacy. The Activity Director
revealed the risk to the residents was that the residents were not comfortable or able to voice their
concerns in an open area where staff could hear them.
Interview on 08/08/24 at 6:19 PM, the Administrator revealed the resident council meeting was supposed to
be held in a place of privacy. The Administrator stated it was the Activity Director's responsibility to ensure
the meeting was held in a private area. The Administrator said that she had not received complaints about
the meeting not being held in a private location. The Administrator stated she would ensure the residents
had a private area for next month's resident council meeting.
Record review of the resident council minutes revealed no requests for a private area.
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 9
Event ID:
675513
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
675513
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/08/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Heritage Place of Decatur
605 W Mulberry
Decatur, TX 76234
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0565
Record review of Resident Council policy dated 12/13/16 revealed: The facility will provide the resident
council with private space .
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675513
If continuation sheet
Page 2 of 9
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
675513
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/08/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Heritage Place of Decatur
605 W Mulberry
Decatur, TX 76234
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0635
Provide doctor's orders for the resident's immediate care at the time the resident was admitted.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to ensure at the time each resident was admitted
the facility had a physician order for the resident's immediate care for 1 of 1 resident (Resident #43)
reviewed for residents receiving care and services upon admission.
Residents Affected - Few
The facility failed to ensure Resident #43 had a current physician's order for use of an indwelling catheter
as well as its treatment and maintenance after readmission to the facility.
The failure could place residents atresidents at risk for not receiving the necessary care and services.
Findings included:
Review of Resident #43's admission record dated 08/08/24 reflected the resident was a [AGE] year-old
female, admitted to the facility on [DATE] with diagnoses that included unspecified fracture of left femur,
unspecified fracture of right wrist and hand, vascular dementia, and retention of urine.
Review of Resident #43's admission MDS assessment, dated 07/17/24, reflected a BIMS score was 00
indicating severely impaired cognition. Her functional status indicated she was dependent on staff for
toileting. The MDS assessment indicated Resident #43 admitted with an indwelling catheter.
Review of Resident #43's care plan, dated 08/08/24, reflected the resident was incontinent. The care plan
reflected: Resident has bladder incontinence. Goals: Resident will remain free from skin breakdown due to
incontinence and brief use through the review date. Interventions: Incontinent: care at least q2h and apply
moisture barrier after each episode. Monitor/document for s/sx UTI: pain, burning, blood-tinged urine,
cloudiness, no output, deepening of urine color, increased pulse, increased temp, urinary frequency, foul
smelling urine, fever chills, altered mental status, change in behavior, change eating patterns.
Monitor/document report to MD PRN possible medical causes of incontinence: bladder infection,
constipation, loss of bladder tone, weakening of control muscles, decreased bladder capacity, diabetes,
stroke, medication side effects. and report signs of urinary tract infection to physician.
Review of Resident #43's undated physician orders reflected no physician orders for a urinary catheter.
Observation and interview on 08/07/24 at 2:08 PM, Resident #43 was in her room in her bed r resting.
Resident #43 had a catheter line with clear yellow fluid draining into her foley drain bag which was covered
by the privacy cover. Resident stated that she had no urinary pain.
Interview on 08/07/24 at 02:50 PM, LVN A revealed Resident #43 entered the facility with a catheter. LVN A
stated that she did not remember checking to see if there was an order for the catheter, and assumed there
was an order. LVN A revealed that there should be an order for all catheters including the gauge of the
catheter as well as an order to change it. LVN A also said that it was the admitting nurse's responsibility to
input the order for the catheter when a resident comes to the facility with the catheter in place. LVN A
revealed it was all oncoming nurses' responsibility to verify that there were orders for Resident #29's
catheter. LVN A also stated that without orders to document input/output of urine, there is a risk that the
nurse will not know if the catheter is flowing
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675513
If continuation sheet
Page 3 of 9
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
675513
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/08/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Heritage Place of Decatur
605 W Mulberry
Decatur, TX 76234
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0635
properly. LVN A revealed there is a risk of infection if the resident's catheter is not changed.
Level of Harm - Minimal harm
or potential for actual harm
Interview on 08/07/24 at 03:08 PM, the ADON revealed that Resident #43 did not have physician's orders
for a catheter. The ADON stated that all residents who have catheters should have orders. The ADON also
stated that it is the admitting nurses' responsibility to input the order for the catheter if the resident comes to
facility with the catheter. The ADON said that it is the ADON and the DONs responsibility to ensure the
order is input correctly in the EHR. The ADON revealed the oncoming nurses should have a continuum of
care and make sure orders are in the chart. The ADON stated if there is no order for the resident's catheter,
the risk to the resident is infection and/or injury to the resident. The ADON concluded by stating that nurses
are in-serviced on infection prevention and catheter care 1-2 times per month.
Residents Affected - Few
Interview on 08/07/2024 at 3:45 PM, the DON revealed Resident #43 did not have an order for a catheter.
The DON stated the resident entered the facility with a catheter. The DON said it was the admitting nurses'
responsibility to input the order and then the oncoming nurses' responsibility to [NAME] the orders are
correct. The DON revealed it is the ADON and DONs responsibility to ensure the orders are correct. The
DON said that if there are no physician's orders for catheters, that the resident can risk infections, sepsis,
and other possible health risks. The DON concluded by stating that she in-services her staff at least one
time per month on infection prevention, peri-care, and catheter care.
Interview on 08/08/24 at 9:31 AM with corporate nurse revealed the facility did not have a policy addressing
the topic of inputting and following physician's order.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675513
If continuation sheet
Page 4 of 9
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
675513
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/08/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Heritage Place of Decatur
605 W Mulberry
Decatur, TX 76234
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0657
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed,
and revised by a team of health professionals.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to ensure each resident's person-centered comprehensive
care plan was reviewed and revised by the interdisciplinary team after each assessment for 1 of 8 residents
(Residents #29), reviewed for care plans.
The facility failed to revise and update Resident #29's comprehensive care plan with new diet orders.
These failures could affect residents of the facility by not addressing their physical, mental, and
psychosocial needs for each to attain or maintain their highest practicable physical, mental, and
psychosocial outcome.
Findings included:
Record review of the admission Record dated 8/8/24 revealed Resident #29 was a [AGE] year-old male
initially admitted on [DATE] and re-admitted on [DATE] with diagnoses including end stage renal disease,
diabetes mellitus, acquired absence of right leg below the knee, congestive heart failure, unspecified
protein-calorie malnutrition, and morbid obesity.
Record review of the quarterly MDS dated [DATE] revealed Resident #29 had a BIMS of 15 meaning,
Resident #29 was cognitively intact. MDS Section K0520 revealed that Resident #29 did not receive a
therapeutic diet.
Record review of Resident #29's undated care plan revealed Resident #29 has a diet order other than
Regular and is at risk for unplanned weight loss or gain. Resident #29's care plan goal revealed Resident
will maintain ideal weight and receive proper nutrition daily x 90 days. Resident #29's Intervention revealed
The resident has a low concentrated sweets diet. The resident's low concentrated sweets diet was
discontinued on 8/11/21 and the care plan did not reflect the current diet order.
Record review of the undated physician's diet orders indicated Resident #29's diet order was a regular diet,
mechanical soft texture, regular consistency with a start date of 7/10/24 and revision date of 7/20/24.
Interview on 08/08/24 at 5:12 PM, the MDS Coordinator revealed care plans should be reviewed quarterly
and updated. MDS Coordinator also stated that she does the standard care plans, but she does not do the
acute clinical care plan. MDS Coordinator said diets should be updated quarterly. MDS also revealed that it
is her responsibility to ensure care plans are accurate. MDS coordinator stated that she was last
in-serviced on care plans about a month ago.
Interview on 08/08/24 at 5:20 PM with DON revealed care plans should be updated when there is a diet
change or order change. DON stated when dietary and speech do evaluations, she has asked that the
results be given to her as well as the MDS coordinator to ensure that care plans be updated. DON said that
it is her responsibility to make sure the care plans reflect current orders. DON also revealed that she last
in-serviced the staff about a month ago on the importance of accurate care plans.
Record review of undated policy and procedure titled, Care Planning Policy revealed .The resident's
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675513
If continuation sheet
Page 5 of 9
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
675513
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/08/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Heritage Place of Decatur
605 W Mulberry
Decatur, TX 76234
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0657
Level of Harm - Minimal harm
or potential for actual harm
care will be reviewed after each Admission, Quarterly, Annual and/or Significant Change MDS assessment,
and revised based on changing goals, preferences and needs of the resident and in response to current
interventions .
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675513
If continuation sheet
Page 6 of 9
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
675513
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/08/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Heritage Place of Decatur
605 W Mulberry
Decatur, TX 76234
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0801
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the
food and nutrition service, including a qualified dietician.
Based on interview and record review, the facility failed to designate a person to serve as the director of
food and nutrition services who met at a minimum one of the following qualifications: a certified dietary
manager or certified food service manager, or had a similar national certification for food service
management and safety from a national certifying body, or had an associate's or higher degree in food
service management or in hospitality, or had 2 or more years of experience in the position of food and
nutrition services in a nursing faciltiy and had completed a course of study in food safety management for
one of one Dietary Manager reviewed for qualifications.
The Dietary Manager did not have the appropriate certification, education, or qualifications to serve as the
Director of Food and Nutrition Services.
This failure could place residents who consumed food prepared by staff in the kitchen at increased risk of
food borne illness and not receiving adequate nutrition.
Findings included:
Record review of the staff roster provided by the facility, undated, reflected the hire date for the Dietary
Manager was 04/22/24.
Record review of the Dietary Manager's records reflected she had completed a Food Handler Essentials
Course. There was no evidence the Dietary Manager met any of the requirements for a Dietary Manager,
which were: a certified dietary manager or certified food service manager, or had a similar national
certification for food service management and safety from a national certifying body, or had an associate's
or higher degree in food service management or in hospitality, or had 2 or more years of experience in the
position of food and nutrition services in a nursing faciltiy and had completed a course of study in food
safety management
Record review of facility employee files revealed the facility's Registered Dietitian worked eight full time
hours during the month of July 2024.
During an interview on 08/06/24 at 8:55 AM with the Dietary Manager, it was revealed she had been
employed at the facility for approximately three months. She stated she had not started taking any dietary
manger classes because she was short-staffed and had to work as a cook on shifts that she was short a
cook. She stated she did not have a certificate evidencing she had completed the Certified Food Protection
Manager. The Dietary Manager confirmed there was no personnel working in the kitchen that was a trained
and certified Food Protection Manager.
Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS,
revealed 2-102.12 Certified Food Protection Manager. (A) The PERSON IN CHARGE shall be a certified
FOOD protection manager who has shown proficiency of required information through passing a test that is
part of an ACCREDITED PROGRAM. 2-102.20 Food Protection Manager Certification. (B) A FOOD
ESTABLISHMENT that has a PERSON IN CHARGE that is certified by a FOOD protection manager
certification program that is evaluated and listed by a Conference for FOOD Protection-recognized
accrediting agency as conforming to the Conference for FOOD Protection Standard for Accreditation of
FOOD Protection Manager Certification Programs is deemed to comply with §2-102.12.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675513
If continuation sheet
Page 7 of 9
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
675513
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/08/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Heritage Place of Decatur
605 W Mulberry
Decatur, TX 76234
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0803
Level of Harm - Minimal harm
or potential for actual harm
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be
updated, be reviewed by dietician, and meet the needs of the resident.
Based on observation, interview, and record review, the facility failed to ensure that menus were followed
for 1 of 5 meals (breakfast [08/07/24]) reviewed for meal accuracy.
Residents Affected - Some
The facility failed to follow the menu for breakfast on 08/07/24.
This failure could place residents at risk for poor intake and weight loss.
Findings included:
Record review for breakfast menu for 08/07/24 reflected the following: Choice of juice, hot or cold cereal,
fresh pasteurized eggs, bacon or sausage, breakfast bread, margarine/jelly, milk, coffee.
Interview on 08/07/24 beginning at 10:05 AM, during a confidential resident group meeting with 12
residents, revealed residents were told they could not have eggs for breakfast on 08/07/24 because the
kitchen was out of eggs.
Observation of the kitchen on 08/07/24 at 11:29 AM revealed the kitchen had no eggs to serve for breakfast
on 08/07/24. However, further observation revealed the foodservice company did deliver the eggs on
08/07/24 at 11:45 AM.
Interview on 08/07/24 at 11:35 AM with the Dietary Manager revealed she had been employed for three
months at the facility. She stated it was her responsibility for ordering food. She stated the kitchen had run
out of eggs the previous day and could not provide residents with eggs for breakfast on 08/07/24.
Interview on 08/08/24 at 6:23 PM with Administrator revealed that based on the facility's census, the dietary
manager knew how much of each item to order per recipe to ensure that enough food is cooked for the
residents.
Record review of undated dietary services policy and procedure manual 2012 titled, Preparation Of Foods
revealed . We will establish safe and nutritional preparation of food. Food is to be prepared in such a
manner as to maximize flavor, appearance, and nutritional value.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675513
If continuation sheet
Page 8 of 9
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
675513
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/08/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Heritage Place of Decatur
605 W Mulberry
Decatur, TX 76234
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0908
Keep all essential equipment working safely.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview, and record review, the facility failed to maintain all mechanical, electrical,
and patient care equipment in safe operating condition for 1 washing machine (Washer A) of 2 reviewed for
essential equipment.
Residents Affected - Some
The facility failed to maintain a laundry washing machine (Washer A) in operating condition.
This failure could place residents at risk of not having clean linen for their beds.
Findings included:
Interview on 08/08/24 at 9:40 AM, Resident #39 stated the facility seemed to have a problem keeping up
with linen. He stated a week prior he had to sleep on six bath towels after he had soiled his linen and staff
said there were no clean sheets available. Resident #39 stated as President of the Resident Counsel he
talked with all the residents, several of whom reported delays in getting their clothing back from laundry and
a shortage of linen, especially on the weekends.
Interview on 08/08/24 at 10:00 AM. the Laundry Aide stated one washing machine (Washer A) was out of
service for a part on order, leaving her with one functioning washer. She stated the washer had been out of
service for two months at least. The Laundry Aide stated linen took priority over resident clothing. She
stated she has had to take clothes to the laundry mat sometimes in order to keep up.
Interview on 08/08/24 at 10:30 AM, the Maintenance Specialist stated the washing machine had been out
of service since April 2024. He stated the two inlet valves were coming from overseas and had not been
delivered yet. He stated he kept checking in with the supplier for updates. He supplied an email chain
detailing his conversations with the supplier.
Record review of email chain provided by the Maintenance Specialist reflected:
04/25/24 - Area Maintenance Specialist inquired about the part, requested two parts.
04/26/24 - Supplier acknowledge the order
04/30/24 - Maintenance Specialist asks for update on order. Supplier did not know, part comes from Spain.
05/21/24 - Maintenance Specialist asks for another update. Supplier had no answer, still waiting for
manufacturer.
06/10/24 - Maintenance Specialist asks for another update.
Interview on 08/08/24 at 5:00 PM, the Administrator stated she was aware of the washing machine being
out of service. She stated when the laundry staff get behind, she supplies them with money to go to the
local laundry mat to wash resident clothes. The Administrator stated laundry staff seemed to be able to
keep up with the linen as she had not had any complaints of being short on linen. She had not spoken to
Corporate about possibly replacing the machine due to delays in getting replacement parts.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675513
If continuation sheet
Page 9 of 9
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Back to topCitations
13 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F908 - Maintain all mechanical, electrical, and patient care equipment in safe
Keep all essential equipment working safely.
F565 - The resident has a right to organize and participate in resident groups in the
Honor the resident's right to organize and participate in resident/family groups in the facility.
F635 - Admission orders
Provide doctor's orders for the resident's immediate care at the time the resident was admitted.
F657 - Comprehensive Care Plans
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
F801 - Staffing
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
F803 - Menus and nutritional adequacy
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
- 0353GeneralS&S Fpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0037GeneralS&S Fpotential for harm
Establish staff and initial training requirements.
- 0324GeneralS&S Fpotential for harm
Provide properly protected cooking facilities.
- 0511GeneralS&S Fpotential for harm
Have properly installed electrical wiring and gas equipment.
- 0521GeneralS&S Cno actual harm
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
F712 - Frequency of physician visits
Have simulated fire drills held at unexpected times.
F918 - Bathroom Facilities
Have generator or other power source capable of supplying service within 10 seconds.
FAQ · About this visit
Common questions about this visit
What happened during the August 8, 2024 survey of HERITAGE PLACE OF DECATUR?
This was a inspection survey of HERITAGE PLACE OF DECATUR on August 8, 2024. The surveyor cited 13 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at HERITAGE PLACE OF DECATUR on August 8, 2024?
Yes, 13 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Keep all essential equipment working safely."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.