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
Chain footprint
8 facilities
Chain averages 4 overall / 4 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Hospital-based
Yes
CMS reports the provider resides in a hospital
Staffing
Hours and turnover
RN hours / resident day
0.63
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
0.73
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
1.89
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
3.25
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
1.35
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
2.85
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.41
Weekend registered nurse coverage · state 0.38 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.59
CMS adjusted RN staffing hours
Adjusted total hours
3.07
CMS adjusted total nurse staffing hours
Case-mix index
1.45
Higher values indicate more complex resident acuity
RN turnover
82%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
56%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,691
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
29.02
Composite VBP score used to determine payment impact.
Payment multiplier
0.9853
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.42
Baseline 18.95% · Performance 19.38% · Measure score 4.42 · Achievement 4.42 · Improvement 0
Healthcare-associated infections
5.88
Baseline 6.49% · Performance 6.08% · Measure score 5.88 · Achievement 5.88 · Improvement 2.25
Total nurse turnover
1.31
Performance 58.33% · Measure score 1.31 · Achievement 1.31 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
0
Baseline 3.31 hours · Performance 3.13 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.78% |
10.72%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 82 · Observed rate 9.76% · Lower 95% interval 7.34% |
| Discharge to community | 62.08% |
50.57%
11.5 pts better
|
Better than the National Rate · Eligible stays 75 · Observed rate 62.67% · Lower 95% interval 52.36% |
| Medicare spending per beneficiary | 0.76 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 59 · Denominator 59 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 59 |
| Discharge self-care score | 61.7% |
53.69%
8 pts better
|
Numerator 29 · Denominator 47 |
| Discharge mobility score | 51.06% |
50.94%
0.1 pts better
|
Numerator 24 · Denominator 47 |
| Pressure ulcers or injuries, new or worsened | 1.69% |
2.29%
0.6 pts better
|
Numerator 1 · Denominator 59 · Adjusted rate 2.03% |
| Healthcare-associated infections requiring hospitalization | 6.08% |
7.12%
1 pts better
|
No Different than the National Rate · Eligible stays 54 · Observed rate 1.85% · Lower 95% interval 3.75% |
| Staff COVID-19 vaccination coverage | 15.09% |
8.2%
6.9 pts better
|
Numerator 8 · Denominator 53 |
| Staff flu vaccination coverage | 67.78% |
42%
25.8 pts better
|
Numerator 61 · Denominator 90 |
| Discharge function score | 57.45% |
56.45%
1 pts better
|
Numerator 27 · Denominator 47 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 95.74% |
96.28%
0.5 pts worse
|
Numerator 45 · Denominator 47 |
| Resident COVID-19 vaccinations up to date | 3.45% |
25.2%
21.8 pts worse
|
Numerator 1 · Denominator 29 |
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 · Adjusted 2.8 · Observed 2.0 · Expected 1.4 · Used in QM five-star |
| 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 · Adjusted 3.6 · Observed 2.6 · Expected 1.2 · Used in QM five-star |
| 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 · Q1 100.0% · Q2 100.0% · Q3 95.0% · Q4 84.1% · 4Q avg 94.4% |
| 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 · 4Q avg 92.7% |
| 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 · Q1 0.0% · Q2 2.6% · Q3 2.5% · Q4 4.5% · 4Q avg 2.5% · Used in QM five-star |
| 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 · Q1 2.9% · Q2 2.9% · Q3 2.8% · Q4 0.0% · 4Q avg 2.4% |
| 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 · Q1 14.3% · Q2 5.4% · Q3 10.3% · Q4 0.0% · 4Q avg 7.3% |
| 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 · Q1 8.3% · Q2 5.3% · Q3 10.0% · Q4 12.2% · 4Q avg 9.0% |
| 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 · Q1 20.7% · Q2 20.0% · Q3 17.1% · Q4 13.9% · 4Q avg 17.7% · Used in QM five-star |
| 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 · 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 | 27.3% |
21.5%
5.8 pts worse
|
16.3%
11 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 27.3% · Used in QM five-star |
| 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 · Q1 12.0% · Q2 9.7% · Q3 27.3% · Q4 23.8% · 4Q avg 17.2% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 3.1% · Q4 1.8% · 4Q avg 1.3% · Used in QM five-star |
| 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 · Q1 2.7% · Q2 10.8% · Q3 2.6% · Q4 2.3% · 4Q avg 4.5% · Used in QM five-star |
| 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 · Q1 10.0% · Q2 9.1% · Q3 15.2% · Q4 11.0% · 4Q avg 11.3% |
| 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 · Q1 0.0% · Q2 4.9% · Q3 0.0% · Q4 2.2% · 4Q avg 1.8% · Used in QM five-star |
| 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 · Q1 79.5% · Q2 84.2% · Q3 82.1% · Q4 61.4% · 4Q avg 77.9% |
| 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 · Adjusted 14.1% · Observed 13.2% · Expected 10.4% · Used in QM five-star |
| 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 · Q1 6.5% · Q2 2.2% · Q3 2.0% · Q4 4.7% · 4Q avg 3.8% · Used in QM five-star |
| 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 · 4Q avg 85.2% |
| 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 · Adjusted 22.0% · Observed 18.9% · Expected 20.4% · Used in QM five-star |
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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#2
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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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