Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Person Memorial Hospital during CMS and state inspections, most recent first.
A resident with anxiety disorder, colon cancer, and severe cognitive impairment, who was on hospice care, had a PRN Lorazepam order for anxiety that remained active for several months without a documented stop date or specified duration. The medication, a psychotropic and controlled substance, was administered two to three times weekly via PEG tube, while the EMR and MARs showed no 14-day limit or documented rationale for extending the PRN order. Nursing staff and a hospice nurse reported the resident experienced agitation and anxiety during care, and facility leadership and physicians acknowledged that PRN psychotropic medications should include a stop date, be reviewed within regulatory timeframes, and have a clear rationale and duration, which did not occur in this case.
Two residents receiving PRN Lorazepam for anxiety and agitation had ongoing psychotropic, controlled substance orders without stop dates, while the consultant pharmacist repeatedly identified this as an irregularity in monthly medication regimen reviews. The pharmacist emailed recommendation reports to the DON and Administrator, but due to leadership turnover, the process for forwarding these recommendations to physicians and obtaining documented acceptance or declination broke down. As a result, physicians did not review, sign, or respond to the pharmacist’s recommendations, and no physician documentation was entered into the residents’ medical records addressing the continued PRN psychotropic use without required stop dates.
Surveyors found that kitchen staff failed to keep two double-door ovens and a grill clean, with visible layers of burnt food, grease, and oil stains remaining after use. During a kitchen tour, a dietary aide acknowledged the equipment had been used earlier and needed cleaning. In addition, surveyors observed multiple food items in a reach-in and a walk-in refrigerator, including gravy, applesauce, and coleslaw, that were either only partially covered or not labeled or dated. The dietary director later confirmed that cooks were expected to clean equipment daily and that all dietary staff were responsible for labeling and dating leftover or opened food stored in the refrigerators, and the administrator stated that all leftover food should be covered and labeled, even if intended for an upcoming meal.
The facility failed to consistently post and maintain accurate daily nurse staffing information for residents and visitors. On observation, the staffing sheet displayed near a common area remained outdated and was not updated by nursing staff over multiple days. Over a multi‑week review period, multiple daily staffing postings were missing or unavailable, and several existing sheets lacked required Nursing Assistant names and hours for specific shifts. Staff interviews showed that the Scheduler was primarily responsible for preparing and maintaining these sheets, with the admission coordinator and nurses assisting when the Scheduler was unavailable, but missing and incomplete records persisted during this time of management turnover.
A resident with a history of stroke and left-sided weakness rolled off a raised bed during incontinence care, resulting in multiple severe fractures. The resident, who required extensive assistance and was dependent on staff for bed mobility, was positioned on her side and instructed to hold onto the upper side rail. She was unable to maintain her grip and fell from the bed, sustaining significant injuries. The care plan identified fall risk and called for side rail use and staff assistance, but only the top rails were up and the resident was expected to hold herself in position. Staff and family interviews confirmed the resident's limited mobility and the facility's awareness of her condition, yet no formal staff training on safe positioning or side rail use was conducted after the incident.
The facility failed to post and update daily nurse staffing information accurately, with discrepancies found between posted and actual staffing levels. Weekend nurses were unaware or forgot to update postings, and the scheduler did not consistently make necessary changes due to call-outs.
The facility failed to schedule an RN for at least 8 consecutive hours on two occasions. On these days, the RN was assigned to work as an NA, and no RN was present for the required shifts. The facility's practice of using RNs to fill NA roles when needed led to this deficiency.
The facility failed to manage medications properly, with expired and undated insulin vials found on medication carts, and loose pills discovered in cart drawers. Nurses did not check or clean the carts before shifts, contrary to facility expectations.
A facility failed to provide a written grievance summary for a resident with severe cognitive impairment. The resident's responsible party reported bruising, leading to an abuse investigation. Although management was notified and actions were taken, there was no documentation confirming the grievance resolution to the satisfaction of the complainant. The Social Worker was unaware of the grievance, and the Administrator did not document the resolution or provide written documentation to the family.
The facility failed to provide adequate nail care for two residents dependent on staff for ADL care. One resident with Parkinson's disease had excessively long and dirty fingernails despite requesting trimming, while another resident with severe cognitive impairment had long, deformed toenails. Miscommunication between facility and hospice staff led to neglect in nail care responsibilities.
The facility failed to assist three cognitively impaired residents with activities, despite their need for total assistance with transfers and locomotion. Staff often did not offer or provide the necessary help for residents to participate in activities of interest, such as music and religious services. The Activity Director had identified these residents' needs, but staff were unable to consistently assist due to other care responsibilities, resulting in missed activities.
The facility failed to make survey results accessible to residents in wheelchairs and did not post notices about their location. Observations revealed the survey book was placed out of reach, and residents were unaware of its location. Staff confirmed the absence of visible postings, and the Administrator acknowledged the inaccessibility.
Failure to Limit and Reevaluate PRN Psychotropic Medication Order
Penalty
Summary
The deficiency involves the facility’s failure to limit the duration of a PRN psychotropic medication order to 14 days or document a specific duration and rationale for extending the order, as required by regulation. Resident #36, admitted with an anxiety disorder and diagnosed with colon cancer, was under hospice care and severely cognitively impaired, with no documented behaviors or rejection of care on the most recent MDS. On 5/9/25, the physician ordered Lorazepam Intensol 2 mg/ml, 1 ml via PEG tube every 2 hours PRN for anxiety. This PRN Lorazepam order, a psychotropic and controlled substance, remained active in the EMR from 5/9/25 through at least 12/17/25 without a documented stop date or specified duration beyond the initial order. Review of the MARs showed that the resident received two to three doses of PRN Lorazepam weekly from 5/9/25 through 12/17/25, with the last documented dose on 12/16/25. Nurse #1 and the hospice nurse both reported that the resident experienced agitation and anxiety during care and received PRN Lorazepam multiple times per week. The hospice nurse stated that hospice medications were reviewed every two weeks by the hospice interdisciplinary team, but the facility physician was responsible for writing and managing all medication orders and could accept or decline hospice recommendations. The interim DON, former Medical Director, and current Medical Director each acknowledged that PRN psychotropic medications should include a stop date, be reviewed within the regulatory timeframe, and have a documented rationale and specified duration, confirming that these requirements were not met for this resident’s ongoing PRN Lorazepam order.
Failure to Act on Consultant Pharmacist PRN Psychotropic Recommendations
Penalty
Summary
The deficiency involves the facility’s failure to ensure that consultant pharmacist recommendations from monthly medication regimen reviews were acted upon and that physician responses were documented in the medical records for two residents receiving PRN psychotropic medications. For one resident with an anxiety disorder and a PEG tube, the physician ordered Lorazepam Intensol 2 mg/ml, 1 ml via PEG every 2 hours PRN for anxiety. This PRN psychotropic and controlled substance order, initiated in early May, remained active through mid-December without a stop date, while the medication was administered two to three times weekly. Monthly pharmacy consultation reports from July through December repeatedly recommended that the physician address the PRN Lorazepam order due to the missing stop date, but there was no evidence in the consultation reports or the resident’s EMR that any physician reviewed, accepted, declined, or otherwise responded to these recommendations. A second resident with major depression and an anxiety disorder had a physician order for Lorazepam 1 mg by mouth every 8 hours PRN for anxiety and agitation, also a psychotropic and controlled substance. This PRN order remained active from mid-October through mid-December without a stop date, and the medication was administered one to two times weekly. A pharmacy consultation report in November recommended that the physician address the PRN Lorazepam order due to the lack of a stop date, but there was no documentation that the physician reviewed or responded to this recommendation. A subsequent pharmacy medication regimen review note in December documented no irregularities or recommendations, despite the ongoing PRN Lorazepam order without a stop date. Interviews revealed that the consultant pharmacist completed monthly medication regimen reviews for all residents and, when regulatory concerns were identified, emailed recommendation reports to the DON and Administrator. The established process was for the DON to handle nursing-related recommendations, forward physician-related recommendations to the appropriate physician, and ensure that the physician reviewed, accepted, or declined them with documented rationale. The consultant pharmacist stated that PRN psychotropic medications required a stop date and physician review before renewal, and that he had sent the relevant reports to facility leadership. However, due to turnover among DONs and Administrators, the process was disrupted, and the pharmacist did not receive responses to his recommendations before the DON left. The interim DON and current Medical Director both reported being unfamiliar with the process and unaware of the unaddressed pharmacy recommendations, and a former Medical Director stated he had not received any pharmacy recommendation reports and confirmed that the consultation reports for the affected residents were not reviewed or signed by a physician.
Unclean Kitchen Equipment and Unlabeled Refrigerated Food Items
Penalty
Summary
The deficiency involves failure to maintain kitchen equipment in a clean condition and to properly label and date leftover food items. During an initial kitchen tour with a dietary aide, surveyors observed that two double-door ovens contained black burnt food stains inside, with oven floors covered by a black crust-like layer of burnt food and doors marked with dark brown oil stains. The grill surface was found with a thick black layer of burnt grease and food, along with some freshly cooked yellow-colored leftover food still present. The dietary aide stated the grill had been used that morning to cook chicken and acknowledged that the ovens needed to be cleaned. Surveyors also observed multiple unlabeled and partially covered food items in the reach-in and walk-in refrigerators. In the reach-in refrigerator, there was a large aluminum pan containing thick white creamy-textured food, covered only three-quarters with cling wrap and lacking any label or date, which the dietary aide identified as breakfast gravy. A white plastic container with a green lid, half-filled with a light yellowish smooth-to-chunky food, identified by the aide as applesauce, was also present without a label or date, and the aide was unsure when it had been placed there. In the walk-in refrigerator, a small aluminum pan of creamy white coleslaw was observed without a label or date; the dietary aide stated it was to be used for the afternoon lunch meal and therefore had not been labeled or dated. The dietary director later confirmed that cooks were expected to clean the ovens and grill daily and that all staff were responsible for labeling and dating leftover or opened food placed in the refrigerators, and the administrator stated that all leftover food should be covered and labeled, even if intended for an upcoming meal, and that kitchen equipment should be cleaned after each use.
Failure to Post and Maintain Accurate Daily Nurse Staffing Information
Penalty
Summary
The deficiency involves the facility’s failure to consistently post and maintain accurate daily nurse staffing information as required. On one of four observed survey days, the daily nurse staffing sheet posted near the elevator was dated several days earlier and was not updated to reflect the current date, census, or staffing, and this outdated posting remained in place during multiple observations that day. Staff interviews revealed that the Scheduler typically prepared the daily nurse staffing sheets and placed them in a folder for nurses to update and post on weekends, but a nurse who worked multiple consecutive days did not notice that the posted sheet had not been updated. The admission coordinator stated that the Scheduler usually completed and posted the sheets, and when the Scheduler was unavailable, she attempted to complete and post them, while nurses were expected to ensure the postings were current and reflected actual staff working. A review of daily nurse staffing sheets over a 45‑day period showed that 10 days of postings were missing or unavailable for review, and on three additional days the sheets were incomplete, lacking required information and hours for Nursing Assistants on specific shifts. The admission coordinator reported that the Scheduler was responsible for maintaining and ensuring the accuracy of these records but was unable to locate the missing sheets. The administrator stated that the Scheduler filled out the daily nurse staffing sheets and provided them to the DON, and that significant management turnover contributed to the facility’s inability to locate the missing documents. No specific residents or clinical conditions were described in relation to this deficiency; the findings focused on documentation and posting of staffing information.
Failure to Ensure Safe Positioning During Bedside Care Results in Resident Fall and Severe Fractures
Penalty
Summary
A deficiency occurred when a resident with a history of stroke and left-sided weakness rolled off a raised bed during incontinence care, resulting in multiple severe fractures. The resident, who required extensive assistance with transfers and was dependent on staff for bed mobility, was being cared for by a nurse aide who positioned her on her left side and instructed her to hold onto the upper side rail with her right hand. During the care, the resident stated she could not hold on any longer, released the rail, and rolled off the bed, landing on her knees and sustaining significant injuries. The care plan for the resident identified her as being at risk for falls due to her medical history, with interventions including the use of side rails during care and staff assistance for repositioning. However, during the incident, only the two top side rails were up, and the two bottom rails were down. The nurse aide was standing on the right side of the bed, performing care while the resident was facing away and holding the rail. The bed was raised to the aide's waist height, and the resident was positioned close to the edge of the bed. Despite the resident's known weakness and dependence, she was expected to maintain her position by holding the rail, which she was unable to do, leading to the fall. Interviews with staff and family members confirmed that the resident had limited mobility, with severe left-sided weakness, and that the facility was aware of her condition. The family expressed concerns that appropriate safety measures were not in place to prevent the resident from rolling out of bed during care. Documentation and staff statements indicated that no formal training or in-service was conducted for staff regarding resident safety or the use of side rails during care following the incident. The facility's investigation concluded the event was accidental, but the lack of adequate supervision and failure to ensure safe positioning during care directly contributed to the resident's fall and subsequent injuries.
Removal Plan
- Quality oversight meetings discussing unit needs including staffing, resources, education, training, and quality issues.
- Audit by the Director of Nursing to review all residents' mobility and transfer needs to ensure correct assistance levels on care plans.
- Update MDS assessments for all residents, including functional abilities and goals.
- Verbal and return demonstration education provided to licensed nursing staff and certified nursing assistants on proper positioning in bed, use of side rails, and adjusting bed height during care.
- Instruction on correct techniques for turning, boosting, and positioning residents.
- Staff required to review care plan and Kardex and follow specified staffing needs for transfers and mobility.
- Mandatory completion of education for all staff prior to their next scheduled shift, with removal from schedule if not completed.
- Responsibility for initiating baseline care plan during admission assessment shifted from MDS RN coordinator to admitting licensed nurse, including interventions for safe positioning during care.
- Update new hire orientation process for certified nursing assistants and licensed nurses to include education on proper positioning in bed, ergonomics, body mechanics, and safety precautions with lifting and moving residents.
- Education materials reviewed by licensed physical therapist and include written materials.
- Risk meetings involving interdisciplinary team members to discuss resident-specific changes in condition, falls, weight loss, infections, and mobility needs, with documentation in the medical record and on paper.
- Use of a risk meeting form by the notetaker.
Failure to Update and Post Accurate Nurse Staffing Information
Penalty
Summary
The facility failed to post the daily nurse staffing information for residents and visitors on one of the four days of the survey period. On 9/15/24, the staffing sheet posted near the facility elevator was outdated, showing information from 9/13/24. Interviews revealed that the scheduler was responsible for preparing the staffing form for the weekend, but the weekend nurses were tasked with updating the posting. However, the MDS Nurse and other weekend nurses were either unaware of this responsibility or forgot to update the posting. Additionally, the facility did not update the daily staffing information to reflect actual staffing changes for six of the 33 days reviewed. Discrepancies were found between the posted staffing information and the staff clock-in sheets, indicating that the actual number of staff working often differed from what was posted. The scheduler mentioned that the staff schedule was prepared a month in advance, and any changes due to call-outs required updates to the posting, which were not consistently made. The Administrator confirmed that the charge nurse, scheduler, or MDS clerk were responsible for ensuring accurate postings during weekdays, with the charge nurse responsible over the weekend.
Failure to Schedule RN for Required Hours
Penalty
Summary
The facility failed to schedule a Registered Nurse (RN) for at least 8 consecutive hours a day on two occasions within a 33-day review period. On one of these days, the daily staff posting indicated an RN was scheduled for the day shift, but the staff clock-in sheet revealed no RN was present during the 7 AM to 3 PM shift. Instead, the RN, who was supposed to work from 7 AM to 7 PM, was assigned to work as a Nurse Aide (NA) from 11 PM to 7 AM. The RN confirmed during an interview that she worked as an NA and was not present in the facility from 7 AM to 7 PM. On another day, the staff clock-in sheet again showed no RN working the 7 AM to 7 PM shift, despite the daily staff posting indicating otherwise. The facility's scheduler and Administrator explained that when there was a call-out by an NA, nurses, including RNs and LPNs, were called to fill in as NAs. The Administrator stated that the requirement for an RN to be present for 8 hours was met as long as an RN was in the building, even if they were working as an NA. This practice led to the deficiency as the facility did not have an RN performing RN duties for the required 8 consecutive hours on the days in question.
Medication Management Deficiencies
Penalty
Summary
The facility failed to adhere to proper medication management protocols, as evidenced by the presence of expired and undated multi-dose vials of insulin on medication administration carts. During observations, it was found that one cart contained an opened and undated vial of Insulin Glargine, while another cart had multiple expired insulin products, including a Basaglar Kwik Pen, Humalog Pen, and Insulin Aspart Flex pen. Interviews with the nurses responsible for these carts revealed that they had not checked the dates of opening or expiration of the insulin vials at the beginning of their shifts, although they did not administer expired insulin during those shifts. The Director of Nursing confirmed that it was the nurses' responsibility to date and check medications for expiration every shift. Additionally, the facility failed to maintain cleanliness and organization in the medication carts, as loose pills were found in the drawers of two different medication carts. Observations revealed loose capsules and pills in the Rehabilitation Hall and Short Hall carts. The nurses responsible for these carts were unable to identify the loose pills and admitted to not cleaning the carts before their shifts. The Director of Nursing and the Administrator both emphasized that nurses were expected to ensure no loose pills or expired items were left in the medication carts, highlighting a lapse in adherence to the facility's medication management policies.
Failure to Provide Written Grievance Summary
Penalty
Summary
The facility failed to provide a written grievance summary for a resident who was severely cognitively impaired. The resident's responsible party (RP) reported concerns about bruising on the resident's arms, which led to an abuse investigation. The grievance form indicated that management was notified, an abuse investigation sheet was completed, law enforcement was informed, and the staff member in question was removed from the schedule. However, there was no documentation indicating that the complainant, resident, or family was contacted to confirm if the grievance was resolved to their satisfaction, and the grievance was not signed off as resolved. Interviews revealed that the Social Worker, who was the grievance coordinator, was unaware of the grievance and did not document it in the grievance log. The Administrator stated that he had spoken with the resident's RP about the abuse allegation shortly after the grievance was received and informed them that the investigation was ongoing. The Administrator did not document the resolution or record any information regarding his conversation with the family in the grievance form. Although the family was informed that the allegation was unsubstantiated, no written documentation regarding the resolution was provided to them.
Failure to Provide Adequate Nail Care for Residents
Penalty
Summary
The facility failed to provide adequate fingernail and toenail care for two residents who were dependent on staff for activities of daily living (ADL) care. Resident #37, diagnosed with Parkinson's disease and moderately cognitively impaired, was entirely dependent on staff for personal hygiene, including nail care. Despite being scheduled for regular bathing, observations revealed that Resident #37's fingernails were excessively long and dirty, and the resident expressed a preference for trimmed nails. Although the resident requested nail trimming from a nurse aide, the task was not completed, and the nurse aide did not notice the need for nail care during routine checks. Resident #24, with a diagnosis of secondary malignant neoplasm of the bone and severe cognitive impairment, was also dependent on staff for ADL care. Observations showed that Resident #24's toenails were excessively long and deformed, with no signs of discomfort reported. The resident received care from both facility and hospice staff, but there was a misunderstanding regarding responsibility for nail care. Facility staff believed hospice staff were responsible, while hospice staff indicated that nail care was the facility's responsibility. Interviews with staff, including the Director of Nursing (DON), confirmed that nurse aides were responsible for trimming nails for non-diabetic residents during bed baths or showers. However, the staff failed to perform this duty for both residents. The DON acknowledged that the assigned nurse aides should have trimmed the nails during routine care, highlighting a lapse in the facility's adherence to care plans and protocols for nail care.
Failure to Assist Residents with Activities
Penalty
Summary
The facility failed to provide an ongoing activity program that met the individual interests and needs of three cognitively impaired residents. These residents were identified as needing assistance with activities due to their cognitive impairments and physical limitations. Despite being coded for total assistance with transfers and locomotion, the residents were not consistently offered or assisted to participate in activities that matched their interests, such as music, religious services, and outside events. Observations revealed that staff often passed by the residents' rooms without offering assistance, and the residents were left in their rooms without engagement in scheduled activities. The Activity Director had developed a list of residents who required assistance to be transported to activities, and this information was shared with the management team. However, the staff, including nurse aides, failed to consistently assist these residents in getting up and ready for activities. Interviews with staff indicated that while they were aware of the residents' needs, they were often unable to assist due to other care responsibilities. This resulted in the residents missing out on activities they expressed interest in, such as church services and music events. The facility had in-serviced staff on the importance of assisting residents with activities, but there was a lack of consistent follow-up and documentation of resident participation or refusals. The Activity Director was unaware of the need to document resident participation in the resident record, and there were no activity notes available for the residents after their assessments. The deficiency was further compounded by the lack of communication and coordination among staff, leading to the residents' needs not being met.
Inaccessible Survey Results for Wheelchair Residents
Penalty
Summary
The facility failed to make the survey results accessible to residents in wheelchairs and did not post notices about the location of these results. During an initial tour, it was observed that the survey results were placed in a black caddy on a large bulletin board near the eye wash station, which was not accessible to residents in wheelchairs. This issue persisted over multiple days of observation, with no signage posted throughout the facility to inform residents, families, or visitors about the availability and location of the survey results. During a Resident Council Members meeting, several residents expressed that they were unaware of the location of the survey result notebook and had not seen any signage indicating its location. Interviews with the Social Worker and Activity Director confirmed the absence of visible postings about the survey results' location. They mentioned that the survey book was initially placed under the bulletin board with the master activity calendar, which was visible upon entry to the facility, but was later moved by the administrator without any notice. The facility Administrator acknowledged that the current location of the survey book was not accessible and that there was no visible posting to inform residents, families, or visitors of its location.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Roxboro
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Roxboro Healthcare & Rehab Center | 0.2 mi | ★★★★★ | 3 | 0 |
| Yanceyville Rehabilitation And Healthcare Center | 20.2 mi | ★★★★★ | 1 | 0 |
| Berry Hill Nursing Home | 20.5 mi | ★★★★★ | 0 | 0 |
| Oxford Health And Rehabilitation Center | 22.2 mi | ★★★★★ | 14 | 0 |
| Treyburn Rehabilitation Center | 22.3 mi | ★★★★★ | 0 | 0 |
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