Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Signature Healthcare At Summit Manor Rehab & Welln during CMS and state inspections, most recent first.
The facility failed to maintain a safe, clean, and well‑maintained environment as required by its own policy, with surveyors observing loose kitchen handrails, damaged doors and wood paneling, exposed concrete and stained flooring in resident rooms and bathrooms, bubbling and chipped paint, rusted door frames, water‑stained ceiling tiles, scuffed walls and baseboards, damaged tiles, and deteriorated outdoor structures such as a raised garden bed. Additional issues included a broken cabinet and taped wall corner guard in shower rooms, an unsecured wall clock, a missing floor tile, dried paint splatter, rusted heating/cooling units with chipped paint, and a pool table with a missing corner guard. A resident reported a heating/air unit in her room with a missing bottom panel exposing dust and debris. Staff interviews revealed that some items had been broken for years, concerns about the safety of the handrails had not resulted in repairs, housekeeping did not consistently log issues for maintenance, and there was no formal system to track and ensure completion of maintenance work orders, as acknowledged by the DON, the Maintenance Director, and the Administrator.
A resident with dementia and documented pain needs fell and was initially assessed as having no injury or pain, but staff later observed significant pain with movement, care, and mobility. An SRNA reported the resident complained of shoulder, hip, and head pain after the fall, and later staff noted soreness, refusal to get up, and pain during turning and walking attempts. An x-ray eventually showed an acute femoral neck fracture, but the result was not promptly retrieved or reported to the physician, and the resident was later hospitalized for hip surgery.
Surveyors found the facility failed to maintain a safe, clean, and well-repaired environment, with unsecured kitchen handrails, damaged doors and wood paneling, holes and stained flooring in resident rooms and bathrooms, bubbling paint, rusted door frames, water-stained ceiling tiles, and scuffed walls and baseboards. Common and shower areas had missing cabinet hardware, taped wall guards, an improperly mounted clock, a pool table with a missing corner guard, and a structurally deteriorated raised garden bed. Flooring defects, rusted heating/cooling units, and exposed dust and debris in a resident’s HVAC unit were also observed, and a resident reported dissatisfaction with the cleanliness. Staff interviews revealed that some items, such as a broken shower cabinet and unsafe handrails, had been problematic for years, that housekeeping did not consistently log issues for maintenance, and that there was no formal system to track and ensure completion of maintenance work orders despite leadership expectations for a safe and clean environment.
Unsafe food handling and sanitation practices were observed in the dietary area. Staff left the tray line and returned without hand hygiene or glove changes, prepared and plated food while wearing false/painted nails, stacked bowls so food-contact surfaces were exposed, handled food with soiled gloves, and served residents wet trays and cups. The kitchen also had poor sanitation, including debris and grime in the walk-in refrigerator area, a leaking oil box in dry storage, an open ice scoop cover, and improper use of a serving spoon to scoop ice.
Improper Garbage Storage and Open Dumpster Lids: The facility failed to keep exterior garbage receptacles closed and sanitary. Observations showed dumpster lids left open, refuse piled above the containers, and discarded furniture stored behind the dumpsters. The Maintenance Director stated he had to shovel garbage away from the receptacles daily and had repeatedly spoken with staff about using the dumpsters properly. The Housekeeping Supervisor, Dietary Manager, DON, and Administrator all acknowledged the lids should stay closed and refuse should be disposed of correctly.
The facility failed to maintain sanitary food service practices, as dietary staff did not wash hands or change gloves before preparing food, and did not check temperatures of several food items. This was against the facility's policy and FDA standards.
Failure to Maintain Safe, Clean, and Well-Maintained Environment
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, and well‑maintained environment as required by its “Home-like Environment” policy, which states residents have a right to a safe, clean, and homelike setting. Surveyors observed multiple unresolved maintenance and housekeeping issues throughout the building and grounds. These included loose and insecure handrails leading into the kitchen, a damaged kitchen entry door with scratches and a missing piece, damaged and chipped wood paneling at the nurses’ station, and multiple areas of damaged flooring in resident rooms where heating/cooling units had been removed, exposing concrete and stained flooring around toilets and sinks. Additional observations included bubbling and chipping wall paint, rusted door frames, discolored and water‑stained ceiling tiles, and scuffed walls and baseboards in hallways and the dining room. Further observations showed environmental issues in resident-use and common areas, including a water hose lying in flowerbeds at the facility entrance, a Styrofoam cup on the ground outside a resident’s window, scratched glass doors to the smoking area, damaged floor tiles at the exit to the smoking area, a cabinet in a resident shower room with a missing handle, and a wall corner guard held in place with multiple strips of tape. Another shower room had a wall clock not mounted properly, resting on cloth hooks. Additional findings included a missing floor tile in a resident room exposing concrete, dried paint splatter at entries to several resident rooms, rust and chipped paint on a heating/cooling unit and adjacent exit door, a pool table in the dining room with a missing corner guard and exposed edges, and a raised garden bed with structural deterioration and a failing, rotted base partially detached and laying on the ground. Interviews confirmed that these conditions had been ongoing and not consistently addressed through the facility’s maintenance processes. A resident reported that the heating/air unit in her room was missing the bottom part, exposing dust and debris on the floor, and stated she would clean it herself if able. A CNA reported the broken cabinet in the shower room had been in that condition for many years and that repairs were not consistently completed after being reported via logbooks. The Housekeeping Manager acknowledged awareness of scuff marks on walls and baseboards but had not entered them into the maintenance logbook. The Dietary Manager stated she had concerns about the safety of the kitchen handrails, which she believed could pose a fall risk, and that maintenance had not repaired them. The Maintenance Director stated there were no outstanding work orders in the logbook, acknowledged that monthly painting had not been done for March, and noted the damaged raised garden bed had not been repaired or removed. The DON and Administrator both acknowledged there was no formal system to track and ensure completion of maintenance work orders, and the Administrator was aware of the unsecured kitchen handrails but was not aware if repairs had ever been completed.
Pain Management Not Timely or Consistent After Resident Fall and Fracture
Penalty
Summary
Safe, appropriate pain management was not provided for a resident with dementia, osteoarthritis, atrial fibrillation, depression, and a documented history of pain. The resident had a fall after which staff documented no apparent injury, no complaints of pain, and normal range of motion, and the resident was returned to bed after the assessment. The resident’s care plan already included pain-related interventions, including observing for non-verbal signs of pain and offering medications as ordered, and the care plan was later updated to include opioid medication. After the fall, multiple staff members observed that the resident had pain with movement and care. An SRNA stated the resident complained of left shoulder pain, left hip pain, and pain in the back of the head when assisted after the fall. The next day, staff reported the resident was sore, did not want to get up to the wheelchair because movement caused significant pain, and had to be handled very gently during incontinent care. An LPN stated she gave acetaminophen for pain, but there was no documented evidence that the medication was administered. Later, when therapy and restorative staff attempted to mobilize the resident, he was unable to stand and complained of back and knee pain, and he was assisted back to bed because of pain. The resident’s condition worsened and an x-ray was ordered after staff reported left hip pain when turning him. The x-ray showed an acute left femoral neck fracture with modest displacement and angulation. The report was faxed to the facility, but staff did not retrieve the results and notify the physician for approximately 15 hours. The resident was later sent to the hospital with hip pain, shortening and outward rotation of the left leg, and hospital records confirmed the fracture and subsequent hemiarthroplasty surgery. The DON stated she expected a complete pain assessment to ensure residents were not in pain, and the Administrator stated x-rays were expected to be reported to the physician as soon as received.
Failure to Maintain Safe, Clean, and Well-Repaired Environment Throughout Facility
Penalty
Summary
The facility failed to provide a safe, clean, and well-maintained environment as required by its "Home-like Environment" policy, which states residents have a right to a safe, clean, and homelike environment. Surveyors observed multiple unrepaired and poorly maintained areas throughout the building. These included unsecured handrails leading into the kitchen with screws coming out of the wall and a loose handrail end, a kitchen entry door with scratches, worn areas, and a missing piece at the bottom corner, and damaged wood paneling at the nurses’ station with numerous chipped or missing sections. Additional observations included holes and damaged flooring in a resident room where heating/cooling units had been removed, stained flooring at the base of a toilet and under a sink, bubbling and chipping wall paint, rusted door frames, discolored and water-stained ceiling tiles, and scuffed walls and baseboards in hallways and the dining room. Surveyors also noted environmental issues in resident-use and common areas that were not addressed. A water hose was left lying in flowerbeds at the facility entrance and a styrofoam cup was observed on the ground outside a resident’s window. The glass door to the smoking area had visible scratches, and floor tiles at the exit from the dining room to the smoking area were damaged, including a tile with a missing corner. In resident shower rooms on the second floor, one cabinet had a missing handle and a wall corner guard was held in place with multiple strips of tape, while another shower room had a wall clock not mounted properly, instead resting on two cloth hooks. A pool table in the first-floor dining room was missing a corner guard, leaving exposed edges, and a raised garden bed outside the dining area showed structural deterioration with a rotted, detached base partially laying on the ground. Further observations showed missing or damaged flooring and deteriorated heating/cooling units near resident rooms. In one resident room, a six-inch by six-inch floor tile had been removed, exposing concrete, and dried white paint splatter was present at the entry to several resident rooms. A heating/cooling unit outside a resident room had rust, discolored paint, and chipping, and an exit door next to it also had rust and chipped paint. Another resident’s heating/air unit was missing its bottom door, exposing dust and debris underneath; the resident reported that if able, she would clean it herself because she liked her home to be clean. Staff interviews revealed that a shower room cabinet had been broken for many years and that repairs were not consistently completed after being reported via logbooks. The Housekeeping Manager acknowledged awareness of scuff marks but had not entered them into the maintenance log, and the Dietary Manager reported long-standing concerns about unsafe handrails that had not been repaired. The Maintenance Director stated there were no outstanding work orders, that painting had not been done for the month, and that there was no formal tracking system for work order completion, which was confirmed by the DON and Administrator, both of whom acknowledged the lack of a formal process to ensure maintenance issues were completed despite expectations for a safe and clean environment.
Unsafe Food Handling and Kitchen Sanitation Practices
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Review of facility policies showed expectations for proper clothing, warewashing, and air drying of dishware, but on 03/26/2026 the DON could not provide policies for infection control, hand hygiene, or glove/PPE use for dietary staff when requested by the SSA surveyor. Observations in the kitchen and tray line showed multiple unsafe practices. A dietary employee left the tray line, handled the steamer and sink, then returned to the tray line without performing hand hygiene or changing gloves before placing biscuits into a storage bag. During lunch tray line, the Dietary District Manager and another staff member were observed preparing and plating food while wearing false/painted nails. The Dietary Manager stacked plastic bowls inside one another so the food-contact portion was exposed, and another staff member handled food with visibly soiled gloves, removed chicken from a divided plate, and returned that same plate to a stack of clean plates. The tray line also served residents with wet trays and one wet tray and cup. Additional observations showed sanitation and storage concerns throughout the kitchen area. A plastic dessert bowl remained on the floor under the sink across three days, the walk-in refrigerator floor and surrounding areas had dark brown and black stains, grime, debris, and dried spills, and the kitchen flooring around the walk-in refrigerator and freezer had visible debris and dust buildup. In dry storage, a visibly discolored cardboard box of cooking oil was leaking and pooling on the floor. The Dietary Manager also used a metal serving spoon to scoop ice from a hallway ice machine and returned it to the clean utensil area, and the ice scoop container lid was left open on later observations. Interviews confirmed staff expectations for hand hygiene, glove changes, proper dishware storage, and sanitary food service practices, and the Administrator acknowledged the kitchen was not being maintained in a clean and sanitary manner.
Improper Garbage Storage and Open Dumpster Lids
Penalty
Summary
The facility failed to maintain sanitary conditions related to the storage and disposal of garbage and refuse waste. Review of the facility policy, titled Home-like Environment, last revised 09/05/2025, showed residents have a right to a safe, clean, and homelike environment. During observation on 03/24/2026 at 8:57 AM, two exterior garbage receptacles were seen with lids left open and refuse piled above the top of the containers, preventing proper closure. Discarded furniture, including upholstered chairs, was also observed stored directly behind the exterior garbage dumpsters and placed on the ground near the waste area, creating clutter. A later observation on 03/25/2026 at 11:26 AM again showed an exterior garbage receptacle with the lid open and refuse inside the container. The Maintenance Director stated the exterior garbage receptacles were emptied three times weekly and that he had to use a shovel to move garbage to prevent it from being piled up around the receptacles daily. He also stated he had spoken to facility staff multiple times but could not get them to understand they could use the back side of the dumpster for garbage. The Housekeeping Supervisor, Dietary Manager, DON, and Administrator each stated the lids should remain closed and refuse should be placed properly in the dumpsters, and they acknowledged ongoing concerns about lids being left open.
Deficiency in Food Service Safety
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey. Dietary staff did not wash their hands or change gloves before preparing resident foods, which is a violation of the facility's policy and the FDA Food Code. Specifically, a dietary aide used a brown paper towel to clean a thermometer between checking the temperature of milk and apple juice, and both the dietary aide and another staff member put on gloves without performing hand hygiene. Additionally, one staff member handled soiled dishes and then returned to the steam table without changing gloves or washing hands, and used a dirty food pusher for pureed bread. Furthermore, the staff failed to check the temperatures of seven out of ten food items on the steam table during the dinner meal. The dietary manager confirmed that staff are expected to change gloves, wash hands, and use alcohol pads to clean thermometers between uses. The administrator also stated that all food temperatures should be checked according to policy. These actions and inactions led to the deficiency in food service safety, as the facility did not ensure that food was prepared, distributed, and served in a sanitary manner.
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Illustrative
What surveyors actually found near you
We read the 4 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Columbia
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Green River Trails | 14.6 mi | ★★★★★ | 0 | 0 |
| Fair Oaks Health And Rehabilitation | 15.1 mi | ★★★★★ | 0 | 0 |
| The Grandview Nursing And Rehabilitation Facility | 16.8 mi | ★★★★★ | 0 | 0 |
| Campbellsville Nursing And Rehabilitation Center | 17.3 mi | ★★★★★ | 4 | 0 |
| Metcalfe Nursing And Rehabilitation Center | 19.2 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.