Cycle 1
Health 2025-02-06 · Fire 2025-02-06
6 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Decatur, TX
Decatur Medical Lodge
3-star overall rating with 4-star inspections with $14,518 in total fines with 6 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
701 W Bennett Rd, Decatur, TX
(940) 626-2800
Overall
3 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
124
Certified beds
Average residents
101
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Priority Management
Operator or chain grouping
Approved since
2009-02-03
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
38 facilities
Chain averages 3 overall / 3 health / 2 staffing / 3 quality stars
Changed ownership
Yes
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.19
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
1.05
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
2.00
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.24
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.24
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.95
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.16
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.17
CMS adjusted RN staffing hours
Adjusted total hours
2.94
CMS adjusted total nurse staffing hours
Case-mix index
1.51
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
69%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,651
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
15.88
Composite VBP score used to determine payment impact.
Payment multiplier
0.9815
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.87
Baseline 19.39% · Performance 19.64% · Measure score 3.87 · Achievement 3.87 · Improvement 0
Healthcare-associated infections
1.28
Baseline 7.87% · Performance 7.45% · Measure score 1.28 · Achievement 1.28 · Improvement 0.94
Total nurse turnover
1.19
Baseline 91.25% · Performance 80.00% · Measure score 1.19 · Achievement 0 · Improvement 1.19
Adjusted total nurse staffing
0
Baseline 2.83 hours · Performance 2.96 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.24% |
10.72%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 156 · Observed rate 12.18% · Lower 95% interval 8.45% |
| Discharge to community | 50.39% |
50.57%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 133 · Observed rate 45.86% · Lower 95% interval 43.37% |
| Medicare spending per beneficiary | 1.44 |
1.02
0.4 pts worse
|
|
| Drug regimen review with follow-up | 98% |
95.27%
2.7 pts better
|
Numerator 98 · Denominator 100 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 100 |
| Discharge self-care score | 43.55% |
53.69%
10.1 pts worse
|
Numerator 27 · Denominator 62 |
| Discharge mobility score | 27.42% |
50.94%
23.5 pts worse
|
Numerator 17 · Denominator 62 |
| Pressure ulcers or injuries, new or worsened | 3% |
2.29%
0.7 pts worse
|
Numerator 3 · Denominator 100 · Adjusted rate 3.28% |
| Healthcare-associated infections requiring hospitalization | 7.45% |
7.12%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 85 · Observed rate 7.06% · Lower 95% interval 4.4% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 106 |
| Staff flu vaccination coverage | 26.92% |
42%
15.1 pts worse
|
Numerator 35 · Denominator 130 |
| Discharge function score | 30.65% |
56.45%
25.8 pts worse
|
Numerator 19 · Denominator 62 |
| Transfer of health information to provider | 96.88% |
95.95%
0.9 pts better
|
Numerator 31 · Denominator 32 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 33 · Denominator 33 |
| Resident COVID-19 vaccinations up to date | 4.44% |
25.2%
20.8 pts worse
|
Numerator 2 · Denominator 45 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.5 |
2.1
0.4 pts worse
|
1.9
0.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 3.0 · Expected 2.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.3 |
2.1
0.2 pts worse
|
1.8
0.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 2.5 · Expected 1.9 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
97.1%
2.9 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
97.9%
2.1 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.4% |
3.3%
3.1 pts worse
|
3.3%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.6% · Q2 6.2% · Q3 3.7% · Q4 7.2% · 4Q avg 6.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 7.8% |
2.7%
5.1 pts worse
|
11.4%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.9% · Q2 6.3% · Q3 5.1% · Q4 3.3% · 4Q avg 7.8% |
| Percentage of long-stay residents who lose too much weight | 2.6% |
3.3%
0.7 pts better
|
5.4%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 0.0% · Q3 4.2% · Q4 0.0% · 4Q avg 2.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 8.6% |
18.9%
10.3 pts better
|
19.6%
11 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.7% · Q2 10.6% · Q3 8.3% · Q4 6.8% · 4Q avg 8.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.7% |
10.8%
4.9 pts worse
|
16.7%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.6% · Q2 13.0% · Q3 16.3% · Q4 14.3% · 4Q avg 15.7% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 5.2% |
15.4%
10.2 pts better
|
16.3%
11.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.6% · 4Q avg 5.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.9% |
16.1%
2.2 pts better
|
14.9%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.0% · Q2 11.3% · Q3 11.8% · Q4 25.7% · 4Q avg 13.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.5%
0.5 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
0.8%
0.8 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 12.4% |
15.0%
2.6 pts better
|
19.8%
7.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.3% · Q2 9.6% · Q3 7.7% · Q4 16.5% · 4Q avg 12.4% |
| Percentage of long-stay residents with pressure ulcers | 2.4% |
4.2%
1.8 pts better
|
5.1%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 2.2% · Q3 2.9% · Q4 2.5% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.6% |
89.7%
9.9 pts better
|
81.7%
17.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.1% · Q2 99.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 17.6% |
12.0%
5.6 pts worse
|
12.0%
5.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 17.6% · Observed 18.4% · Expected 11.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.5% |
1.5%
About the same
|
1.6%
0.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 2.2% · Q3 0.0% · Q4 2.5% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.3% |
88.0%
10.3 pts better
|
79.7%
18.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 17.0% |
25.9%
8.9 pts better
|
23.9%
6.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 17.0% · Observed 16.5% · Expected 23.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-14 · Fire 2023-12-14
7 health deficiencies
Top issue: Nutrition and Dietary (3 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2022-10-26 · Fire 2022-10-26
10 health deficiencies
Top issue: Nutrition and Dietary (4 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-02-06
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2025-03-20
F · Potential for more than minimal harm
2023-12-14
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2024-01-20
E · Potential for more than minimal harm
2023-12-14
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-01-20
E · Potential for more than minimal harm
2023-12-14
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-01-20
E · Potential for more than minimal harm
2023-12-14
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-01-20
E · Potential for more than minimal harm
2023-12-14
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-01-20
F · Potential for more than minimal harm
2022-10-26
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-11-09
E · Potential for more than minimal harm
2022-10-26
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2022-11-09
E · Potential for more than minimal harm
2022-10-26
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-11-09
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-06-25
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-07-25
E · Potential for more than minimal harm
2025-02-06
F761 · Pharmacy Service Deficiencies
Health
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 2025-03-07
E · Potential for more than minimal harm
2025-02-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-07
D · Potential for more than minimal harm
2025-02-06
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-03-07
D · Potential for more than minimal harm
2025-02-06
F693 · Quality of Life and Care Deficiencies
Health
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 2025-03-07
D · Potential for more than minimal harm
2025-02-06
F700 · Quality of Life and Care Deficiencies
Health
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 2025-03-07
D · Potential for more than minimal harm
2024-05-10
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-06-10
D · Potential for more than minimal harm
2024-04-17
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-05-13
E · Potential for more than minimal harm
2023-12-14
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-01-15
E · Potential for more than minimal harm
2023-12-14
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2024-01-15
D · Potential for more than minimal harm
2023-12-14
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2024-01-15
D · Potential for more than minimal harm
2023-12-14
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2024-01-15
D · Potential for more than minimal harm
2023-12-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-01-15
E · Potential for more than minimal harm
2023-11-29
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-12-09
J · Immediate jeopardy
2023-10-11
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-08-28
D · Potential for more than minimal harm
2023-10-11
F584 · Resident Rights Deficiencies
Health
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 2023-10-31
D · Potential for more than minimal harm
2023-10-11
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-10-12
D · Potential for more than minimal harm
2023-10-11
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-10-12
C · Minimal harm
2023-10-11
F809 · Nutrition and Dietary Deficiencies
Health
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 2023-11-10
E · Potential for more than minimal harm
2023-08-29
F802 · Nutrition and Dietary Deficiencies
Health
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Corrected 2023-10-02
E · Potential for more than minimal harm
2023-08-29
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-10-02
D · Potential for more than minimal harm
2023-08-29
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2023-10-02
F · Potential for more than minimal harm
2022-10-26
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-10-31
Penalties and ownership
What sits behind the stars
$14,518
2023-08-29
Fine
Fine · fine $14,518
Fine
Ownership
Decatur Hospital Authority
5% Or Greater Direct Ownership Interest · Organization
Bauder, William
Operational/Managerial Control · Individual
Caretrust Reit Inc
5% Or Greater Mortgage Interest · Organization
Ctr Partnership LP
5% Or Greater Mortgage Interest · Organization
Pmg Opco Decatur LLC
Operational/Managerial Control · Organization
Scroggins, Brian
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
The Hills Nursing & Rehabilitation
Decatur, TX
1-star overall rating with 1-star inspections with $29,325 in total fines with 9 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Heritage Place Of Decatur
Decatur, TX
4-star overall rating with 4-star inspections with 6 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Bridgeport Medical Lodge
Bridgeport, TX
1-star overall rating with 2-star inspections with abuse icon flag with $37,795 in total fines with 4 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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