South Boston Health & Rehab Center

In the surveyor’s words

From the most serious findings on record at South Boston Health & Rehab Center, in the surveyor’s own words.

• Immediate jeopardy, patternF689Dec 4, 2025

  Based on observation, resident interview, staff interviews, clinical record review, and facility documentation review, the facility staff failed to provide adequate supervision and ensure the environment was free of accident hazards to prevent residents from exiting the facility without staff knowledge and resulted resulting in one resident (Resident #3- R3) having eloped the facility for an undetermined amount of time. The deficient practice had the potential to affect residents identified at risk for elopement residing on two of the three occupied units, which resulted in the identification of Immediate Jeopardy (IJ) and substandard quality of care. Immediate jeopardy began on 1/17/25 and when removed on 12/4/25, the scope and severity was lowered to a level two, isolated (D). […]

• Immediate jeopardy, isolatedF580Jan 28, 2022

  Based on observation, resident interview, staff interview, clinical record review and facility document review, the facility staff failed to notify the physician for a need to alter treatment for one of 36 residents in the survey sample, Resident #313. The facility failed to notify the physician that Resident #313 had not received physician ordered IV (intravenous) antibiotics for 5 days, and failed to notify the physician that the IV antibiotic medication was not available for administration, which resulted in the identification of Immediate Jeopardy (Level 4-Isolated) on 01/25/2022 at 4:25 PM. Findings include: Resident #313 was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• Immediate jeopardy, isolatedF684Jan 28, 2022

  Based on observation, resident interview, staff interview, clinical record review and facility document review, the facility staff failed to follow physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #313 was not administered IV (intravenous) antibiotic medication as ordered by the physician, which resulted in the identification of Immediate Jeopardy (Level 4-Isolated) on 01/25/2022 at 4:25 PM. The facility also failed to follow physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident # 135 and 149 were not administered the [MEDICATION(S)] vaccine as ordered by the physician. Resident #88 was administered [MEDICATION(S)] without food when the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• Actual harm, isolatedF600Oct 24, 2024

  Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to protect a resident's right to be free from sexual abuse for one resident (Resident #8 - R8) in a survey sample of 10 residents, which resulted in harm for R8. The findings included: On 10/22/24, during an entrance conference conducted at 1:45 p.m., the facility administrator was asked to provide any and all information the facility had with regards to a sexual assault. Following the entrance conference, the facility administrator stated that the incident binder with the facility's investigation and response to the sexual assault had been misplaced following a fire the facility had in August 2023. […]

• No harm, potential for more than minimal, widespreadF576May 22, 2025

  Based on resident interviews and staff interviews, the facility staff failed to ensure residents received mail timely and on weekends for three of three nursing units. The findings included: On 5/20/25 at 2:45 p.m., a group interview was conducted with fourteen residents in attendance. During the meeting, multiple residents residing on three of three nursing units, expressed concern and frustration that many times they do not receive mail on Fridays or weekends. One resident said that he doesn't get his Friday newspaper until Monday. On 5/20/25 at 3:27 p.m., an interview was conducted with the activities director (AD). The AD stated that her department is responsible for passing out resident mail. The AD said, On Fridays, the mail has been running later. […]