Cycle 1
Health 2025-11-21 · Fire 2024-08-01
13 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Rocky Mount, NC
Rocky Mount Rehabilitation Center
2-star overall rating with 2-star inspections with $27,872 in total fines with 13 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
160 S Winstead Avenue, Rocky Mount, NC
(252) 443-7666
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
117
Certified beds
Average residents
106
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Sovereign Healthcare Holdings
Operator or chain grouping
Approved since
1987-07-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
43 facilities
Chain averages 4 overall / 3 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
Staffing
Hours and turnover
RN hours / resident day
0.54
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
0.90
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
2.16
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
3.60
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
1.44
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
3.14
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.27
Weekend registered nurse coverage · state 0.38 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.49
CMS adjusted RN staffing hours
Adjusted total hours
3.27
CMS adjusted total nurse staffing hours
Case-mix index
1.51
Higher values indicate more complex resident acuity
RN turnover
67%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
44%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,229
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
17.61
Composite VBP score used to determine payment impact.
Payment multiplier
0.9818
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.25
Baseline 19.16% · Performance 20.85% · Measure score 1.25 · Achievement 1.25 · Improvement 0
Healthcare-associated infections
0
Baseline 6.05% · Performance 8.86% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
4.63
Baseline 50.91% · Performance 44.74% · Measure score 4.63 · Achievement 4.63 · Improvement 1.87
Adjusted total nurse staffing
1.16
Baseline 3.24 hours · Performance 3.41 hours · Measure score 1.16 · Achievement 1.16 · Improvement 0.16
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.41% |
10.72%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 173 · Observed rate 13.29% · Lower 95% interval 8.83% |
| Discharge to community | 50.94% |
50.57%
0.4 pts better
|
No Different than the National Rate · Eligible stays 171 · Observed rate 42.11% · Lower 95% interval 40.14% |
| Medicare spending per beneficiary | 0.98 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 87.79% |
95.27%
7.5 pts worse
|
Numerator 115 · Denominator 131 |
| Falls with major injury | 2.29% |
0.77%
1.5 pts worse
|
Numerator 3 · Denominator 131 |
| Discharge self-care score | 32.31% |
53.69%
21.4 pts worse
|
Numerator 21 · Denominator 65 |
| Discharge mobility score | 32.31% |
50.94%
18.6 pts worse
|
Numerator 21 · Denominator 65 |
| Pressure ulcers or injuries, new or worsened | 9.92% |
2.29%
7.6 pts worse
|
Numerator 13 · Denominator 131 · Adjusted rate 8.24% |
| Healthcare-associated infections requiring hospitalization | 8.86% |
7.12%
1.7 pts worse
|
No Different than the National Rate · Eligible stays 116 · Observed rate 12.07% · Lower 95% interval 5.7% |
| Staff COVID-19 vaccination coverage | 11.51% |
8.2%
3.3 pts better
|
Numerator 16 · Denominator 139 |
| Staff flu vaccination coverage | 23.53% |
42%
18.5 pts worse
|
Numerator 40 · Denominator 170 |
| Discharge function score | 33.85% |
56.45%
22.6 pts worse
|
Numerator 22 · Denominator 65 |
| Transfer of health information to provider | 98.94% |
95.95%
3 pts better
|
Numerator 93 · Denominator 94 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 41.18% |
25.2%
16 pts better
|
Numerator 28 · Denominator 68 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.7 |
1.8
0.9 pts worse
|
1.9
0.8 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.7 · Observed 3.9 · Expected 2.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.5 |
1.8
1.7 pts worse
|
1.8
1.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.5 · Observed 4.5 · Expected 2.1 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
91.5%
8.5 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
94.1%
5.9 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 | 3.5% |
3.6%
0.1 pts better
|
3.3%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 2.2% · Q3 3.6% · Q4 6.0% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.4% |
4.8%
0.4 pts better
|
11.4%
7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 3.1% · Q3 5.3% · Q4 4.5% · 4Q avg 4.4% |
| Percentage of long-stay residents who lose too much weight | 6.4% |
7.2%
0.8 pts better
|
5.4%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.5% · Q2 8.8% · Q3 8.1% · Q4 5.3% · 4Q avg 6.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.1% |
21.6%
9.5 pts better
|
19.6%
7.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.0% · Q2 11.0% · Q3 16.7% · Q4 6.6% · 4Q avg 12.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 4.6% |
15.0%
10.4 pts better
|
16.7%
12.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.0% · Q2 2.9% · Q3 1.6% · Q4 4.8% · 4Q avg 4.6% · 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 | 32.5% |
21.5%
11 pts worse
|
16.3%
16.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 47.4% · 4Q avg 32.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 7.6% |
16.8%
9.2 pts better
|
14.9%
7.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.9% · Q2 6.1% · Q3 9.0% · Q4 7.5% · 4Q avg 7.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.2% |
0.9%
0.7 pts better
|
1.0%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.8% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.9% |
2.6%
0.3 pts worse
|
1.7%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 1.1% · Q3 2.5% · Q4 6.1% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.1% |
21.2%
0.9 pts worse
|
19.8%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.7% · Q2 22.4% · Q3 24.7% · Q4 20.7% · 4Q avg 22.1% |
| Percentage of long-stay residents with pressure ulcers | 8.7% |
6.0%
2.7 pts worse
|
5.1%
3.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.6% · Q2 10.5% · Q3 7.7% · Q4 5.7% · 4Q avg 8.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 89.4% |
79.9%
9.5 pts better
|
81.7%
7.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.0% · Q2 99.1% · Q3 98.4% · Q4 65.2% · 4Q avg 89.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 19.9% |
13.2%
6.7 pts worse
|
12.0%
7.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 19.9% · Observed 21.9% · Expected 12.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.1% |
1.5%
0.4 pts better
|
1.6%
0.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 1.2% · Q3 0.0% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 94.1% |
78.1%
16 pts better
|
79.7%
14.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 94.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.4% |
22.9%
0.5 pts better
|
23.9%
1.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.4% · Observed 24.6% · Expected 26.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-08-01 · Fire 2023-04-13
12 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-04-13 · Fire 2021-12-02
0 health deficiencies
No concentrated health issue counts in this cycle.
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-08-01
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2024-11-29
F · Potential for more than minimal harm
2024-08-01
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-11-29
F · Potential for more than minimal harm
2024-08-01
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-11-29
F · Potential for more than minimal harm
2024-08-01
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-11-29
F · Potential for more than minimal harm
2024-08-01
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-11-29
F · Potential for more than minimal harm
2024-08-01
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-11-29
E · Potential for more than minimal harm
2024-08-01
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-11-29
D · Potential for more than minimal harm
2024-08-01
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2024-11-29
D · Potential for more than minimal harm
2024-08-01
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-11-29
D · Potential for more than minimal harm
2024-08-01
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-11-29
D · Potential for more than minimal harm
2024-08-01
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-11-29
E · Potential for more than minimal harm
2023-04-13
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-06-16
E · Potential for more than minimal harm
2023-04-13
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-06-16
D · Potential for more than minimal harm
2023-04-13
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 2023-06-16
D · Potential for more than minimal harm
2023-04-13
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-06-16
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-11-21
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 2025-12-08
E · Potential for more than minimal harm
2025-11-21
F839 · Administration Deficiencies
Health
Employ staff that are licensed, certified, or registered in accordance with state laws.
Corrected 2025-12-08
E · Potential for more than minimal harm
2025-11-21
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 2025-12-08
D · Potential for more than minimal harm
2025-11-21
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2025-12-08
D · Potential for more than minimal harm
2025-11-21
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-12-08
D · Potential for more than minimal harm
2025-11-21
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-12-08
D · Potential for more than minimal harm
2025-11-21
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2025-12-08
D · Potential for more than minimal harm
2025-11-21
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-12-08
D · Potential for more than minimal harm
2025-11-21
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2025-12-08
D · Potential for more than minimal harm
2025-11-21
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-12-08
C · Minimal harm
2025-11-21
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2025-12-08
C · Minimal harm
2025-11-21
F838 · Administration Deficiencies
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2025-12-08
B · Minimal harm
2025-11-21
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-12-08
J · Immediate jeopardy
2025-01-09
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-01-29
D · Potential for more than minimal harm
2025-01-09
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 2025-01-29
D · Potential for more than minimal harm
2025-01-09
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 2025-01-29
G · Actual harm
2024-11-19
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-12-04
D · Potential for more than minimal harm
2024-11-19
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 2024-12-04
D · Potential for more than minimal harm
2024-11-19
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-12-04
D · Potential for more than minimal harm
2024-08-01
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-08-23
D · Potential for more than minimal harm
2024-08-01
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-08-23
D · Potential for more than minimal harm
2024-08-01
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 2024-08-23
D · Potential for more than minimal harm
2024-08-01
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-08-23
D · Potential for more than minimal harm
2024-08-01
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-08-23
C · Minimal harm
2024-08-01
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2024-08-23
Penalties and ownership
What sits behind the stars
$17,345
2025-01-09
Fine
Fine · fine $17,345
Fine
$10,527
2024-11-19
Fine
Fine · fine $10,527
Fine
Ownership
Cronquist, Royce
Operational/Managerial Control · Individual
Deiter, Sara
Operational/Managerial Control · Individual
Melton, Donald
Operational/Managerial Control · Individual
O Brien, Patrick
Operational/Managerial Control · Individual
Southern Healthcare Management LLC
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
The Lodge at Rocky Mount Health and Rehabilitation
Rocky Mount, NC
3-star overall rating with 2-star inspections with $31,505 in total fines with 7 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
The Carrolton of Nash
Rocky Mount, NC
4-star overall rating with 4-star inspections with 2 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Autumn Care of Nash
Nashville, NC
3-star overall rating with 3-star inspections with 8 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
Jump out