Cycle 1
Health 2025-04-06 · Fire 2025-04-06
7 health deficiencies
Top issue: Administration (2 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Dublin, GA
Southland Healthcare And Rehab Center
1-star overall rating with 1-star inspections with $16,801 in total fines with 7 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
606 Simmons St, Dublin, GA
(478) 272-1666
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
126
Certified beds
Average residents
58
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1989-06-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.28
Registered nurse staffing · state 0.49 · national 0.68
LPN hours / resident day
1.29
Licensed practical nurse staffing · state 0.93 · national 0.87
Aide hours / resident day
1.94
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.51
All reported nurse hours · state 3.57 · national 3.89
Licensed hours
1.57
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
3.13
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.21
Weekend registered nurse coverage · state 0.33 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.23
CMS adjusted RN staffing hours
Adjusted total hours
2.84
CMS adjusted total nurse staffing hours
Case-mix index
1.69
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
13,726
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
0
Composite VBP score used to determine payment impact.
Payment multiplier
0.9803
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 21.32% · Performance 22.00% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 6.05% · Performance 9.01% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
0
Baseline 53.03% · Performance 64.18% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
0
Baseline 3.10 hours · Performance 3.15 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.98% |
10.72%
0.7 pts better
|
No Different than the National Rate · Eligible stays 36 · Observed rate 8.33% · Lower 95% interval 6.53% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 10 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 1.36 |
1.02
0.3 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 25 · Denominator 25 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 25 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 25 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 9.01% |
7.12%
1.9 pts worse
|
No Different than the National Rate · Eligible stays 28 · Observed rate 21.43% · Lower 95% interval 4.79% |
| Staff COVID-19 vaccination coverage | 1.2% |
8.2%
7 pts worse
|
Numerator 1 · Denominator 83 |
| Staff flu vaccination coverage | 21.43% |
42%
20.6 pts worse
|
Numerator 15 · Denominator 70 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 4.5 |
2.2
2.3 pts worse
|
1.9
2.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 4.5 · Observed 4.8 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.1 |
2.0
0.1 pts worse
|
1.8
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 2.2 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 87.3% |
91.2%
3.9 pts worse
|
93.4%
6.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 98.1% · Q2 100.0% · Q3 75.5% · Q4 75.9% · 4Q avg 87.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.0%
5 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.9% |
3.2%
1.3 pts better
|
3.3%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 0.0% · Q3 0.0% · Q4 3.7% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 21.1% |
9.6%
11.5 pts worse
|
11.4%
9.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 4.3% · Q3 26.5% · Q4 46.8% · 4Q avg 21.1% |
| Percentage of long-stay residents who lose too much weight | 10.3% |
5.9%
4.4 pts worse
|
5.4%
4.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.6% · Q2 8.7% · Q3 15.9% · Q4 5.9% · 4Q avg 10.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 26.0% |
20.7%
5.3 pts worse
|
19.6%
6.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.3% · Q2 23.4% · Q3 26.0% · Q4 32.7% · 4Q avg 26.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 26.1% |
21.4%
4.7 pts worse
|
16.7%
9.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.0% · Q2 17.9% · Q3 20.0% · Q4 37.5% · 4Q avg 26.1% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 20.9% |
17.9%
3 pts worse
|
16.3%
4.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 20.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 24.5% |
16.2%
8.3 pts worse
|
14.9%
9.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 15.6% · Q3 51.1% · Q4 11.8% · 4Q avg 24.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.4% |
1.1%
1.3 pts worse
|
1.0%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 1.7% · Q3 1.8% · Q4 3.4% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.0% |
2.5%
0.5 pts better
|
1.7%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 4.3% · Q4 3.8% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 10.8% |
16.1%
5.3 pts better
|
19.8%
9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.1% · Q2 4.5% · Q3 13.3% · Q4 9.4% · 4Q avg 10.8% |
| Percentage of long-stay residents with pressure ulcers | 4.2% |
6.2%
2 pts better
|
5.1%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.8% · Q2 6.4% · Q3 2.3% · Q4 2.4% · 4Q avg 4.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 59.8% |
80.4%
20.6 pts worse
|
81.7%
21.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q2 71.4% · Q3 41.7% · Q4 40.9% · 4Q avg 59.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.9% |
12.2%
4.3 pts better
|
12.0%
4.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.9% · Observed 8.6% · Expected 12.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
2.2%
2.2 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 40.0% |
78.2%
38.2 pts worse
|
79.7%
39.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 40.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 31.6% |
24.2%
7.4 pts worse
|
23.9%
7.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 31.6% · Observed 34.3% · Expected 25.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-22 · Fire 2024-02-22
10 health deficiencies
Top issue: Administration (2 deficiencies)
8 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Cycle 3
Health 2022-04-08 · Fire 2022-04-08
4 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-04-06
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2025-05-06
D · Potential for more than minimal harm
2025-04-06
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2025-05-06
D · Potential for more than minimal harm
2025-04-06
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-05-06
D · Potential for more than minimal harm
2025-04-06
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2025-05-06
D · Potential for more than minimal harm
2025-04-06
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-05-06
D · Potential for more than minimal harm
2025-04-06
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-05-06
D · Potential for more than minimal harm
2025-04-06
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-05-06
E · Potential for more than minimal harm
2024-02-22
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-04-05
E · Potential for more than minimal harm
2024-02-22
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-04-05
E · Potential for more than minimal harm
2024-02-22
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-04-05
D · Potential for more than minimal harm
2024-02-22
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2024-04-05
D · Potential for more than minimal harm
2024-02-22
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-04-05
D · Potential for more than minimal harm
2024-02-22
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-04-05
D · Potential for more than minimal harm
2024-02-22
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-04-05
D · Potential for more than minimal harm
2024-02-22
K922 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use and maintenance of medical gas equipment.
Corrected 2024-04-05
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-04-06
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2025-05-07
F · Potential for more than minimal harm
2025-04-06
F801 · Nutrition and Dietary Deficiencies
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2025-05-07
F · Potential for more than minimal harm
2025-04-06
F850 · Administration Deficiencies
Health
Hire a qualified full-time social worker in a facility with more than 120 beds.
Corrected 2025-05-07
F · Potential for more than minimal harm
2025-04-06
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2025-05-07
D · Potential for more than minimal harm
2025-04-06
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2025-05-07
D · Potential for more than minimal harm
2025-04-06
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-05-07
D · Potential for more than minimal harm
2025-04-06
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-05-07
J · Immediate jeopardy
2024-07-11
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-08-20
J · Immediate jeopardy
2024-07-11
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-08-20
J · Immediate jeopardy
2024-07-11
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2024-08-20
D · Potential for more than minimal harm
2024-07-11
F568 · Resident Rights Deficiencies
Health
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Corrected 2024-08-20
D · Potential for more than minimal harm
2024-07-11
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-08-20
D · Potential for more than minimal harm
2024-07-11
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-08-20
E · Potential for more than minimal harm
2024-05-01
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2024-05-25
D · Potential for more than minimal harm
2024-05-01
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-05-25
C · Minimal harm
2024-05-01
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2024-05-25
F · Potential for more than minimal harm
2024-02-22
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-04-05
D · Potential for more than minimal harm
2022-04-08
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2022-05-23
D · Potential for more than minimal harm
2022-04-08
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2022-05-23
D · Potential for more than minimal harm
2022-04-08
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-05-23
D · Potential for more than minimal harm
2022-04-08
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2022-05-23
Penalties and ownership
What sits behind the stars
$6,500
2024-07-11
Fine
Fine · fine $6,500
Fine
$10,301
2024-07-11
Fine
Fine · fine $10,301
Fine
$0
2024-07-11
Payment Denial
Payment Denial · denial start 2024-07-17 · 34 days
34 day denial
Ownership
Griffin, Cheryl
Operational/Managerial Control · Individual
Morrison, Brent
Corporate Officer · Individual
Peacock, Michael
Operational/Managerial Control · Individual
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#3
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