Below average — CMS composite of the measures below.
A standard survey is most likely before around October 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 Southport Center For Nursing & Rehabilitation Llc during CMS and state inspections, most recent first.
Two residents experienced delays in receiving necessary dental care due to failures in scheduling and communication among staff. One resident's broken tooth was not extracted for an extended period despite repeated recommendations, leading to infection and a fistula. Another resident did not have a needed oral surgeon consultation scheduled after referral, with no documentation of scheduling or refusal. These deficiencies occurred despite facility policies requiring timely coordination and documentation of ancillary services.
The facility failed to notify physicians and/or resident representatives in multiple cases, including when a resident left AMA, when a resident experienced significant blood sugar abnormalities, and when a dental provider identified a possible abscess. Required notifications and documentation were not completed by nursing staff, contrary to facility policy.
The facility did not ensure that the dishwasher's sanitizing solution was properly tested and maintained, resulting in inadequate sanitation of tableware. Dietary staff relied on temperature readings instead of using test strips to measure sanitizer concentration, and there was a lack of documented staff training on proper procedures. A mechanical issue also prevented the sanitizer from dispensing, and the facility could not provide a relevant sanitation policy.
The facility did not have a program in place to monitor antibiotic use, as required. Surveyors found no evidence of tracking or evaluating antibiotic administration among residents.
The facility did not adequately promote or facilitate resident self-determination, resulting in a failure to support resident choice as required. This was due to actions or omissions by staff that did not encourage or honor the resident's right to make decisions about their care or daily activities.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
Two residents did not receive comprehensive care plans addressing their specific needs: one with a hand contracture was not provided with documented interventions or goals, and another with schizoaffective disorder and PTSD did not have a care plan addressing management of disruptive behaviors. Staff were unaware of or unable to implement appropriate interventions, and facility policy requiring individualized, interdisciplinary care planning was not followed.
Multiple deficiencies were identified, including failure to address a resident's hand contracture in the care plan, lack of ongoing assessment and intervention for contractures, missed and undocumented skin checks and treatments for a resident with venous ulcers, improper medication self-administration without assessment, and lack of RN assessment or documentation following an elevated blood sugar in a diabetic resident. Staff interviews and observations confirmed that required care, monitoring, and documentation were not consistently provided according to physician orders and facility policy.
Two residents with pressure ulcers did not receive consistent weekly skin audits as required by facility policy, and documentation of these checks was missing for multiple weeks. Additionally, a low air loss mattress intended to prevent further skin breakdown was not set according to the physician's order, with staff failing to verify or document the correct settings and function each shift. Communication barriers and lack of care planning for resident behaviors further contributed to the deficiencies.
A resident did not receive appropriate care or services to maintain or improve ROM or mobility, and there was no documented medical reason for the decline.
Multiple residents with high risk for accidents, including those with substance abuse history and those requiring aspiration precautions, were not adequately supervised. One resident experienced two unresponsive episodes requiring Narcan after self-administering pain medication and taking a Methadone pill. Two other residents with dysphagia were left unsupervised during meals, did not receive required 1:1 feeding assistance, and consumed inappropriate food or liquids, resulting in repeated coughing episodes. Staff were unaware of or did not follow prescribed dietary and supervision orders.
Surveyors found that appropriate care was not provided for residents regarding continence management, catheter care, and UTI prevention, resulting in a deficiency.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
A nurse aide did not receive the required 12 hours of annual in-service education or annual competency evaluations, as confirmed by documentation review and staff interviews. The staff development nurse lacked a tracking system for monitoring staff training, and education was provided only as time allowed, with limited assistance from other nursing leadership who were also managing multiple responsibilities.
The facility did not notify the State-designated authority when several residents received new mental health diagnoses, and failed to implement PASARR recommendations for a resident with a history of self-harm and violent behavior. Required crisis/safety plans were not included in care plans, and staff were unaware of PASARR directives, resulting in noncompliance with regulatory requirements.
A resident with a history of dental issues and other diagnoses did not have complete or readily accessible dental records in their clinical file after receiving services from a consulting dentist. The resident reported a tooth extraction and requested their dental records, but the facility did not follow up or ensure documentation was present as required by policy. Staff interviews confirmed the records were not immediately available until requested by surveyors.
A resident with advanced breast cancer was not followed up with their oncology office within the timeframe specified in hospital discharge instructions. Facility records and staff interviews confirmed that the required contact was not made, and there was no documentation to show that the follow-up occurred, despite facility policy requiring timely scheduling of such appointments.
Failure to Provide Timely Dental Services and Specialty Referrals
Penalty
Summary
The facility failed to provide or obtain timely dental services for two residents, resulting in unaddressed dental issues and progression of oral health problems. For one resident with a history of stroke and hemiplegia, repeated recommendations for extraction of a broken tooth (#18) were not acted upon over a period of 17 months. Despite multiple dental consultations, nursing notes, and provider recommendations indicating the need for extraction and referral to an oral surgeon, the necessary appointment was not scheduled. This inaction led to the development of a fistula and abscess at the site of the affected tooth. Interviews with staff revealed ongoing communication breakdowns and lack of follow-through in scheduling and documenting specialty dental care, despite the issue being previously identified and discussed among nursing leadership. Another resident, admitted with hypertension and peripheral vascular disease, was identified as needing an oral surgeon evaluation for removal of excess tissue and biopsy of a growth in the mouth. Although a referral was made following a dental assessment, there was no documentation that the appointment was scheduled or that the resident or representative refused the consultation. The resident reported that the dental appointment was never completed, and staff interviews confirmed that the required oral surgeon consultation had not been scheduled due to oversight and lack of communication between the scheduler and nursing staff. Facility policy required that ancillary services, including dental care, be provided or coordinated and that all services and outcomes be documented. The policy also directed that outside medical appointments be arranged, documented, and communicated effectively. However, the facility failed to ensure timely follow-up on dental recommendations, proper scheduling of specialty appointments, and adequate documentation of actions taken, resulting in prolonged resident discomfort and progression of dental conditions.
Failure to Notify Physician and Resident Representatives of Significant Changes
Penalty
Summary
The facility failed to notify physicians and/or resident representatives as required in several situations involving three residents. In one case, a resident who was admitted with multiple diagnoses, including acute embolism, alcohol abuse, and pain, left the facility against medical advice (AMA). The clinical record did not contain a physician’s order for the AMA discharge, nor was there documentation that the physician was notified when the resident left. The nurse’s note also lacked documentation of the resident’s departure and the required notifications, despite facility policy mandating immediate physician notification and documentation in such cases. Another resident, with a history of traumatic brain injury and diabetes, experienced both hypoglycemic and hyperglycemic episodes. The facility failed to notify the resident’s representative of a hypoglycemic event that required intervention, and there was no documentation that the physician was notified of a subsequent blood sugar reading above 400. Interviews confirmed that the advanced practice registered nurse (APRN) was not notified of the elevated blood sugar, and the LPN involved could not recall or document the necessary notifications or follow-up actions. Facility policy required prompt notification and documentation of abnormal blood sugar levels and changes in condition, which was not followed. A third resident, with a history of stroke and hemiplegia, was found by a dental provider to have moderate inflammation and a possible abscess of a tooth root. The clinical record did not show that the physician was notified of this finding, and the nurse who received the dental consultation did not communicate the change in condition as required. Interviews with dental and medical staff confirmed that the physician was not made aware of the dental issue, despite facility policy requiring notification of providers and families for any change in a resident’s baseline condition.
Failure to Maintain and Monitor Dishwasher Sanitizer Levels
Penalty
Summary
The facility failed to ensure that the sanitizing solution in the dishwasher was tested and maintained at an adequate level according to manufacturer guidelines, resulting in tableware not being properly sanitized. Observations and documentation review revealed that while the kitchen service report previously showed satisfactory sanitizer concentration, a test run of the dishwasher later recorded a sanitizer level of 0-10 ppm, which is below the required 50-100 ppm range. Review of the dishwasher temperature log indicated that staff were recording only temperature readings from the dishwasher gauge and not using test strips to measure sanitizer concentration. Multiple dietary staff confirmed that they documented wash and rinse information based solely on temperature readings and did not use test strips as required. Further interviews revealed that the Food Service Director (FSD) was responsible for educating dietary staff on proper sanitation procedures but could not provide documentation of any prior training. One staff member misinterpreted the sanitizer test strip results, indicating a lack of understanding of the correct range. A dishwasher technician identified a mechanical issue that prevented the sanitizing solution from dispensing, which was subsequently fixed. Manufacturer guidelines confirmed that sanitizer levels should be maintained between 50-100 ppm, and the facility was unable to provide a policy for ensuring clean and sanitary plates and utensils.
Failure to Monitor Antibiotic Use
Penalty
Summary
The facility failed to implement a program that monitors antibiotic use. There is no evidence provided that the facility had a system in place to track, review, or evaluate the use of antibiotics among residents. The absence of such a program was identified during the survey, indicating that the facility did not take necessary actions to ensure appropriate antibiotic stewardship.
Failure to Support Resident Self-Determination and Choice
Penalty
Summary
The facility failed to honor the resident's right to self-determination by not promoting and facilitating resident choice. This deficiency was identified based on observations or findings that the facility did not adequately support or encourage residents to make their own choices regarding their care or daily life, as required by regulations. Specific actions or omissions by the facility staff led to a lack of support for resident autonomy and decision-making.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report documents that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Develop and Implement Comprehensive Care Plans for Residents with Contracture and Behavioral Needs
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents, one with a contracture and another exhibiting disruptive behaviors. For the first resident, who was admitted with dementia, cerebral infarction, and adult failure to thrive, an admission observation identified a right-hand contracture. However, the care plan did not address this contracture, nor did it specify therapeutic or nursing interventions or functional goals. The Minimum Data Set (MDS) also failed to document the contracture, and the MDS Coordinator was unaware of its presence due to this omission. Facility policy requires individualized care plans for contractures, including specific interventions and goals, but this was not followed in this case. For the second resident, who had schizoaffective disorder and PTSD, the care plan included general interventions for anxiety and mood swings and instructions regarding smoking, but did not address the management of escalating or disruptive behaviors. An incident was observed where the resident became agitated and verbally aggressive after being denied a nicotine lozenge until after a shower. The assigned LPN did not implement any interventions to de-escalate the situation and was unable to articulate appropriate actions to address the resident's behavior. The nursing supervisor was not notified of the incident, and staff interviews revealed a lack of clarity regarding behavioral interventions for this resident. The facility's failure to develop and implement individualized, comprehensive care plans for both residents resulted in unmet needs related to contracture management and behavioral support. Staff were either unaware of the residents' specific conditions or unable to describe or implement appropriate interventions, contrary to facility policy and expectations for interdisciplinary care planning.
Failure to Provide Care and Treatment According to Professional Standards
Penalty
Summary
The facility failed to provide care and treatment in accordance with professional standards for multiple residents, as evidenced by direct observations, record reviews, and staff interviews. For one resident with a right-hand contracture, the care plan did not address the contracture, and there was no documentation of ongoing assessment, monitoring, or specific nursing interventions for the contracture. Staff were unaware of any specific orders for the care of the contracture, and there was evidence of pain and skin issues, such as yellow crust between the contracted fingers, that were not reported or managed according to policy. The interdisciplinary approach required by facility policy was not implemented, and the contracture was not accurately reflected in the Minimum Data Set (MDS) assessments. Another resident with venous ulcers and lymphedema did not receive ace wraps to the lower extremities as ordered by the physician. Instead, the resident was observed multiple times with kerlix wraps and without the prescribed ace wraps, and the treatments were not completed before the resident was out of bed, as required. Additionally, weekly skin checks ordered by the physician were not consistently performed or documented, with only 3 out of 13 checks completed over a three-month period. Staff interviews confirmed that treatments and assessments were missed due to workload and lack of communication, and the facility's policies for implementing physician orders and documenting skin checks were not followed. A resident prescribed a Budesonide-Formoterol inhaler was found to have the inhaler at the bedside for self-administration without a completed self-administration assessment or a physician order permitting self-administration. The resident reported using the inhaler as needed without knowledge of the correct dosage or schedule, and the medication was not stored securely as required by policy. In another case, a resident with diabetes and a history of blood sugar fluctuations had an elevated blood sugar reading that was not followed by an RN assessment or proper documentation. The LPN involved could not recall if the appropriate notifications were made, and there was no evidence in the clinical record of follow-up or interventions as required by the facility's hyperglycemia management policy.
Failure to Complete and Document Weekly Skin Audits and Maintain Proper Air Mattress Settings
Penalty
Summary
The facility failed to ensure that weekly skin audits were completed and documented according to facility policy for two residents with pressure ulcers. For one resident with peripheral vascular disease, obesity, and diabetes, there was no physician's order for weekly skin checks until after surveyor inquiry, and the clinical record lacked documentation that weekly skin checks were being performed. Interviews with clinical staff confirmed that weekly skin checks were expected but not documented, and the facility's policy required these checks to be completed and recorded on shower days. The care plan for this resident also required weekly assessment of the pressure ulcer, but there was no evidence this was done. For another resident with spina bifida, hearing loss, and kidney disease, who had a stage 4 facility-acquired pressure ulcer, weekly body audits were inconsistently documented, with several weeks missing documentation over multiple months. The resident had a physician's order for a low air loss mattress set to a specific weight, but observations revealed the mattress was frequently set incorrectly, sometimes far above or below the resident's actual weight. The resident reported intermittent mattress function and communication barriers with staff, and staff interviews revealed that mattress settings were not always checked as required, with some staff signing off on checks without verifying the actual settings. Facility policies required that skin checks be completed and documented by nurses on shower days, and that air mattress settings be verified per physician's orders and checked every shift. However, documentation and staff interviews indicated these procedures were not consistently followed. There was also no documentation or care plan addressing the resident's reported habit of changing mattress settings, and staff were sometimes unaware of changes or malfunctions in the mattress equipment.
Failure to Provide Appropriate Care for Range of Motion and Mobility
Penalty
Summary
A deficiency was identified regarding the provision of care to maintain and/or improve a resident's range of motion (ROM), limited ROM, and/or mobility. The facility failed to provide appropriate care or services to prevent a decline in ROM or mobility, except in cases where such decline was due to a documented medical reason. The report indicates that the necessary interventions to maintain or improve the resident's physical abilities were not implemented or followed, resulting in a deficiency.
Failure to Provide Adequate Supervision and Implement Aspiration Precautions
Penalty
Summary
The facility failed to provide adequate supervision and implement care planned interventions for multiple residents at risk for accidents, including those with a history of substance abuse and those requiring aspiration precautions. One resident with a known history of opioid abuse and a recent drug overdose was not sufficiently monitored, resulting in two separate incidents where the resident became unresponsive and required Narcan administration. Documentation revealed that the resident was able to save and self-administer multiple doses of pain medication, and also admitted to taking a Methadone pill provided by another resident. The care plan interventions were limited to offering substance abuse group attendance and support, without specific measures to prevent medication hoarding or unauthorized drug use. Another resident with hemiplegia, dysphagia, and dementia required 1:1 supervision with meals and strict aspiration precautions, as recommended by speech therapy and hospital discharge documentation. However, observations showed that this resident was left unsupervised during meals, both in their room and in the dining room, and was able to access and consume food and liquids without staff present. Staff interviews revealed confusion about the resident's dietary orders and supervision requirements, and the care plan did not reflect the most current speech therapy recommendations. The resident was observed coughing repeatedly during meals, a sign of aspiration risk, without immediate staff intervention. A third resident with a history of traumatic brain injury and dysphagia, who had transitioned from tube feeding to oral intake, was also not provided with the required 1:1 feeding assistance. Despite physician and speech therapy orders for ground solids, nectar thick liquids, and close supervision, the resident was observed eating unsupervised, taking large bites, and consuming thin liquids not consistent with their prescribed diet. Staff were not present to monitor or assist during meals, and the resident experienced coughing episodes indicative of aspiration risk. Facility policies on aspiration precautions and therapeutic diets were not consistently followed, and staff were not always aware of or implementing the required interventions.
Deficient Continence and Catheter Care Practices
Penalty
Summary
The report identifies a deficiency related to the provision of care for residents who are continent or incontinent of bowel and bladder, as well as the management of catheter care and the prevention of urinary tract infections (UTIs). Surveyors found that appropriate care was not provided in these areas, indicating lapses in the facility's practices for maintaining continence care, catheter hygiene, and UTI prevention. Specific details regarding the actions or omissions that led to this deficiency, as well as information about the residents involved, are not provided in the report.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report notes the absence of a comprehensive infection prevention and control program but does not provide further details regarding specific actions, inactions, or events, nor does it mention any particular residents or staff involved.
Failure to Provide Required Annual In-Service Education and Competency Evaluations for Nurse Aide
Penalty
Summary
The facility failed to ensure that a nurse aide received the required 12 hours of annual in-service education and annual competency evaluations. Documentation review for the years 2023, 2024, and 2025 did not show evidence that education and competency assessments were completed for a nurse aide who began employment in December 2022. Interviews with staff revealed that the staff development and infection control nurse, who was responsible for tracking and providing education, did not have a system in place to monitor which staff members needed updated training or competencies. Education was provided as time allowed, and there was reliance on sign-in sheets and competency packets without a comprehensive tracking mechanism. Additional interviews indicated that the assistant director of nursing provided some help with in-services and competencies but was also responsible for multiple other roles, limiting her availability. The director of nursing was not aware of any issues related to in-service education and stated that staff should receive required education and competencies after hire and annually. The facility's own assessment tool specified that annual in-servicing, training, and competencies would be provided, and that the staff development nurse was responsible for maintaining these records, but this was not consistently implemented.
Failure to Notify State Authority and Implement PASARR Recommendations for Residents with Mental Health Diagnoses
Penalty
Summary
The facility failed to comply with requirements for the Pre-Admission Screening and Resident Review (PASARR) process for several residents with mental health diagnoses. For three residents, the facility did not notify the State-designated authority when new mental health diagnoses were identified. Specifically, one resident was diagnosed with major depressive disorder, recurrent, but this was not reported to the State authority as required. Another resident received a new diagnosis of schizoaffective disorder, bipolar type, which was also not communicated to the State. A third resident was diagnosed with schizoaffective disorder, but the facility did not update the State-designated authority with this information. Additionally, for a resident with a history of schizoaffective disorder, bipolar disorder, attempted self-harm, and violent behaviors, the facility did not incorporate PASARR recommendations into the care plan. The PASARR had recommended a crisis/safety plan due to the resident's history, but the care plan lacked this intervention. Interviews and record reviews confirmed that the required crisis/safety plan was not present in the clinical record, and staff were unaware of the PASARR recommendations for this resident. The facility's own PASARR policy requires notification of the State-designated authority when a resident receives a new mental health diagnosis or shows signs of mental illness not previously identified. Despite this, the responsible staff did not conduct audits to ensure compliance, and new diagnoses were not consistently reported or incorporated into care plans as required. These failures were identified through review of clinical records, facility documentation, and staff interviews.
Failure to Maintain Complete and Accessible Dental Records
Penalty
Summary
The facility failed to maintain a complete and readily accessible medical record for a resident who was reviewed for dental services. The resident, who had diagnoses including partial loss of teeth, anxiety, and obesity, was care planned to attend appointments without an escort and to receive education about appointment status. Despite the resident's report of a dental extraction performed by the facility's Consultant Dentist and subsequent complaints of pain and requests for dental records, the clinical record did not contain documentation of dental care and services provided by the consulting dental group for a significant period. The resident also reported that after the extraction, they began receiving dental care from a community dentist and had requested their dental records from the facility without follow-up. Upon surveyor inquiry, dental records from the Consultant Dentist were obtained and made accessible, revealing details of the extraction and subsequent dental complaints. Interviews with facility staff indicated a lack of awareness regarding the resident's request for dental records and confirmed that the dental records from the consulting provider were not immediately available in the resident's clinical record as required by facility policy. The facility's policy directs that all ancillary services, including dental, must be documented in the resident's medical record, specifying the type of service and outcome.
Failure to Follow Up with Oncology Office Post-Discharge
Penalty
Summary
Staff failed to follow hospital discharge instructions for a resident with a diagnosis of Stage 4 left breast cancer. The discharge summary and nursing admission note both directed that the resident's oncology office be contacted within two weeks post-discharge. However, record review did not show any evidence that this follow-up contact was made within the specified timeframe. Interviews with the oncology office RN, the Director of Nursing Services (DNS), and the Administrator confirmed that the oncology office did not receive a call from the facility, and facility leadership could not locate documentation of any such contact. The facility's own policy required the admitting RN to review discharge instructions and schedule necessary follow-up appointments in a timely manner, but this was not done for the resident in question.
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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 Southport
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Carolton Chronic & Convalescent Hospital Inc | 1.1 mi | ★★★★★ | 0 | 0 |
| Cambridge Health And Rehabilitation Center | 4.3 mi | ★★★★★ | 2 | 0 |
| Springs At 3030 Park, The | 5.1 mi | ★★★★★ | 3 | 0 |
| Mozaic Senior Life | 5.5 mi | ★★★★★ | 34 | 0 |
| Civita Care Northbridge | 5.9 mi | ★★★★★ | 22 | 0 |
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