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 July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Southland Healthcare And Rehab Center during CMS and state inspections, most recent first.
Missing Privacy Curtains During Shower Care: A resident with little to no cognitive impairment and needing assistance with bathing was observed naked in a shower chair while two CNAs provided shower care in a shower room where all shower stalls and the toilet area lacked privacy curtains or barriers. The resident said the curtains had been missing for two months or more and felt uncomfortable and deprived of privacy, while staff and the Administrator confirmed the curtains were missing and had not been replaced after being removed for cleaning.
Unauthorized medications were found at a resident’s bedside, including prescription topical cream and nystatin cream. The resident had severe cognitive impairment, required substantial/maximal ADL assistance, and had diagnoses including bipolar disorder, COPD, chronic systolic HF, and suicidal ideations. The EHR showed no active orders for the creams, no order authorizing self-administration, and no completed self-administration assessment; the DON confirmed the medications were present at the bedside without authorization.
Failure to Provide Written Notice of Treatment Rights and Advance Directives: The facility did not ensure that two residents were given written information about their right to accept or refuse medical and surgical treatment and to formulate an advance directive. One resident had moderate cognitive impairment and the other had intact cognition; both did not recall receiving the information. The Admissions Nurse stated she did not provide the written notice, and the CNO confirmed the residents were not given it.
Unsafe and Unhomelike Environment Conditions: Surveyors observed multiple environmental deficiencies, including misfitted and torn ceiling tiles, chipped and missing paint on resident furniture, a bathroom floor that was black and scuffed, and a shower room with damaged, loose, cracked, and bulging baseboard tiles caused by water infiltration. Broken tile pieces were on the floor in front of the toilet and shower bed, and the Administrator and Maintenance Director confirmed the conditions were not conducive to a homelike environment.
The facility conducted blood glucose and urinalysis testing for multiple residents without a current CMS CLIA Certificate of Waiver, as the certificate had expired and was not renewed during a company transition. Staff confirmed the lapse, and the deficiency was identified through interviews and record review.
The facility did not employ a qualified RD for approximately two months, with staff and leadership unaware of the vacancy and unable to provide documentation or confirm interim coverage. This left 56 residents at risk of unmet nutritional needs due to the absence of required oversight in the food and nutrition service.
A facility licensed for 126 beds did not have a qualified Social Service Worker employed full-time to provide necessary services. Personnel files and staff interviews confirmed that the position had been vacant since the previous Social Services Director left, with no one providing consultation or oversight for residents during this period.
The facility did not provide or document the required in-service training for its CNAs, as mandated by its own policy. The DON was responsible for providing education, and the HRD for submitting in-service hours to the State Agency, but the 2024 records were missing and had not been submitted, potentially affecting 56 residents.
Staff did not ensure that a resident's oxygen concentrator was kept clean and that respiratory masks, including nebulizer and CPAP masks, were stored in protective bags when not in use. The resident, who was dependent on staff for mobility and respiratory care, had her equipment left uncovered and exposed to the environment, and staff interviews confirmed lapses in proper cleaning and storage procedures.
A resident with multiple respiratory conditions was observed receiving oxygen at a higher flow rate than ordered by the physician. Despite facility policy requiring staff to set the oxygen flow meter according to the physician's order, staff provided oxygen at 4 LPM instead of the ordered 3 LPM. Staff interviews confirmed the discrepancy, and the unit manager acknowledged the expectation to follow physician orders.
A resident experienced respiratory distress with symptoms like shortness of breath and low oxygen saturation, but the facility failed to notify the physician or Administrator of the condition or the resident's subsequent death. Staff interviews revealed a lack of communication and documentation, leading to an Immediate Jeopardy situation due to the potential for serious harm.
A resident in a LTC facility experienced respiratory distress and was neglected by staff, leading to his death. Despite showing signs of distress, such as sweating and holding his chest, the staff did not notify a physician or send him to the hospital. The RN Supervisor and LPN CC assessed the resident but focused on administrative tasks, dismissing the severity of the situation due to the resident's DNR status. Vital signs and assessments were not documented, and the facility's staff failed to follow the policy on abuse, neglect, and exploitation prevention.
A resident in respiratory distress was neglected by facility staff, resulting in their death. Despite the resident's ability to communicate their needs, the staff failed to notify the physician of the resident's significant change in condition, including shortness of breath and low oxygen saturation. The DON and Administrator were unaware of the circumstances until after the incident, and the physician stated the resident should have been sent to the ER immediately.
A facility failed to manage a resident's burial account funds properly, using them to pay care costs without authorization. The Business Office Manager transferred funds from the trust account to the burial account, unaware that burial funds were restricted to burial expenses. Checks from the burial account were issued, including one payable to the facility, indicating misuse of funds.
The facility failed to document vital signs as ordered for two residents, potentially affecting their health. One resident with hypertension and diabetes had no vital signs recorded in May and incomplete records in June. Another resident with hypertension and depression also lacked vital sign documentation in May. The DON stated that staff should document vital signs during the shift and enter any missing documentation within 24 hours.
A facility failed to maintain complete and accurate clinical documentation for a resident, resulting in a deficiency. The resident exhibited symptoms such as sweating, shaking, and chest pain, and was assessed by two nurses. However, there was no documentation of these observations or vital signs in the resident's medical records, contrary to the facility's policy. The Director of Nursing confirmed that documentation should be completed within 24 hours, which was not done.
Missing Privacy Curtains During Shower Care
Penalty
Summary
The facility failed to ensure privacy during shower care for one resident who was admitted with diagnoses including discitis of the unspecified lumbar region, polyneuropathy, lumbar spinal fusion, and lumbar spinal stenosis without neurogenic claudication. The resident’s Quarterly MDS documented a BIMS score of 15, indicating little to no cognitive impairment, and Section GG showed the resident required a walker for ambulation, supervision or touching assistance for bathing and showering, and touching assistance for most ADLs. During observation of the Hall 1 Shower Room, two CNAs were providing shower care to the resident while she was naked and seated in a shower chair inside a shower stall that had no privacy curtain. Continued observation showed that none of the shower stalls had privacy curtains in place, and the toilet area also lacked privacy curtains or barriers. The resident stated the curtains had been missing for two months or more and said the lack of curtains and the possibility of being exposed to anyone entering the shower room made her feel uncomfortable and deprived of personal privacy. The CNAs confirmed that all shower stall and toilet area curtains were missing and said the curtains had been removed for cleaning weeks earlier and had not been replaced. The Administrator and Environmental Supervisor also confirmed the missing curtains and acknowledged that providing shower care without privacy due to the missing curtains was a dignity issue.
Unauthorized Medications at Bedside
Penalty
Summary
The facility failed to ensure that one sampled resident, R40, did not have unauthorized and unsecured medications at the bedside. R40’s EHR showed diagnoses including bipolar disorder, COPD, chronic systolic heart failure, and suicidal ideations. The quarterly MDS assessment documented a BIMS score of 6, indicating severe cognitive impairment, and Section GG showed impairment on one side to the upper and lower extremities with substantial/maximal assistance needed for ADLs. The physician’s orders did not include any active orders for eye drops or creams, and there were no orders authorizing R40 to self-administer medications. The EHR also showed no evidence that a self-administration of medications assessment had been completed. During observation, prescription topical cream and nystatin cream were found sitting on the bedside table in R40’s room. The DON confirmed that the creams were on top of the bedside table, that R40 had not been assessed to self-administer medications, and that there was no order in place for R40 to self-administer medications.
Failure to Provide Written Notice of Treatment Rights and Advance Directives
Penalty
Summary
The facility failed to ensure that residents or their representatives were informed in writing of the right to accept or refuse medical and surgical treatment and the right to formulate an advance directive for two sampled residents. Review of the facility's Advance Directives policy stated that the resident or representative is to be provided written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if chosen. However, the medical records for two residents showed no documented evidence or signed acknowledgment that this information had been provided. One resident was admitted with diagnoses including other intervertebral disc degeneration in the lumbar region with lower extremity pain only and had a quarterly MDS showing moderate cognitive impairment with a BIMS score of 8. During interview, the resident did not recall receiving written information about advance directives or the right to accept or deny treatment. The second resident was admitted with type 1 diabetes mellitus with diabetic nephropathy and had an intact cognition score with a BIMS of 15; this resident also did not recall receiving written information about advance directives or the right to refuse or accept medical or surgical treatment. The Admissions Nurse stated she completed the admission packet but did not provide the written information and was not aware she was supposed to do so, and the CNO stated she had never heard of giving written information on these rights before later confirming the two residents were not given the written information.
Unsafe and Unhomelike Environment Conditions
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment on two of five halls, as observed by surveyors and confirmed by the Administrator and Maintenance Director. In resident rooms, surveyors observed ceiling tiles that were not fitted correctly with visible gaps, torn or ripped ceiling tiles, a chipped headboard with missing paint, a stand-up closet with a cabinet door that did not fully close, dresser drawers with chipped and missing paint, and a bathroom floor that was black, discolored, scuffed, and in need of repair. In other rooms, surveyors observed chipped paint on closet cabinet doors and dresser drawers, including a two-foot paint chip near a handle and several areas of chipped paint on the top drawer. In the shower room on Hall One, surveyors observed badly damaged, loose, cracked, and uneven bulging baseboard tiles along the walls in two areas, caused by water infiltration. Large and small pieces of broken baseboard tile were lying on the floor, including in front of the toilet and in front of the shower bed, and the flooring was coated with dark, thick brown substances and debris within the floor grooves. The Administrator stated the problem had been identified earlier, was caused by water infiltration, and that staff continued to use the shower area, though he was unsure whether staff were using the toilet area. He also stated there was no PIP or QAPI plan in place and that the issue was on the facility's to-do list.
Expired CLIA Certificate of Waiver for Laboratory Testing
Penalty
Summary
The facility failed to maintain a current Centers for Medicare & Medicaid Services (CMS) CLIA Certificate of Waiver, as required by the Clinical Laboratory Improvement Amendments of 1988 (CLIA). Review of facility records showed that the CLIA waiver had expired, and the facility continued to conduct blood glucose checks for 15 residents daily and urinalysis testing as ordered by physicians. Staff interviews confirmed that the certificate had expired and was not renewed due to a transition between companies, and a renewal request had been denied. The deficiency was identified through staff interviews, record review, and verification against CDC and CLIA regulations.
Failure to Employ a Qualified Registered Dietitian
Penalty
Summary
The facility failed to employ a qualified Registered Dietitian (RD) to oversee the food and nutrition service, as required. During the survey, staff interviews and document reviews revealed that the facility had been without an RD for approximately two months. The Dietary Manager confirmed the absence of an RD and stated that she communicated with the MDS nurse regarding residents' diets. However, the MDS Coordinator reported that she did not communicate with the Dietary Manager about residents' diets. The facility was unable to provide a job description for the RD position, and the only documentation available described the Dietary Manager's role as assisting the Dietitian. Further interviews indicated confusion among facility leadership regarding the RD's status. The Administrator initially believed the former RD was still offering support until a replacement was hired, but the former RD clarified that her last day was over two months prior and she was no longer affiliated with the facility. The Administrator was unaware that there was no RD currently serving the facility and could not confirm any interim coverage. The Building Manager, involved in a change of company ownership, was also unaware that the RD's contract had ended. This lack of a qualified RD had the potential to affect the nutritional needs and quality of life for the 56 residents in the facility.
Failure to Employ Qualified Full-Time Social Worker
Penalty
Summary
The facility, licensed for 126 beds, failed to employ a qualified Social Service Worker on a full-time basis to provide services to its residents. Review of personnel files confirmed that there was no Social Services Worker employed at the time of the survey, and no evidence of consultation or oversight for the resident population was found. Staff interviews revealed that the previous Social Services Director's last day was February 28, 2025, and since then, no one had filled the role. The Human Resources Director and Administrator both acknowledged the absence of a qualified Social Service Worker, while the Building Manager was unaware of the vacancy.
Failure to Provide Required CNA In-Service Training and Documentation
Penalty
Summary
The facility failed to provide the required in-service training for its Certified Nursing Assistants (CNAs), as evidenced by the absence of documentation for the mandated continuing education programs. The facility's own policy required CNAs to attend a minimum of 12 continuing education programs to maintain certification. Interviews with the Human Resource Director (HRD) and Administrator revealed that the Director of Nursing (DON) was responsible for providing the education, while the HRD was responsible for submitting in-service hours to the State Agency. However, the DON had not submitted the 2024 in-service hours, and the HRD confirmed that the State Agency had not received them. Additionally, the Administrator was unable to provide evidence of the required in-service training for the CNAs for 2024, and the education records could not be found. This deficiency had the potential to adversely affect the 56 residents residing in the facility.
Failure to Maintain Sanitary Respiratory Equipment
Penalty
Summary
Staff failed to maintain respiratory equipment in a sanitary manner for a resident with multiple respiratory diagnoses, including respiratory failure, COPD, emphysema, and heart failure. The resident was dependent on staff for mobility and unable to reposition herself or reach her nightstand. Observations revealed that the oxygen concentrator used by the resident was covered with debris on multiple occasions. Additionally, the nebulizer and CPAP masks were found lying uncovered and exposed to the environment on the resident's nightstand, rather than being stored in protective bags as required. Interviews with the resident and staff confirmed that the resident could not independently manage her respiratory equipment and that nurses were responsible for placing and removing the masks. Staff acknowledged that the masks had been left uncovered and that there was confusion regarding responsibility for cleaning the oxygen concentrator and bagging the masks. The unit manager confirmed the findings after reviewing photographic evidence and stated that staff were expected to keep the equipment clean and properly stored. The facility was unable to provide a policy related to oxygen equipment maintenance and storage when requested.
Failure to Follow Physician Order for Oxygen Therapy
Penalty
Summary
A deficiency occurred when staff failed to follow a physician's order for oxygen therapy for a resident with multiple respiratory diagnoses, including acute and chronic respiratory failure, asthma, COPD, and pneumonia. The facility's policy required staff to check the clinical record for the physician's order and set the oxygen flow meter to the ordered rate. However, observations on multiple occasions showed that the resident was receiving oxygen at 4 liters per minute (LPM) via nasal cannula, while the physician's order specified 3 LPM as needed. Interviews with staff confirmed that the oxygen was set higher than ordered, and the unit manager stated that staff are expected to follow physician orders and ensure the correct oxygen flow rate. The resident was cognitively intact, as indicated by a BIMS score of 15, and was documented as receiving oxygen therapy in the medical record. The failure to adhere to the ordered oxygen flow rate constituted a deviation from both physician orders and facility policy.
Failure to Notify Physician of Resident's Respiratory Distress and Death
Penalty
Summary
The facility failed to notify the physician of a significant change in condition for a resident experiencing respiratory distress, which included symptoms such as shortness of breath, tripoding, and a decreased oxygen saturation of 83 percent. Despite these symptoms, there was no evidence in the Electronic Medical Record (EMR) that the physician or the Administrator was informed of the resident's condition or subsequent death. Interviews with staff revealed that the Licensed Practical Nurse (LPN) documented a call to the Director of Nursing (DON) and the Administrator, but there was no evidence of notification to the Administrator. The Registered Nurse (RN) Supervisor and LPN involved did not contact the physician, believing the resident was stable, and the physician was unaware of the resident's death until informed by the surveyor. The deficiency was identified as an Immediate Jeopardy situation, indicating the facility's noncompliance had the potential to cause serious harm or death. The facility's Administrator, DON, and Corporate President of Compliance and Regulatory Services were informed of the Immediate Jeopardy, but an acceptable Immediate Jeopardy Removal Plan had not been received by the time of the survey exit. Interviews with the DON and Administrator revealed a lack of awareness regarding the resident's death circumstances, and the Administrator only became aware after the surveyor's interviews, prompting an Ad Hoc meeting to address notification and documentation procedures.
Neglect Leads to Resident's Death Due to Inadequate Response to Respiratory Distress
Penalty
Summary
The facility failed to protect a resident's right to be free from neglect, resulting in a significant change in the resident's condition and eventual death. The resident, identified as R1, experienced respiratory distress and required further medical treatment. Despite showing signs of distress, such as sweating, shaking, and holding his chest, the staff did not adequately respond to his needs. The resident was placed back in bed by staff without proper medical intervention, and he expired less than four hours later. Interviews with staff revealed that there was a lack of communication and documentation regarding R1's condition. Certified Nursing Aides (CNAs) reported that R1 was asking for help and was in distress, but the assigned nurse was unavailable. The RN Supervisor and LPN CC assessed R1 but did not take appropriate action, such as notifying a physician or sending the resident to the hospital. Instead, they focused on administrative tasks and dismissed the severity of the situation due to R1's Do Not Resuscitate (DNR) status. Further investigation showed that vital signs and assessments were not documented in the Electronic Medical Record (EMR), and the facility's staff failed to follow the policy on abuse, neglect, and exploitation prevention. The physician and Director of Nursing (DON) were not informed of the resident's critical condition, and the facility's Administrator was unaware of the circumstances until the surveyor's investigation. This lack of communication and failure to provide necessary care contributed to the resident's death.
Neglect of Resident in Respiratory Distress
Penalty
Summary
The facility administration failed to ensure that a resident, identified as R1, was free from neglect while experiencing respiratory distress. Despite R1's cognitive ability to verbalize his needs, he was left unattended and in need of further medical treatment, ultimately resulting in his death. The staff did not notify the physician of R1's significant change in condition, which included shortness of breath, tripoding, and a decreased oxygen saturation level of 83 percent. This lack of action and oversight by the facility's administration, including the Administrator and Director of Nursing (DON), contributed to the neglect of R1. Interviews with the facility's staff revealed a lack of awareness and communication regarding R1's condition and subsequent death. The DON was unaware of the circumstances surrounding R1's death and was misinformed that R1 had passed in his sleep. The Administrator also did not know about the situation until the surveyor began interviewing the staff. The physician, identified as Physician QQ, stated that R1 should have been sent to the emergency room immediately and expressed that there was no excuse for the lack of care provided, emphasizing that a Do Not Resuscitate (DNR) status does not mean withholding necessary medical care.
Improper Use of Resident Burial Account Funds
Penalty
Summary
The facility failed to properly manage a resident's burial account funds, which were inappropriately used to pay for care costs. The Resident Fund Management Service document indicated that the resident's trust fund account was meant for care cost payments with a monthly allowance, while the burial account was designated solely for burial expenses. However, a significant amount of money was transferred from the trust fund to the burial account, and subsequently, funds from the burial account were used to settle an outstanding care cost balance without proper authorization from the responsible party. The Business Office Manager admitted to transferring funds from the trust account to the burial account but was unaware that burial funds could not be used for care costs. The review of financial documents showed that checks were issued from the burial account, one of which was made payable to the facility, indicating the use of burial funds for care costs. The resident in question had passed away, and there was no evidence of authorization for the transfer of funds from the burial account to cover care costs, highlighting a deficiency in the facility's management of resident funds.
Failure to Document Vital Signs as Ordered
Penalty
Summary
The facility failed to ensure that vital signs were obtained as ordered for two residents, R1 and R3, which had the potential to negatively affect their physical health and well-being. R1 was admitted with diagnoses including hypertension and type 2 diabetes mellitus. An order was placed for R1 to have vital signs taken every Monday during the day shift starting from May 8, 2024. However, no vital signs were documented in May 2024, and only two entries were recorded in June 2024, with missing documentation for June 10 and June 17, 2024. Similarly, R3, who was admitted with diagnoses including hypertension and major depressive disorder, had an order for vital signs to be taken every Monday during the day shift starting from January 15, 2024. The records showed no evidence of vital signs being obtained in May 2024. The Director of Nursing confirmed that staff should document vital signs during the shift and that any missing documentation should be entered within 24 hours.
Incomplete Clinical Documentation for Resident
Penalty
Summary
The facility failed to ensure complete and accurate clinical documentation for a resident, identified as R1, which is a violation of their policy titled Clinical Documentation. The policy mandates that nursing staff document the provision of care according to nursing standards and regulatory requirements, ensuring that all interdisciplinary team members have access to appropriate information regarding treatment interventions and responses. However, a review of R1's medical records revealed a lack of documentation of vital signs and events leading up to R1's death, with the last recorded vital signs dated several days prior to the incident. Interviews with staff members highlighted further discrepancies in documentation. A Certified Nursing Assistant (CNA) reported that on the evening of the incident, R1 exhibited symptoms such as sweating, shaking, and chest pain, and was assessed by two nurses who checked his pulse, oxygenation, and vital signs, and administered oxygen. Despite these critical observations, there was no corresponding documentation in R1's medical records. The Director of Nursing confirmed that staff are expected to document during their shift and complete any missing documentation within 24 hours, which was not adhered to in this case.
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Illustrative
What surveyors actually found near you
We read the 29 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Dublin
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Dublin Trails Of Journey Llc | 0.4 mi | ★★★★★ | 0 | 0 |
| Dublinair Health & Rehab | 2.9 mi | ★★★★★ | 11 | 0 |
| Wrightsville Manor Health And Rehab | 18.1 mi | ★★★★★ | 10 | 0 |
| Scott Health & Rehabilitation | 19.1 mi | ★★★★★ | 5 | 0 |
| Treutlen County Health And Rehabilitation | 21.4 mi | ★★★★★ | 3 | 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.