Cycle 1
Health 2025-01-08 · Fire 2025-01-08
13 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
3 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Roanoke Rapids, NC
Signature Healthcare of Roanoke Rapids
2-star overall rating with 2-star inspections with $9,110 in total fines with 13 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
305 East Fourteenth Street, Roanoke Rapids, NC
(252) 537-6181
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
108
Certified beds
Average residents
75
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Signature Healthcare
Operator or chain grouping
Approved since
1990-12-05
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
71 facilities
Chain averages 3 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
0.36
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
0.86
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
2.01
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
3.22
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
1.21
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
2.67
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.24
Weekend registered nurse coverage · state 0.38 · national 0.47
Physical therapist
0.14
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.36
CMS adjusted RN staffing hours
Adjusted total hours
3.29
CMS adjusted total nurse staffing hours
Case-mix index
1.34
Higher values indicate more complex resident acuity
RN turnover
60%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
71%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,135
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
27.69
Composite VBP score used to determine payment impact.
Payment multiplier
0.9847
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.82
Baseline 19.07% · Performance 19.20% · Measure score 4.82 · Achievement 4.82 · Improvement 0
Healthcare-associated infections
3.95
Baseline 6.28% · Performance 6.65% · Measure score 3.95 · Achievement 3.95 · Improvement 0
Total nurse turnover
2.31
Baseline 74.07% · Performance 60.26% · Measure score 2.31 · Achievement 0.84 · Improvement 2.31
Adjusted total nurse staffing
0
Baseline 3.21 hours · Performance 3.17 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.64% |
10.72%
0.1 pts better
|
No Different than the National Rate · Eligible stays 147 · Observed rate 12.93% · Lower 95% interval 7.89% |
| Discharge to community | 58.58% |
50.57%
8 pts better
|
No Different than the National Rate · Eligible stays 143 · Observed rate 47.55% · Lower 95% interval 48.53% |
| Medicare spending per beneficiary | 0.89 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 88.52% |
95.27%
6.8 pts worse
|
Numerator 54 · Denominator 61 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 61 |
| Discharge self-care score | 63.04% |
53.69%
9.4 pts better
|
Numerator 29 · Denominator 46 |
| Discharge mobility score | 80.43% |
50.94%
29.5 pts better
|
Numerator 37 · Denominator 46 |
| Pressure ulcers or injuries, new or worsened | 1.64% |
2.29%
0.7 pts better
|
Numerator 1 · Denominator 61 · Adjusted rate 1.39% |
| Healthcare-associated infections requiring hospitalization | 6.65% |
7.12%
0.5 pts better
|
No Different than the National Rate · Eligible stays 98 · Observed rate 7.14% · Lower 95% interval 4.05% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 71 |
| Staff flu vaccination coverage | 18.94% |
42%
23.1 pts worse
|
Numerator 25 · Denominator 132 |
| Discharge function score | 71.74% |
56.45%
15.3 pts better
|
Numerator 33 · Denominator 46 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 87.88% |
96.28%
8.4 pts worse
|
Numerator 29 · Denominator 33 |
| Resident COVID-19 vaccinations up to date | 18.75% |
25.2%
6.4 pts worse
|
Numerator 6 · Denominator 32 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.1 |
1.8
0.7 pts better
|
1.9
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 1.2 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.9 |
1.8
2.1 pts worse
|
1.8
2.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.9 · Observed 3.9 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.6% |
91.5%
8.1 pts better
|
93.4%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 98.4% · Q4 100.0% · 4Q avg 99.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.6% |
94.1%
4.5 pts better
|
95.5%
3.1 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
3.6%
3.6 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 6.1% |
4.8%
1.3 pts worse
|
11.4%
5.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q2 1.7% · Q3 3.4% · Q4 5.2% · 4Q avg 6.1% |
| Percentage of long-stay residents who lose too much weight | 13.3% |
7.2%
6.1 pts worse
|
5.4%
7.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.7% · Q2 12.1% · Q3 12.5% · Q4 17.9% · 4Q avg 13.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.8% |
21.6%
8.8 pts better
|
19.6%
6.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.0% · Q2 15.3% · Q3 10.0% · Q4 6.9% · 4Q avg 12.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 6.6% |
15.0%
8.4 pts better
|
16.7%
10.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.7% · Q2 4.1% · Q3 7.7% · Q4 5.9% · 4Q avg 6.6% · 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 | 25.5% |
21.5%
4 pts worse
|
16.3%
9.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 25.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.0% |
16.8%
2.8 pts better
|
14.9%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.7% · Q2 12.7% · Q3 10.7% · Q4 17.0% · 4Q avg 14.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.9%
0.9 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.8% |
2.6%
1.8 pts better
|
1.7%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.7% · Q3 0.0% · Q4 1.6% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 19.9% |
21.2%
1.3 pts better
|
19.8%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.5% · Q2 28.8% · Q3 14.8% · Q4 22.2% · 4Q avg 19.9% |
| Percentage of long-stay residents with pressure ulcers | 10.3% |
6.0%
4.3 pts worse
|
5.1%
5.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.2% · Q2 10.4% · Q3 10.3% · Q4 9.4% · 4Q avg 10.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.1% |
79.9%
18.2 pts better
|
81.7%
16.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.5% · Q2 98.4% · Q3 98.6% · Q4 97.1% · 4Q avg 98.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.5% |
13.2%
5.7 pts better
|
12.0%
4.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.5% · Observed 7.7% · Expected 11.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.5% |
1.5%
About the same
|
1.6%
0.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.2% · Q4 3.5% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 97.7% |
78.1%
19.6 pts better
|
79.7%
18 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 97.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 13.4% |
22.9%
9.5 pts better
|
23.9%
10.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 13.4% · Observed 14.3% · Expected 25.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-09 · Fire 2023-11-09
3 health deficiencies
Top issue: Nursing and Physician Services (1 deficiency)
4 fire-safety deficiencies
Top issue: Services (2 deficiencies)
Cycle 3
Health 2022-08-25 · Fire 2022-08-25
5 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-01-08
K361 · Smoke Deficiencies
Fire Safety
Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.
Corrected 2025-03-24
D · Potential for more than minimal harm
2025-01-08
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2025-03-24
D · Potential for more than minimal harm
2025-01-08
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-03-24
D · Potential for more than minimal harm
2023-11-09
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-12-22
D · Potential for more than minimal harm
2023-11-09
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-12-22
D · Potential for more than minimal harm
2023-11-09
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-12-22
D · Potential for more than minimal harm
2023-11-09
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 2023-12-22
D · Potential for more than minimal harm
2022-08-25
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 2022-10-17
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-12-03
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2026-01-06
D · Potential for more than minimal harm
2025-12-03
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2026-01-06
G · Actual harm
2025-05-01
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 2025-04-04
F · Potential for more than minimal harm
2025-01-08
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 2025-01-29
E · Potential for more than minimal harm
2025-01-08
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-01-29
E · Potential for more than minimal harm
2025-01-08
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 2025-01-29
E · Potential for more than minimal harm
2025-01-08
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 2025-01-29
E · Potential for more than minimal harm
2025-01-08
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2025-01-29
D · Potential for more than minimal harm
2025-01-08
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2025-01-29
D · Potential for more than minimal harm
2025-01-08
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-01-29
D · Potential for more than minimal harm
2025-01-08
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-01-29
D · Potential for more than minimal harm
2025-01-08
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-01-29
B · Minimal harm
2025-01-08
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2025-01-29
E · Potential for more than minimal harm
2023-11-09
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 2023-11-27
D · Potential for more than minimal harm
2023-11-09
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 2023-11-27
B · Minimal harm
2023-11-09
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2023-11-22
J · Immediate jeopardy
2022-08-25
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2022-08-03
E · Potential for more than minimal harm
2022-08-25
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-09-20
E · Potential for more than minimal harm
2022-08-25
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2022-09-20
D · Potential for more than minimal harm
2022-08-25
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2022-09-20
B · Minimal harm
2022-08-25
F661 · Resident Assessment and Care Planning Deficiencies
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2022-09-20
Penalties and ownership
What sits behind the stars
$9,110
2025-05-01
Fine
Fine · fine $9,110
Fine
Ownership
Shc LP Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
Asbr Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Harrison, John
Corporate Officer · Individual
Houston, Ingrid
W-2 Managing Employee · Individual
Jjla LLC
5% Or Greater Indirect Ownership Interest · Organization
Lpsnf LLC
5% Or Greater Indirect Ownership Interest · Organization
Smedra, Ira
5% Or Greater Indirect Ownership Interest · Individual
Steier Iii, Elmer
5% Or Greater Indirect Ownership Interest · Individual
Wheaten LLC
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Other facilities in reach
#1
Liberty Commons Nursing and Rehabilitation Center
Weldon, NC
4-star overall rating with 4-star inspections with 1 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Northampton Nursing and Rehabilitation Center
Jackson, NC
3-star overall rating with 4-star inspections with 6 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Emporia Rehabilitation And Healthcare Center
Emporia, VA
2-star overall rating with 2-star inspections with 19 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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