Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
HERITAGE PLACE OF DECATUR
DECATUR, TX · 60 certified beds · Last Life Safety survey November 21, 2025
CMS Certification Number 675513 · first certified July 1995
Ownership
Operated by CREATIVE SOLUTIONS IN HEALTHCARE · For profit - Corporation
- Ownership changed February 1, 2021 (change of ownership)from DECATUR NURSING AND REHABILITATION LP
Position within TX
13 citations — more than 79% of the 1,177 certified nursing homes in TX. Compared within TX rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 3 citations; the earlier surveys in the window averaged 4.3. With 4 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window opens December 2026 — about 3 months from now. This facility’s last Life Safety survey was November 2025. Facilities in TX are typically surveyed 13–14 months after the last one (median 14), measured over 1,905 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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2 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
1 of the 13 citations on file is Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
4 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 13 Life Safety citations above. The Physical Environment Index
- F-0880 Provide and implement an infection prevention and control program.
- F-0584 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.
- F-0908 Keep all essential equipment working safely.
How that compares
Compared with the median facility in TX, and nationally. Surveyors differ markedly between states, so the TX figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 13 |
| Median facility in TX | 7 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| June 22, 2023 | 3 |
| August 8, 2024 | 7 |
| November 21, 2025 | 3 |
| November 21, 2025 | 3 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | 3 | 2025-11-21 |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 2 | 2025-11-21 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 1 | 2024-08-08 |
| K-0712 | Have simulated fire drills held at unexpected times. | 1 | 2024-08-08 |
| K-0324 | Provide properly protected cooking facilities. | 1 | 2024-08-08 |
| K-0341 | Install a fire alarm system that can be heard throughout the facility. | 1 | 2023-06-22 |
| K-0511 | Have properly installed electrical wiring and gas equipment. | 1 | 2024-08-08 |
| E-0037 | Establish staff and initial training requirements. | 1 | 2024-08-08 |
What the citations cover
- Services Deficiencies 4
- Smoke Deficiencies 4
- Gas, Vacuum, and Electrical Systems Deficiencies 2
- Emergency Preparedness Deficiencies 1
- Other 2
| Category | Citations |
|---|---|
| Services Deficiencies | 4 |
| Smoke Deficiencies | 4 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 2 |
| Emergency Preparedness Deficiencies | 1 |
| Miscellaneous Deficiencies | 1 |
| Egress Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
November 21, 2025 — 3 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (October 2, 2025) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (October 2, 2025) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (October 2, 2025) |
August 8, 2024 — 7 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0037 | Establish staff and initial training requirements. | Deficient, Provider has date of correction (September 22, 2024) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (September 22, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (September 22, 2024) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (September 22, 2024) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (August 9, 2024) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (September 22, 2024) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (September 22, 2024) |
June 22, 2023 — 3 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0293 | Have properly located and lighted "Exit" signs. | Deficient, Provider has date of correction (July 22, 2023) |
| K-0341 | Install a fire alarm system that can be heard throughout the facility. | Deficient, Provider has date of correction (July 22, 2023) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (July 22, 2023) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.