Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Signature Healthcare Of Spencer County during CMS and state inspections, most recent first.
Two residents with severe cognitive impairment were found together in one resident’s bed, prompting immediate separation and assessment by nursing staff, who noted no injuries, distress, or change from baseline. The DON and Administrator were promptly informed, and internal assessments and interviews were initiated in line with the facility’s abuse policy. However, despite a written requirement that all abuse allegations be reported to State authorities within 2 hours, the allegation was not reported to the OIG until four days later, after leadership realized that no timely external notification had been made.
Facility Assessment Did Not Address Daily Staffing Needs: The facility failed to develop a complete facility assessment that included census-based staffing decisions, unit-specific licensed nurse and nurse aide coverage, and staffing needs for each shift and weekends. The assessment listed weekly average FTEs for nurses and nurse aides but did not document the census used, and interviews confirmed the SDC, Scheduler, DON, and other management staff were not involved in developing the assessment.
The facility failed to keep care plans current for two residents. One resident’s plan did not reflect a new bed order for a mobility bar on the right side only, and observation showed half rails on both sides of the bed. Another resident’s plan did not include a PTSD diagnosis or known triggers such as loud noises and war-related movies, even though staff were aware of them and a psych consult documented the history. Staff interviews confirmed the care plans were not revised to match the residents’ current needs and orders.
Medication Allergy Not Clarified Before Administration: A resident with a documented allergy to hydrocodone-acetaminophen and acetaminophen was prescribed Percocet, which contains acetaminophen, as well as PRN acetaminophen. Facility policy and nursing references required staff to review allergies and clarify unclear orders before medication administration, but interviews showed the allergy record was not specific and no clarification was documented.
Staff failed to follow infection control practices when two SRNAs entered a room with uncovered meal trays and provided care to a resident on EBP without the gown and gloves indicated on the door sign. In a separate event, an RN placed a soiled glucometer on a cart without a barrier and wiped it once with a Clorox wipe instead of maintaining the required wet contact time for the device. The facility’s IP policy, EBP signage, and glucometer cleaning instructions were not followed.
The facility failed to maintain sanitary conditions during food preparation and service. Dietary staff did not wash hands or wear gloves, and a cook was observed crying without a face mask while serving food. Additionally, a contract staff member entered the kitchen without a hair net. The District Dietary Manager handled food without washing hands or wearing gloves, violating the facility's policy and FDA Food Code standards.
The facility failed to maintain an effective infection prevention and control program, with deficiencies in water management, laundry practices, and contractor activities. The Unit Two ice machine was not monitored for Legionella, laundry staff allowed linens to touch the floor and their bodies, and a contractor entered the kitchen without proper hygiene while meal trays were prepared. These actions violated infection control policies, potentially risking resident health.
The facility failed to ensure safe drinking water availability during a water supply loss for 89 residents. Emergency water was stored improperly in an unsecured, non-temperature-controlled building, with torn boxes and scattered jugs. The Maintenance Director and Administrator indicated confusion over responsibility for water storage, acknowledging the need for temperature control to prevent contamination.
Chemical products were improperly stored under sinks in public bathrooms near a nurse's station, with open doors and residents nearby, without staff supervision. The facility lacked an Accident/Supervision Policy and failed to provide SDS for the chemicals, which posed potential health hazards. Staff interviews revealed inadequate oversight and responsibility for chemical storage.
The facility failed to maintain a pest-free environment, as gnats were observed in the rooms of several residents over multiple days. Staff interviews revealed that despite pest control measures, the issue persisted, partly due to residents leaving food items open. The facility's policy to ensure a pest-free environment was not upheld.
A facility failed to maintain a clean and homelike environment for three residents due to a persistent urine odor in a shared bathroom. Despite regular cleaning, the odor, attributed to urine being absorbed into the floor, persisted. Staff, including the SSD, ESD, and DON, were aware of the issue but unable to resolve it effectively.
The facility failed to serve food at palatable temperatures for three residents, as confirmed by a test tray showing scrambled eggs at 90.7°F. Residents reported their food was often cold, and the District Dietary Manager acknowledged the issue. The facility's policy requires proper temperature maintenance, but this was not adhered to, leading to dissatisfaction among residents.
A resident with quadriplegia and hearing impairment was admitted to the facility and faced communication barriers due to staff's failure to use the provided communication tools. The resident reported feeling isolated and unable to communicate his needs, leading to a deficiency in treating the resident with respect and dignity.
Failure to Timely Report Alleged Abuse Involving Two Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of abuse immediately, and no later than two hours after the allegation was made, as required by its own policy and by Federal and State law. On 03/30/2026 at approximately 3:32 PM, staff found Resident 4 in Resident 3’s bed. Certified nursing staff immediately separated the two residents and assessed them, finding no physical injuries, no signs of distress, no need for acute medical intervention, and no changes from baseline behavior. The Director of Nursing (DON) was in the building at the time and was notified right away, and the Administrator was notified at 3:55 PM the same day. The facility’s written policy on Abuse, Neglect, and Misappropriation of Property, revised 01/31/2026, states that all alleged violations involving abuse, neglect, exploitation, or mistreatment must be reported immediately, but no later than two hours after the allegation is made, and that any abuse allegation must be reported to the State within two hours from the time the allegation is received. The DON acknowledged in interview that notifications of such incidents are required to be made immediately or within two hours of when the allegation is received. The Administrator also stated that this incident should have been reported to the State within two hours of the allegation being made. Despite these clear policy requirements and the leadership’s awareness of them, the allegation was not reported to the Office of Inspector General (OIG) until 04/03/2026, four days after the incident. Resident 3 and Resident 4 both had severe cognitive impairment documented in their clinical records. Resident 4, admitted on 03/07/2025, had diagnoses including generalized muscle weakness, cognitive communication deficit, depression, and mild dementia, and had a Brief Interview for Mental Status (BIMS) score of seven on a recent Quarterly MDS, indicating severe cognitive impairment. Resident 3, admitted on 12/15/2025, had diagnoses including mild cognitive impairment, aphasia, dysphagia, generalized muscle weakness, and cognitive communication deficit, and had a BIMS score of one on an Annual MDS, also indicating severe cognitive impairment. Staff interviews indicated that both residents were poor historians and were unable to reliably recall the incident. Although the facility’s internal investigation and assessments found no injuries, no distress, and no changes from baseline for either resident, the central deficiency was that the allegation of possible abuse involving two severely cognitively impaired residents was not reported to the State and OIG within the required two-hour timeframe, but instead was reported four days later when the Administrator and Clinical Care Consultant realized the notification had not been made. The facility’s investigation documents, including the Initial Report dated 03/30/2026 and the Five-Day Follow Up dated 04/03/2026, showed that internal steps such as resident assessments, staff interviews, and documentation were initiated on the day of the incident. The Initial Report indicated that certain external entities (DCBS, the Attorney General, and the Ombudsman) were notified on 03/30/2026, but did not include times of notification, and the Five-Day Follow Up noted that the incident was reported to DCBS and OIG without specifying date and time. Interviews with the Administrator and the Clinical Care Consultant clarified that neither had actually notified the State within the required timeframe and that the OIG notification was not made until 04/03/2026. This sequence of events—prompt internal response to the incident but delayed mandatory external reporting—constitutes the cited failure to ensure timely reporting of an abuse allegation as required by policy and regulation.
Facility Assessment Did Not Address Daily Staffing Needs
Penalty
Summary
The facility failed to develop a facility-wide assessment that adequately addressed informed staffing decisions to ensure there were sufficient numbers of staff with the appropriate competencies and skill sets to meet resident needs identified through resident assessments and plans of care. Review of the facility policy showed the assessment was intended to use evidence-based, data-driven methods to determine resources needed for day-to-day operations and emergencies, and to consider census, resident acuity, preferences, and staff competencies for day, evening, and night shifts. However, the assessment reviewed on 01/22/2026 listed only average FTEs for licensed nurses and nurse aides for year-end 2024 and did not document the census used to determine staffing levels. The Facility Assessment also did not include staffing breakdowns by unit, shift, or weekend coverage, and it did not show adjustments based on changes in the resident population. Interviews with the SDC, Scheduler, and CEO/Administrator confirmed that the SDC and Scheduler had not participated in developing the current assessment, and the CEO stated that corporate managers and he developed it without the DON or other management staff. The CEO further stated that the assessment was based on weekly staffing totals and did not include unit breakdowns or HPRD, while daily staffing breakdowns were posted at unit entrances rather than included in the assessment.
Care plans not updated for current orders and PTSD-related triggers
Penalty
Summary
The facility failed to develop and revise comprehensive care plans for two residents to reflect current assessments, orders, and known needs. For one resident with mild dementia, arthritis of the right knee, and a history of falls, the care plan identified fall risk and multiple interventions, but it did not reflect a new order for the bed to be against the wall and a mobility bar on the right side only. During observation, the resident was in bed with half-sized rails on both sides, which did not match the current order. Staff interviews confirmed that new orders should prompt care plan updates, but the care plan had not been revised to reflect the change. For another resident with diagnoses including psychotic disorder with delusions, major depressive disorder, vascular dementia, hallucinations, cognitive communication deficit, and anxiety, the care plan addressed behavioral problems but did not include the later-identified PTSD diagnosis or the specific triggers associated with it. A psychiatric consult note documented a previous PTSD diagnosis related to the Vietnam War, and the record showed this was the first time PTSD had been noted in the resident’s chart. The care plan continued to list behavior concerns tied to dementia, anxiety, and hallucinations, but it was not revised to include the resident’s known triggers such as loud sudden noises and war-related movies. Interviews showed that staff were aware of the resident’s PTSD history and triggers, and that these details were commonly known among staff and discussed in huddles, but they were not documented in the care plan. The DON and MDS nurse stated that care plans were expected to be updated when new concerns or orders were identified, and the Administrator stated the care plan should have reflected the resident’s needs and that the clinical management team was responsible for ensuring accuracy. The report also cited the facility policy requiring comprehensive care plans to be revised as necessary with changes.
Medication Allergy Not Clarified Before Administration
Penalty
Summary
The facility failed to ensure nursing staff followed the standard of care for medication administration for one resident with a documented allergy to acetaminophen. The resident’s face sheet listed allergies to hydrocodone and acetaminophen that would result in a rash, and the medication administration record also listed an allergy to hydrocodone-acetaminophen. Despite this, the resident had active orders for oxycodone (Percocet), which contains acetaminophen, and acetaminophen 650 mg every four hours as needed for pain. Facility policy required medications to be administered as prescribed and for staff to note allergies or contraindications before administration. The nursing reference used by staff stated that nurses should assess medication history and allergies, clarify unclear orders before giving medications, and follow the rights of medication administration. The charge nurse job description stated responsibility for ensuring compliance with facility policies and procedures. During interviews, the NP stated she believed the resident had a sensitivity to hydrocodone rather than acetaminophen and that oxycodone had been ordered in place of hydrocodone. The contracted pharmacist stated the record was not specific about which drug the resident was sensitive to and had no record of clarification. The DON stated nurses were expected to review the allergy list before administering medications and follow up with the pharmacy and NP to clarify concerns, and the Administrator stated staff were expected to question the order and document follow-up appropriately.
Infection Control Failures With PPE Use and Glucometer Disinfection
Penalty
Summary
The facility failed to maintain its infection prevention and control program during two separate observations involving resident care and equipment cleaning. One issue involved staff entering a shared room to deliver lunch trays to two residents, including one resident on Enhanced Barrier Precautions because of an indwelling gastric tube. The trays were uncovered while staff provided care to the resident, and two SRNAs entered the room without wearing the gown and gloves indicated on the door sign for the resident on Enhanced Barrier Precautions. The staff then provided care behind the curtain and later washed their hands after leaving the room. A second issue involved a nurse performing a finger stick blood sugar on a resident using an Assure Platinum glucometer. After the test, the nurse placed the soiled glucometer on the medication cart without a barrier, then wiped it once with a Clorox wipe for about nine seconds and allowed it to dry on a paper towel before returning it to the resident’s room. The nurse did not use a timer to ensure the required wet contact time was met. Facility staff later stated there had been confusion about the wet time requirements for different glucometer models, and the observed device required three minutes of continuous wet surface according to the facility competency and the product label. The report also states that the facility’s infection control policy required staff to follow manufacturer guidance for glucometer cleaning and disinfection, and that Enhanced Barrier Precautions required the use of PPE as indicated by signage. The DON and Administrator stated they expected the infection control policy to be followed, and the DON stated that the resident’s EBP status required staff to wear appropriate PPE anytime there was physical contact with the resident, including being pulled up in bed.
Sanitation Lapses in Food Preparation and Service
Penalty
Summary
The facility failed to maintain sanitary conditions in food preparation and service, as observed during a survey. Dietary staff did not wash hands or wear gloves while preparing and serving food, violating professional standards for food safety. Specifically, the District Dietary Manager (DDM) handled food without washing hands or wearing gloves, including when preparing mashed potatoes and checking food temperatures. Additionally, a cook was observed crying without a face mask while serving food, and a contract staff member entered the kitchen without a hair net, passing by food trays being prepared for residents. The facility's policy, which aligns with the FDA Food Code, requires proper handwashing and glove use to prevent contamination. However, these protocols were not followed, as confirmed by interviews with the DDM and the Administrator. The DDM, who was temporarily filling in for the dietary manager, acknowledged the importance of these guidelines but noted the absence of the dietary manager, who had recently quit. The Administrator expected the kitchen supervisory staff to educate and enforce sanitation policies but was unaware of the contract staff's actions in the kitchen.
Infection Control Deficiencies in Water Management, Laundry, and Contractor Practices
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies. The facility did not adhere to its Legionella Water Management Plan, specifically failing to monitor the Unit Two ice machine for potential Legionella growth between January and July 2024. The Plant Operation Director was unable to provide documentation of the required weekly or monthly checks, despite acknowledging the importance of monitoring water sources to prevent resident illness. The Administrator confirmed that non-compliance with water monitoring policies could lead to bacterial contamination and resident sickness. Additionally, the facility's laundry practices were found to be inadequate. A laundry worker was observed folding linens in a manner that allowed them to touch the floor and the worker's body, contrary to infection control policies. The Environmental Services Director noted that such practices could transfer bacteria from the floor or the worker's clothing to the linens, potentially causing resident illness. The Administrator reiterated the expectation that all staff follow proper laundering procedures to prevent bacterial transfer to residents. Furthermore, a contractor maintaining the facility's fish tank was observed cleaning the tank without gloves and entering the kitchen without washing hands or wearing a hair net. This occurred while meal trays were being prepared, posing a risk of contamination. The Administrator admitted that the contractor had not been educated on the facility's infection control policies, which should have included using a different water source and avoiding the kitchen to prevent germ spread.
Deficiency in Emergency Water Supply Storage
Penalty
Summary
The facility failed to ensure the availability of safe drinking water for all residents in the event of a loss of normal water supply. The facility had a census of 89 residents at the time of the survey. The contracted dietary services company was responsible for maintaining an adequate supply of emergency water, as per state guidelines. However, the facility's emergency potable water was stored in a 10-foot by 10-foot metal storage building outside the facility, which lacked a locking device and had a dirt floor covered with gravel. Numerous boxes of plastic gallon jugs of water were observed in the building, with the cardboard boxes torn open and the jugs lying in different areas, partially covered with a tarp. Although the water was not expired, there was no temperature control in the building. Interviews with the Maintenance Director and the Administrator revealed a lack of clarity regarding responsibility for the emergency water supply. The Maintenance Director stated that the contracted kitchen company was responsible for non-potable water and that he was not involved with it, only knowing that the water had always been stored in the outside building. The Administrator confirmed that the emergency water was provided by the contracted dietary company, but the facility was responsible for its storage. The Administrator acknowledged that the water should have been stored in a temperature-controlled environment to prevent potential contamination from temperature extremes affecting the plastic containers.
Chemical Hazards Found in Public Bathrooms
Penalty
Summary
The facility failed to maintain a resident environment free from accident hazards, as observed on 07/30/2024. Chemical products, including Dermafungal cream, Hydrogel wound gel, and disinfectant wipes, were found stored under the sinks of two public bathrooms near the back nurse's station. The doors to these bathrooms were open, and eight residents in wheelchairs, along with other residents walking nearby, were observed in the vicinity without staff supervision. The facility was unable to provide an Accident/Supervision Policy upon request, and the Safety Data Sheets (SDS) for the chemicals indicated potential health hazards if ingested or if they came into contact with eyes or skin. Interviews with facility staff revealed a lack of proper oversight and responsibility for the storage of these chemicals. The Environmental Services Director stated that housekeeping checks under common bathroom sinks infrequently and that any chemicals found should be disposed of due to their potential harm. The Administrator acknowledged the absence of SDS for the disinfectant wipes and confirmed that the chemicals should not have been stored under the sinks, suggesting they were left by staff. The Administrator also recognized the potential hazards these chemicals posed to residents, including the risk of illness or death.
Pest Control Deficiency in Resident Rooms
Penalty
Summary
The facility failed to maintain a pest-free environment for four of the 34 sampled residents, as evidenced by the presence of gnats in the rooms of residents. Observations during facility rounds revealed multiple gnats flying around in the rooms shared by two residents and in a shared bathroom. Additionally, a gnat was observed flying around a breakfast tray while another resident was attempting to eat. These observations were made over several days, indicating a persistent issue. Interviews with facility staff, including an LPN, the Social Services Director, the Environmental Services Director, the Plant Operation Director, the Director of Nursing, and the Administrator, revealed that gnats and flies had been a recurring problem. The pest control company had been contacted to spray the facility, and a product called Finito was used daily to prevent pests. However, staff noted that residents leaving food items open contributed to the issue. Despite these efforts, the presence of gnats persisted, contradicting the facility's policy to ensure a pest-free environment.
Persistent Urine Odor in Shared Bathroom
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for three residents, as evidenced by a persistent strong urine odor in a shared bathroom. The facility's policy on resident rights emphasizes the importance of maintaining an environment that enhances each resident's quality of life, including a clean and homelike setting. However, during initial facility rounds, a strong urine odor was detected in the shared bathroom of two residents' rooms, which persisted over several days despite regular cleaning efforts. Interviews with facility staff, including the Social Services Director, Environmental Services Director, and Director of Nursing, revealed awareness of the issue but an inability to effectively eliminate the odor. The Social Services Director acknowledged the importance of a clean environment and attributed the odor to urine being absorbed into the floor. The Environmental Services Director noted that the bathroom was cleaned at least twice daily, but the efforts were not always successful. The Director of Nursing confirmed the odor was due to a male resident missing the commode. The facility Administrator also recognized the issue, describing it as a lingering odor despite frequent cleaning attempts.
Failure to Serve Food at Palatable Temperatures
Penalty
Summary
The facility failed to provide food at a palatable temperature for hot foods for three of 34 sampled residents. Residents reported that their food was often cold, which was confirmed by a test tray observation. The test tray revealed scrambled eggs at 90.7 degrees Fahrenheit, which is below the expected palatable temperature. The facility's policy on meal distribution, revised in February 2023, requires that foods be transported in a manner that ensures proper temperature maintenance and timely delivery. However, the facility did not adhere to this policy, resulting in food being served at inadequate temperatures. Interviews with residents indicated dissatisfaction with the temperature of the food served. One resident, who was cognitively intact, reported that the food was often cold. Another resident, with moderately impaired cognition, also stated that the food was frequently cold. A third resident, who was hard of hearing but cognitively intact, communicated similar concerns. The District Dietary Manager acknowledged that food should be served at a palatable temperature and expressed uncertainty about why the eggs were served at such a low temperature. The facility administrator conducted test trays every two weeks but had not identified any concerns prior to this incident.
Failure to Ensure Effective Communication for Resident
Penalty
Summary
The facility failed to treat a resident with respect and dignity, compromising their right to a dignified existence and self-determination. The resident, who was admitted with cervical disc disorder, quadriplegia, and cervical fusion, was cognitively intact but hearing impaired and communicated via sign language, a communication book, a whiteboard, and an iPad. Despite being informed of the resident's communication needs upon admission, the staff did not ensure effective communication. The resident reported to family members that he was unable to communicate his needs to the State Registered Nurse Aides (SRNAs) and did not have access to his call light all night, which left him feeling isolated and unable to get assistance. The Occupational Therapist found the resident frustrated and signing, and upon assisting him with a video call to his family, it was revealed that the resident felt abused due to the lack of communication and assistance. The Social Worker and Assistant Director of Nursing acknowledged the communication issues faced by the staff in the initial days of the resident's stay. The Director of Nursing and Administrator confirmed that the resident's needs were not initially met, and communication with the resident was necessary to assess and address his health needs effectively.
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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.
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Nursing homes near Taylorsville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sanders Ridge Health Campus | 9.2 mi | ★★★★★ | 0 | 0 |
| Green Meadows Health & Rehabilitation | 12.1 mi | ★★★★★ | 0 | 0 |
| Crestview Healthcare And Rehabilitation | 12.8 mi | ★★★★★ | 3 | 0 |
| Glen Ridge Health Campus | 13.8 mi | ★★★★★ | 0 | 0 |
| Maple Grove Senior Living Llc | 14.3 mi | ★★★★★ | 5 | 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 July 2026) and official state health department websites.