Decatur Medical Lodge

Penalties

• Aug 29, 2023 — Fine ($14,518)

Inspection findings

1. Apr 28, 2026 Fire Safety · 15 findings
   • Not serious Scope/severity F

     E0006 Emergency Preparedness Deficiencies

     Conduct risk assessment and an All-Hazards approach.

     Corrected May 30, 2026 · CMS fire safety

   • Not serious Scope/severity F

     E0037 Emergency Preparedness Deficiencies

     Establish staff and initial training requirements.

     Corrected May 30, 2026 · CMS fire safety

   • Not serious Scope/severity E

     F0628 Resident Rights Deficiencies

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

     Corrected May 30, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0644 Resident Assessment and Care Planning Deficiencies

     Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

     Corrected May 30, 2026 · CMS health inspection

   • Not serious Scope/severity E

     F0676 Quality of Life and Care Deficiencies

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

     Corrected May 30, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected May 30, 2026 · CMS health inspection

   • Not serious Scope/severity E

     F0805 Nutrition and Dietary Deficiencies

     Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

     Corrected May 30, 2026 · CMS health inspection

   • Not serious Scope/severity E

     F0812 Nutrition and Dietary Deficiencies

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

     Corrected May 30, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected May 30, 2026 · CMS health inspection

   • Not serious Scope/severity F

     K0324 Smoke Deficiencies

     Provide properly protected cooking facilities.

     Corrected May 30, 2026 · CMS fire safety

   • Not serious Scope/severity F

     K0345 Smoke Deficiencies

     Have approved installation, maintenance and testing program for fire alarm systems.

     Corrected May 30, 2026 · CMS fire safety

   • Not serious Scope/severity F

     K0352 Smoke Deficiencies

     Properly install and monitor supervisory attachments on automatic sprinkler systems.

     Corrected May 30, 2026 · CMS fire safety

   • Not serious Scope/severity F

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Jun 3, 2026 · CMS fire safety

   • Not serious Scope/severity F

     K0522 Services Deficiencies

     Have an externally vented heating system.

     Corrected May 30, 2026 · CMS fire safety

   • Not serious Scope/severity F

     K0923 Gas, Vacuum, and Electrical Systems Deficiencies

     Have proper medical gas storage and administration areas.

     Corrected May 30, 2026 · CMS fire safety

2. Jun 25, 2025 Health · 1 finding
   • Not serious Scope/severity E Complaint

     F0804 Nutrition and Dietary Deficiencies

     Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

     Corrected Jul 25, 2025 · CMS health inspection

3. Feb 6, 2025 Health · 6 findings
   • Not serious Scope/severity D

     F0656 Resident Assessment and Care Planning Deficiencies

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

     Corrected Mar 7, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0693 Quality of Life and Care Deficiencies

     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.

     Corrected Mar 7, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0700 Quality of Life and Care Deficiencies

     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.

     Corrected Mar 7, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0761 Pharmacy Service Deficiencies

     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.

     Corrected Mar 7, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Mar 7, 2025 · CMS health inspection

   • Not serious Scope/severity D

     K0916 Gas, Vacuum, and Electrical Systems Deficiencies

     Have a battery powered remote alarm panel in a location accessible by operating personnel.

     Corrected Mar 20, 2025 · CMS fire safety

4. May 10, 2024 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0695 Quality of Life and Care Deficiencies

     Provide safe and appropriate respiratory care for a resident when needed.

     Corrected Jun 10, 2024 · CMS health inspection

5. Apr 17, 2024 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0580 Resident Rights Deficiencies

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

     Corrected May 13, 2024 · CMS health inspection

6. Dec 14, 2023 Health · 10 findings
   • Not serious Scope/severity D

     F0805 Nutrition and Dietary Deficiencies

     Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

     Corrected Jan 15, 2024 · CMS health inspection

   • Not serious Scope/severity E

     F0812 Nutrition and Dietary Deficiencies

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

     Corrected Jan 15, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0814 Nutrition and Dietary Deficiencies

     Dispose of garbage and refuse properly.

     Corrected Jan 15, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Jan 15, 2024 · CMS health inspection

   • Not serious Scope/severity E

     F0925 Environmental Deficiencies

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

     Corrected Jan 15, 2024 · CMS health inspection

   • Not serious Scope/severity E

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Jan 20, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0355 Smoke Deficiencies

     Properly select, install, inspect, or maintain portable fire extinguishes.

     Corrected Jan 20, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0363 Smoke Deficiencies

     Install corridor and hallway doors that block smoke.

     Corrected Jan 20, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0741 Miscellaneous Deficiencies

     Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

     Corrected Jan 20, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0923 Gas, Vacuum, and Electrical Systems Deficiencies

     Have proper medical gas storage and administration areas.

     Corrected Jan 20, 2024 · CMS fire safety

7. Nov 29, 2023 Health · 1 finding
   • Not serious Scope/severity E Complaint

     F0755 Pharmacy Service Deficiencies

     Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

     Corrected Dec 9, 2023 · CMS health inspection

8. Oct 11, 2023 Health · 5 findings
   • Not serious Scope/severity D Complaint

     F0584 Resident Rights Deficiencies

     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.

     Corrected Oct 31, 2023 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0607 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Develop and implement policies and procedures to prevent abuse, neglect, and theft.

     Corrected Oct 12, 2023 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0609 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

     Corrected Oct 12, 2023 · CMS health inspection

   • Serious Scope/severity J Complaint

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Aug 28, 2023 · CMS health inspection

   • Not serious Scope/severity C Complaint

     F0809 Nutrition and Dietary Deficiencies

     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.

     Corrected Nov 10, 2023 · CMS health inspection

9. Aug 29, 2023 Health · 3 findings
   • Not serious Scope/severity E Complaint

     F0802 Nutrition and Dietary Deficiencies

     Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.

     Corrected Oct 2, 2023 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0812 Nutrition and Dietary Deficiencies

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

     Corrected Oct 2, 2023 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0925 Environmental Deficiencies

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

     Corrected Oct 2, 2023 · CMS health inspection

Owners and managers (as published by CMS)

• BAUDER, WILLIAM — operational/managerial control, NOT APPLICABLE, since 03/01/2025
• BOULWARE, DOUGLAS — individual is an owner, partner or trustee of any adp of the snf, NOT APPLICABLE, since 02/11/2025
• BOULWARE, STEVEN — individual is an owner, partner or trustee of any adp of the snf, NOT APPLICABLE, since 02/12/2025
• PINEGAR, JOHN — adp of the snf, NOT APPLICABLE, since 03/01/2025
• RICHARDSON, JOHN — adp of the snf, NOT APPLICABLE, since 03/01/2025
• SCROGGINS, BRIAN — corporate officer, NOT APPLICABLE, since 03/01/2025
• BRIDGEPOINTE FINANICAL SERVICES, LLC — adp of the snf, NOT APPLICABLE, since 03/01/2025
• CARETRUST REIT INC — 5% or greater mortgage interest, NOT APPLICABLE, since 03/01/2025
• CARETRUST REIT INC — adp of the snf, NOT APPLICABLE, since 03/01/2025
• CTR PARTNERSHIP LP — 5% or greater mortgage interest, NOT APPLICABLE, since 03/01/2025
• CTR PARTNERSHIP LP — adp of the snf, NOT APPLICABLE, since 03/01/2025
• DECATUR HOSPITAL AUTHORITY — 5% or greater direct ownership interest, 100%, since 03/01/2025
• INNOVATIVE NURSE CONSULTING, LLC — adp of the snf, NOT APPLICABLE, since 03/01/2025
• PMG OPCO DECATUR LLC — adp of the snf, NOT APPLICABLE, since 02/11/2025
• PMG OPCO DECATUR LLC — operational/managerial control, NOT APPLICABLE, since 03/01/2025
• PRIORITY MANAGEMENT GROUP, LLC — adp of the snf, NOT APPLICABLE, since 03/01/2025
• PROGRESSIVE REHAB SOLUTIONS, LLC — adp of the snf, NOT APPLICABLE, since 03/01/2025