Cycle 1
Health 2025-12-17 · Fire 2024-09-19
5 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Roxboro, NC
Person Memorial Hospital
2-star overall rating with 2-star inspections with $73,796 in total fines with 5 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
615 Ridge Road, Roxboro, NC
(336) 503-5707
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
56
Certified beds
Average residents
47
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Lifepoint Health
Operator or chain grouping
Approved since
1967-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.63
Registered nurse staffing
LPN hours / resident day
0.73
Licensed practical nurse staffing
Aide hours / resident day
1.89
Nurse aide staffing
Weekend hours
2.85
Weekend nurse staffing
RN turnover
82%
Annual RN turnover
Total nurse turnover
56%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.8 |
1.8
1 pts worse
|
1.9
0.9 pts worse
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.6 |
1.8
1.8 pts worse
|
1.8
1.8 pts worse
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 94.4% |
91.5%
2.9 pts better
|
93.4%
1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 92.7% |
94.1%
1.4 pts worse
|
95.5%
2.8 pts worse
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.5% |
3.6%
1.1 pts better
|
3.3%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 2.4% |
4.8%
2.4 pts better
|
11.4%
9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 7.3% |
7.2%
0.1 pts worse
|
5.4%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 9.0% |
21.6%
12.6 pts better
|
19.6%
10.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 17.7% |
15.0%
2.7 pts worse
|
16.7%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose ability to walk independently worsened | 27.3% |
21.5%
5.8 pts worse
|
16.3%
11 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 17.2% |
16.8%
0.4 pts worse
|
14.9%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.3% |
0.9%
0.4 pts worse
|
1.0%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 4.5% |
2.6%
1.9 pts worse
|
1.7%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 11.3% |
21.2%
9.9 pts better
|
19.8%
8.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 1.8% |
6.0%
4.2 pts better
|
5.1%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 77.9% |
79.9%
2 pts worse
|
81.7%
3.8 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 14.1% |
13.2%
0.9 pts worse
|
12.0%
2.1 pts worse
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.8% |
1.5%
2.3 pts worse
|
1.6%
2.2 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 85.2% |
78.1%
7.1 pts better
|
79.7%
5.5 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.0% |
22.9%
0.9 pts better
|
23.9%
1.9 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-09-19 · Fire 2023-08-23
7 health deficiencies
Top issue: Nursing and Physician Services (2 deficiencies)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2023-08-23 · Fire 2022-01-07
10 health deficiencies
Top issue: Nursing and Physician Services (3 deficiencies)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-09-19
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-12-20
F · Potential for more than minimal harm
2023-08-23
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-10-08
F · Potential for more than minimal harm
2023-08-23
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2023-11-05
F · Potential for more than minimal harm
2023-08-23
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-11-05
D · Potential for more than minimal harm
2023-08-23
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-11-05
D · Potential for more than minimal harm
2023-08-23
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-11-05
D · Potential for more than minimal harm
2022-01-07
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-03-25
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-12-17
F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2026-01-14
E · Potential for more than minimal harm
2025-12-17
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2026-01-14
E · Potential for more than minimal harm
2025-12-17
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 2026-01-14
C · Minimal harm
2025-12-17
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2026-01-14
J · Immediate jeopardy
2025-11-25
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-11-26
F · Potential for more than minimal harm
2024-09-19
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 2024-10-17
F · Potential for more than minimal harm
2024-09-19
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-10-17
E · Potential for more than minimal harm
2024-09-19
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 2024-10-17
D · Potential for more than minimal harm
2024-09-19
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 2024-10-17
D · Potential for more than minimal harm
2024-09-19
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 2024-10-17
D · Potential for more than minimal harm
2024-09-19
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2024-10-17
C · Minimal harm
2024-09-19
F577 · Resident Rights Deficiencies
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2024-10-17
E · Potential for more than minimal harm
2023-08-23
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2023-10-08
E · Potential for more than minimal harm
2023-08-23
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2023-10-08
E · Potential for more than minimal harm
2023-08-23
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 2023-10-08
E · Potential for more than minimal harm
2023-08-23
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 2023-10-08
E · Potential for more than minimal harm
2023-08-23
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-10-08
D · Potential for more than minimal harm
2023-08-23
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2023-10-08
D · Potential for more than minimal harm
2023-08-23
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 2023-10-08
D · Potential for more than minimal harm
2023-08-23
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2023-10-08
B · Minimal harm
2023-08-23
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2023-10-08
B · Minimal harm
2023-08-23
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2023-10-08
Penalties and ownership
What sits behind the stars
$24,850
2025-11-25
Fine
Fine · fine $24,850
Fine
$0
2025-11-25
Payment Denial
Payment Denial · denial start 2025-11-25 · 1 days
1 day denial
$4,545
2023-10-02
Fine
Fine · fine $4,545
Fine
$13,635
2023-09-11
Fine
Fine · fine $13,635
Fine
$4,545
2023-08-28
Fine
Fine · fine $4,545
Fine
$4,196
2023-08-21
Fine
Fine · fine $4,196
Fine
$3,846
2023-08-14
Fine
Fine · fine $3,846
Fine
$3,496
2023-08-07
Fine
Fine · fine $3,496
Fine
$8,391
2023-07-17
Fine
Fine · fine $8,391
Fine
$2,098
2023-06-26
Fine
Fine · fine $2,098
Fine
$4,194
2023-06-05
Fine
Fine · fine $4,194
Fine
Ownership
Dlp Healthcare LLC
5% Or Greater Direct Ownership Interest · Organization
Beard, Bertrand
Operational/Managerial Control · Individual
Dlp Partner LLC
5% Or Greater Indirect Ownership Interest · Organization
Dsb Acquisition LLC
5% Or Greater Indirect Ownership Interest · Organization
Grooms, John
Corporate Officer · Individual
Historic Lifepoint Hospitals, LLC
5% Or Greater Indirect Ownership Interest · Organization
Lawrence, Charlotte
Corporate Officer · Individual
Legacy Lifepoint Health LLC
5% Or Greater Indirect Ownership Interest · Organization
Lifepoint Health Inc
5% Or Greater Indirect Ownership Interest · Organization
Lifepoint Holdings 2 LLC
5% Or Greater Indirect Ownership Interest · Organization
Lifepoint Hospitals Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Monte, Christopher
Corporate Officer · Individual
Polite, Elmer
Corporate Officer · Individual
Poppell, Marcus
Corporate Officer · Individual
Rials, Loren
Corporate Officer · Individual
Nearby options
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Roxboro, NC
2-star overall rating with 3-star inspections with $56,778 in total fines with 3 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#2
Yanceyville Rehabilitation and Healthcare Center
Yanceyville, NC
2-star overall rating with 2-star inspections with 11 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#3
Berry Hill Nursing Home
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2-star overall rating with 2-star inspections with 14 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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