Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at South Boston Health & Rehab Center during CMS and state inspections, most recent first.
A resident with cognitive impairments and a history of exit-seeking behaviors was able to elope from the facility due to lapses in supervision, inconsistent use of a wander guard, and unsecured exit doors lacking alarms. Staff were unaware of the resident's absence until after the event, and several exit points remained unmonitored, placing other at-risk residents in danger.
Facility staff did not consistently deliver resident mail and newspapers in a timely manner, particularly on Fridays and weekends. Multiple residents reported delays, and staff interviews confirmed that late-arriving mail was sometimes not distributed until Monday due to unclear procedures and limited access to mailboxes.
Staff failed to properly store and label medications, including storing new insulin pens in medication carts instead of the refrigerator and not dating an opened eye drop bottle. Multiple staff confirmed knowledge of correct procedures, but these were not followed, as observed on three medication carts.
Surveyors found that staff failed to store and prepare food in a sanitary manner, including unlabeled and undated dry goods, expired milk in the refrigerator, improper sanitizer concentration in the 3-compartment sink, and wet, nested pans stored as ready to use. The dietary manager confirmed these practices were not in line with facility policy.
Facility staff did not implement a comprehensive infection surveillance system, as only residents treated with antibiotics were tracked and no proactive monitoring of infection signs or symptoms was conducted. The infection preventionist confirmed that surveillance was only done retrospectively and could not provide evidence of ongoing monitoring, despite policy requirements. The administrator and DON were made aware of these findings.
Facility staff did not consistently implement an antibiotic stewardship program, resulting in multiple residents being prescribed antibiotics without meeting McGeer criteria and incomplete documentation. In two cases, antibiotics were given without proper assessment or communication among staff, and one resident was not tested for COVID-19 despite symptoms and an active order. The facility's policy for antimicrobial stewardship was not followed, and oversight was lacking.
Facility staff did not provide or document COVID-19 vaccine education or offers to three eligible residents, as required by policy. Clinical records lacked evidence of vaccination status, education, or offers, and the infection preventionist confirmed that immunization discussions had not occurred.
A resident with advanced dementia and mental health diagnoses received increased doses and additional psychotropic medications without adequate documentation or consistent behavior monitoring. Facility staff did not initiate timely medication monitoring, failed to document non-pharmacological interventions, and did not attempt gradual dose reductions as required by policy, resulting in unnecessary use of psychotropic medications.
A resident admitted with a PICC and a suprapubic catheter did not have these devices or their care needs included in the baseline care plan. The plan only addressed toileting assistance and contact precautions, omitting specific instructions for the PICC and catheter, despite facility policy requiring such information based on admission assessments.
Staff failed to notify a physician about significant weight changes for a resident with heart failure, as required by orders, and did not administer prescribed heart and sleep medications to another resident on the evening of admission and the following morning, despite the medications being available in the backup supply. The LPN did not follow protocol to resolve a backup medication access issue, and required notifications and documentation were not completed.
Surveyors found that staff declined pharmacy recommendations for gradual dose reductions of psychotropic medications for two residents without providing required patient-specific rationales. In both cases, the attending physician either left the rationale section blank or cited only a family request, contrary to facility policy and regulatory requirements.
Facility staff did not maintain a complete clinical record for a resident with significant cognitive impairment, failing to include pharmacy recommendations and the provider's response regarding psychotropic medication management. Despite requests from surveyors, the missing documentation was not provided before the survey ended.
Facility staff did not provide required education or offer influenza and pneumococcal immunizations to two residents, as evidenced by missing documentation in clinical records and confirmation from the infection preventionist. Physician orders and facility policy required these actions, but neither education nor vaccine offers were made, and responsible family members were not contacted for consent or information.
A resident in a LTC facility was sexually assaulted by another resident, who had a history of inappropriate sexual behavior and cognitive deficits. The facility's investigation and documentation were incomplete, with missing evidence of corrective actions and inconsistent staff training on abuse prevention. Several residents were not interviewed following the incident, and the facility failed to provide sufficient documentation to confirm past non-compliance.
A facility failed to conduct a thorough investigation following a sexual assault incident involving two residents. A male resident was observed engaging in non-consensual sexual activity with a cognitively impaired female resident. Despite immediate actions taken, the facility did not maintain credible evidence of a comprehensive investigation, as required by policy. The original investigation binder was misplaced after a fire, and the recreated binder lacked sufficient documentation, leading to a deficiency finding.
The facility failed to provide functional furniture in two rooms, with broken closet door hinges and handles preventing proper closure. These issues were observed during a tour of nursing units, and facility staff acknowledged the problem, citing ongoing maintenance efforts.
Failure to Prevent Resident Elopement Due to Inadequate Supervision and Unsecured Exits
Penalty
Summary
Facility staff failed to provide adequate supervision and maintain an environment free from accident hazards, resulting in a resident with cognitive impairments eloping from the facility for an undetermined amount of time. The resident had a history of alcohol abuse, disorientation, anxiety disorder, and other cognitive symptoms. Although an elopement risk assessment was completed on admission and a wander guard was ordered and documented as in place due to exit-seeking behaviors, there were lapses in ensuring the device was consistently used and functioning. Staff interviews and documentation revealed that the resident's wander guard was removed during a leave of absence and not replaced upon return, and staff did not notice its absence during routine checks. The facility's physical environment contributed to the deficiency, as several exit doors, including those leading to a courtyard and a side parking lot, lacked alarms or locking mechanisms to alert staff when opened. The maintenance director confirmed that certain doors did not have alarms at the time of the elopement, and staff were unaware when the resident exited. Additionally, the facility had not conducted regular elopement risk assessments as required by policy, with only two assessments documented for the resident despite ongoing risk factors. Staff interviews indicated a lack of awareness regarding which residents were at risk for elopement and which had wander guards in place. The incident was further compounded by the facility's failure to identify and address all unsecured exit points, as well as inconsistent implementation of elopement prevention protocols. The resident was able to leave the facility without staff knowledge, and was later found by police outside the facility, having been exposed to cold weather conditions. The facility had identified multiple residents at risk for elopement, yet at the time of survey, unsecured exits remained, placing all at-risk residents in jeopardy.
Removal Plan
- Installed screamer door alarms to the Unit 5 living room area door and the breezeway exit door to the courtyard.
- Ensured the doors will alarm when opened to alert staff of exiting.
- Education completed with all on duty staff and off duty staff via phone calls.
- All staff unable to reach via phone will be in-serviced before they come on duty.
Failure to Ensure Timely Resident Mail Delivery
Penalty
Summary
Facility staff failed to ensure timely delivery of resident mail, including newspapers, across all three nursing units. During a group interview, multiple residents reported not receiving mail on Fridays or weekends, with one resident specifically stating that his Friday newspaper was not delivered until Monday. These concerns were echoed by several residents, indicating a pattern of delayed mail distribution affecting the entire facility. Interviews with the activities director and activity assistant revealed inconsistencies in the mail delivery process. The activities director acknowledged that late-arriving Friday mail was sometimes not distributed until Monday, especially when part-time staff were unaware of mail locations. The activity assistant further explained that access to mail was limited due to locked mailboxes and lack of keys, resulting in sporadic mail delivery and occasional delays over weekends. The facility's leadership was informed of these issues, and a request for the mail policy was made, but no additional information was provided before the survey concluded.
Improper Medication Storage and Labeling on Medication Carts
Penalty
Summary
Facility staff failed to properly label and store medications on three of five medication carts inspected. Observations revealed that new insulin pens were being stored in medication carts instead of in the refrigerator as required by the manufacturer's label instructions. Additionally, an eye drop bottle was found without an opened date, and staff confirmed that opened medications are supposed to be dated. Multiple staff interviews confirmed awareness of the correct procedures for insulin pen and eye drop storage and labeling, but these procedures were not consistently followed during the inspection. A review of facility documentation indicated that safe and secure storage of medications includes proper temperature controls. Despite this, unopened insulin pens were found outside the refrigerator, and opened medications lacked appropriate dating. The facility's administration and nursing leadership were informed of these findings during the end-of-day meeting.
Deficient Food Storage and Sanitation Practices in Kitchen
Penalty
Summary
Facility staff failed to store and prepare food in a sanitary manner in the main kitchen. During an inspection of the kitchen, surveyors observed four 8-quart containers of dry cereal not in their original packaging and lacking labels indicating the date opened or a discard date. Additionally, two partially used packages of gravy mix and an opened package of corn meal were found without date labels. Eighty-four cartons of whole milk were stored in the walk-in refrigerator with expiration dates that had passed. The 3-compartment sink was in use with pots and pans soaking, but the sanitizer concentration was measured at 100 ppm, below the facility's policy requirement of 200-400 ppm, and there was no supply of sanitizer connected to the sink pump at the time of observation. Further inspection revealed that prep and service pans identified as ready to use were stored nested and wet, including three 8-quart plastic containers and a large stainless pan with standing water on the rim. The dietary manager confirmed that all food items were supposed to be labeled with the date opened and a discard date, expired milk was to be discarded, and pans were not to be stored nested and wet. Facility policies reviewed documented requirements for proper food labeling, sanitizer concentration, and air drying of pans and dishes before stacking or nesting. These findings were confirmed in interviews with the dietary manager and reviewed with facility leadership.
Failure to Implement Infection Surveillance in Infection Control Program
Penalty
Summary
Facility staff failed to implement an effective infection prevention and control program, as evidenced by the lack of a comprehensive infection surveillance system across all three nursing units. The infection preventionist (IP) was responsible for the program but only tracked residents who were treated with antibiotics, using an Antibiotic Use Tracking Sheet. No logs were completed for the current month, and the IP confirmed that surveillance was conducted retrospectively at the end of each month, rather than proactively. Residents who developed signs or symptoms of infection were not tracked unless they were prescribed antibiotics. During interviews, the IP acknowledged that the purpose of infection surveillance is to identify symptoms and trends to prevent the spread of infection, but admitted that no proactive tracking or documentation was in place. The IP stated that she reviewed the 24-hour report daily but could not provide evidence of infection surveillance. Review of the facility's policy confirmed that the IP was responsible for conducting surveillance of staff and residents for infections, but this was not being carried out as required. The administrator and DON were informed of these findings, and no additional information was provided.
Failure to Implement and Adhere to Antibiotic Stewardship Program
Penalty
Summary
Facility staff failed to implement an effective, facility-wide antibiotic stewardship program, as evidenced by interviews, clinical record reviews, and documentation. The Infection Preventionist (IP) described a process using McGeer criteria to determine the need for antibiotics, but acknowledged that antibiotics were sometimes prescribed even when residents did not meet these criteria, often at the discretion of the physician. Tracking forms revealed that, over several months, a significant number of residents were prescribed antibiotics without meeting McGeer criteria, and documentation was often incomplete regarding whether criteria were met prior to initiating treatment. For one resident, antibiotics were prescribed for urinary symptoms, and later, duplicate antibiotic therapy was initiated without documented discussion of this with the medical provider. The resident subsequently received additional antibiotics for a positive urinalysis without documented symptoms, and the IP's event report indicated that McGeer criteria were not met. There was no evidence that the IP or other staff discussed the lack of criteria with the prescribing provider. Another resident was prescribed antibiotics for acute bronchitis based on symptoms of cough and congestion, but there were no preceding notes documenting symptoms, and the IP's event report again indicated that McGeer criteria were not met. Additionally, despite an active order to test for COVID-19 as needed, there was no documentation that the resident was tested after developing respiratory symptoms. The facility's policy required collaborative oversight of antimicrobial stewardship, but the process was not consistently followed, and there was a lack of communication among staff and providers regarding adherence to established criteria.
Failure to Educate and Offer COVID-19 Vaccine to Eligible Residents
Penalty
Summary
Facility staff failed to provide education and offer the COVID-19 vaccine to three residents selected for immunization review. Clinical record reviews for these residents showed no documentation of COVID-19 vaccination status, education regarding the benefits and risks of the vaccine, or evidence that the vaccine had been offered. The infection preventionist (IP) confirmed during interview that she had not discussed immunization with the residents and that information from the state immunization portal was not entered into the clinical record. The IP also stated that she tracks immunization status using the state portal and records it in the electronic health record, but did not document education or offers of vaccination as required by facility policy. The facility's policy requires that vaccination history, education, and consents or refusals be documented in the health record, and that the IP is responsible for ensuring this process. For the three residents in question, there was no evidence in their records of any COVID-19 vaccine education or offer, despite at least two being eligible or overdue for vaccination according to the state immunization system. The deficiency was confirmed through staff interviews, record reviews, and review of facility policy.
Failure to Prevent Unnecessary Psychotropic Medication Use
Penalty
Summary
Facility staff failed to ensure that a resident was free from unnecessary psychotropic medications and chemical restraints. The resident, who had a history of generalized anxiety disorder, major depressive disorder, and advanced dementia, was observed to be confused and unable to answer questions appropriately. Upon review, it was found that the resident's psychotropic medication doses were increased and new medications were added without adequate supporting documentation or clear evidence of behaviors warranting such changes. There was also a lack of consistent and detailed monitoring of the resident's behaviors and the effectiveness of non-pharmacological interventions. The clinical records and medication administration records revealed that behavior monitoring for psychotropic medication use was not initiated upon admission and was delayed for several months. Documentation of behaviors was sporadic and inconsistent between nursing and CNA records, with many instances lacking detail or correlation. Additionally, there was no documentation from the psychiatric nurse practitioner for the dates when medication increases were ordered, and progress notes often did not align with the reported behaviors or medication changes. The facility's own policy required initiation of behavior monitoring and documentation of non-medication interventions, which was not followed. Interviews with the medical director and psychiatric nurse practitioner indicated that decisions regarding medication increases were based on staff reports of behaviors, but these reports were not substantiated in the resident's clinical record. There was also no evidence that gradual dose reductions were attempted or considered, as required by facility policy. The lack of supporting documentation, inadequate monitoring, and failure to attempt dose reductions led to the resident receiving unnecessary psychotropic medications.
Failure to Include PICC and Suprapubic Catheter Care in Baseline Care Plan
Penalty
Summary
Facility staff failed to include essential initial care needs for a resident who was admitted with a peripherally inserted central catheter (PICC) and a suprapubic urinary catheter. The resident's baseline care plan, created within 48 hours of admission, did not mention the presence of the PICC or the suprapubic catheter, nor did it address specific care needs related to these devices. The baseline care plan only referenced toileting assistance for bowel/bladder needs and contact precautions for infection control, omitting any mention of the urinary catheter and PICC care requirements. Interviews with the registered nurse unit manager and the director of nursing confirmed that the resident was admitted with both a PICC and a suprapubic catheter, and that these were not included in the baseline care plan. The facility's policy requires that the baseline care plan include the minimum health care information necessary to care for a resident, based on admission orders and assessments. The omission was identified during a review of the clinical record, staff interviews, and facility documentation, with no additional information provided by facility leadership prior to the end of the survey.
Failure to Follow Physician Orders for Weight Monitoring and Medication Administration
Penalty
Summary
Facility staff failed to follow physician orders for two residents, resulting in deficiencies related to treatment and medication administration. For one resident with diagnoses including heart failure, hypertension, acute kidney failure, and acute respiratory failure, there was an active physician order requiring daily weights and notification to the cardiologist if the resident's weight increased by 3 pounds in one day or 5 pounds in one week. The resident's records showed weight gains above these parameters on multiple dates, but there was no documentation that the physician was notified as required. Interviews with nursing staff and review of progress notes confirmed the lack of notification. In a separate incident, another resident with multiple diagnoses, including atrial fibrillation, COPD, lung cancer, congestive heart failure, and hypertension, did not receive prescribed heart and sleep medications on the evening of admission and the following morning. The medication administration record confirmed that trazodone, Eliquis, and midodrine were not administered as ordered, despite these medications being available in the backup supply. The LPN on duty reported being unable to access the medications due to a malfunctioning Omnicell unit but did not attempt to contact the pharmacy, service number, or supervisor for assistance, as required by facility protocol. Both deficiencies were confirmed through staff interviews, clinical record reviews, and review of facility protocols. No documentation or evidence was provided to show that the required actions were taken in either case prior to the survey exit.
Failure to Document Rationale for Declining Pharmacy Recommendations for Psychotropic Medication Dose Reductions
Penalty
Summary
The facility failed to ensure that a licensed pharmacist's recommendations for gradual dose reductions (GDR) of psychotropic medications were properly addressed and documented for two residents. In the first case, a resident with significant cognitive impairment and multiple psychotropic medications had pharmacy recommendations for GDRs, but the attending physician declined these recommendations without providing a patient-specific rationale, as required by facility policy. The physician simply checked a box indicating that a GDR was clinically contraindicated but left the rationale section blank. Additionally, the facility was unable to provide documentation of a previous pharmacy recommendation for this resident, despite requests from surveyors. In the second case, another resident with dementia, major depression, and mood disorder was prescribed Seroquel for mood disorder. The pharmacy recommended GDRs on two occasions, but the physician declined these recommendations. On one occasion, the only rationale provided was a family request, and on the other, no rationale was documented at all. Facility policy and the State Operations Manual require that a specific explanation be provided when recommendations are rejected, but this was not done. Both cases demonstrate that the facility did not follow its own policies and procedures regarding medication regimen reviews and the documentation of physician decisions related to pharmacy recommendations. The lack of patient-specific rationales for declining GDRs and the absence of required documentation were directly observed and confirmed through staff interviews, clinical record reviews, and facility documentation.
Incomplete Clinical Record for Pharmacy Recommendations
Penalty
Summary
Facility staff failed to maintain a complete clinical record for one resident, specifically omitting documentation of pharmacy recommendations and the provider's response. The resident in question had significant cognitive impairments and was unable to answer questions appropriately during the surveyor's visit. Clinical record review showed that the resident was on multiple psychotropic medications, with changes to dosages and the addition of new medications over time. On a specific date, the pharmacist made recommendations regarding the resident's medications, but this recommendation and any response from the provider were not found in the clinical record. Despite requests from the surveyor to the facility administrator and follow-up by the DON and corporate staff, the requested documentation was not provided before the survey concluded.
Failure to Educate and Offer Flu and Pneumococcal Vaccines to Residents
Penalty
Summary
Facility staff failed to provide education and offer influenza and pneumococcal immunizations to two residents, as required by physician orders and facility policy. Clinical record reviews for both residents showed no documentation of immunization status, education, or offers of the vaccines in the preventative health care tab. Physician orders for both residents specified that high dose flu vaccines should be offered annually and pneumococcal vaccines administered unless contraindicated, but there was no evidence these actions were taken. The infection preventionist (IP) confirmed during interviews that she had not provided education or offered the pneumonia vaccine to one resident, who was past due for both pneumococcal and influenza immunizations according to the state immunization information system. For the second resident, the IP stated she was waiting for the resident's confusion to clear before asking about immunizations, despite the family being responsible for care decisions. The family had not been contacted regarding immunization education or consent, even though they were involved in other care decisions. Facility policy required documentation of historical vaccinations, tracking of immunizations, and ensuring timely administration and documentation of consents or refusals. The CDC's Adult Immunization Standards emphasize the importance of assessing immunization status, providing education, making clear recommendations, and documenting vaccines. The facility failed to meet these standards for the two residents reviewed.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility staff failed to protect a resident's right to be free from sexual abuse, resulting in harm to a resident. On December 17, 2022, a registered nurse observed a male resident engaging in non-consensual sexual activity with a female resident who was cognitively impaired and unable to give consent. The male resident, who had a history of inappropriate sexual behavior and cognitive deficits, was found on top of the female resident in her bed. The nurse intervened, and the male resident was subsequently taken into police custody. The facility's response to the incident was inadequate, as the investigation and documentation were incomplete. The facility administrator reported that the incident binder containing the investigation and response was misplaced following a fire in August 2023. The facility attempted to recreate the binder, but it lacked sufficient evidence to verify that necessary corrections were made. Interviews with staff and reviews of clinical records revealed that several residents who were cognitively intact were not interviewed following the incident to determine if they had been victims of abuse. Additionally, the facility's documentation of staff training on abuse prevention and response was inconsistent. Some staff members had not received adequate training, and there was no credible evidence of resident interviews, skin assessments, or audits conducted in response to the abuse incident. The facility's failure to provide sufficient documentation and evidence of corrective actions led to the survey team's inability to confirm past non-compliance.
Incomplete Investigation of Sexual Assault Incident
Penalty
Summary
The facility staff failed to conduct a complete and thorough investigation following an incident of sexual assault involving two residents. The incident involved a male resident, identified as R9, who was observed by a registered nurse (RN #1) engaging in non-consensual sexual activity with a female resident, identified as R8, who was cognitively impaired and unable to give consent. The nurse intervened, and the male resident was subsequently taken into police custody. Despite the immediate actions taken to address the incident, the facility did not maintain credible evidence of a comprehensive investigation as required by their policy. The facility's documentation was incomplete, lacking witness statements, staff or resident interviews, and resident assessments. The facility administrator claimed that the original investigation binder was misplaced following a fire in August 2023, and the facility was unable to locate it after reopening. The recreated binder provided to the surveyors did not contain sufficient evidence to demonstrate that a thorough investigation had been conducted. The facility's policy mandates that an investigation be completed within five working days, including interviews with all involved parties and documentation of the findings, which was not adequately demonstrated in the provided materials. The facility's failure to maintain proper documentation and conduct a thorough investigation was highlighted during the survey. The administrator acknowledged the incident and the subsequent actions taken, such as notifying the police and transferring the victim to the hospital. However, without credible evidence of a complete investigation, the survey team could not accept the facility's claim of past non-compliance. The lack of documentation and investigation protocol adherence resulted in a deficiency finding by the surveyors.
Deficiency in Functional Furniture for Residents
Penalty
Summary
The facility failed to provide functional furniture appropriate for resident use in two rooms, specifically rooms 208 and 323, on two of the four units. During a tour and observation of nursing units 2 and 3, it was noted that the closet door in one room had a broken hinge and handle, preventing it from closing properly. Similarly, the closet door in another room was observed to be ajar due to a broken hinge, which also prevented it from being closed. These deficiencies were reported to the facility staff, including the administrator, director of nursing, and the regional director of clinical services, who acknowledged the issue and mentioned ongoing efforts to replace door handles and hinges as part of building maintenance.
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Illustrative
What surveyors actually found near you
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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.
Illustrative
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Illustrative
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Nursing homes near South Boston
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Berry Hill Nursing Home | 2.5 mi | — | 0 | 0 |
| Clarksville Health & Rehab Center | 20.8 mi | — | 0 | 0 |
| Heritage Hall - Brookneal | 21.4 mi | — | 0 | 0 |
| Roxboro Healthcare & Rehab Center | 22.7 mi | — | 3 | 0 |
| Person Memorial Hospital | 22.9 mi | — | 5 | 1 |
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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 August 2026) and official state health department websites.