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 Roxboro Healthcare & Rehab Center during CMS and state inspections, most recent first.
Nine ceiling vents in the dining room were observed with visible dust buildup and chipped paint, resulting in airborne particles over dining tables during multiple meal services. Staff and administrators confirmed the lack of vent cleaning and maintenance documentation, despite regular HVAC filter changes. No dust or paint chips were observed in residents' food.
Surveyors found that kitchen ceiling vents, ceiling fans, and industrial fans had visible dust, with particles blowing onto food preparation areas and clean dishes. The Dietary Manager and Maintenance Director confirmed the presence of dust and lack of documented cleaning, and maintenance logs only showed filter changes, not vent or fan cleaning.
A resident with multiple chronic conditions did not have a care plan meeting conducted or documented for an extended period, despite being cognitively intact and expressing a desire to participate. Although an invitation was sent to the resident's representative for a scheduled meeting, the resident was not invited, and the meeting did not occur due to lack of response. Facility staff acknowledged missed scheduling and failure to involve the resident in the care planning process.
The facility failed to address a buildup of dust and condensation on the kitchen HVAC vent, resulting in moisture damage to the ceiling. Observations showed a water puddle on the floor beneath the vent, which had a visible dust buildup and discoloration. The Dietary Manager was aware of the issue but did not report it to maintenance. The Maintenance Manager, unaware of the problem, noted that the thermostat was set too low, causing continuous operation and increased condensation. The Administrator confirmed these conditions led to the ceiling damage.
A resident with intact cognition and a history of diabetes and exocrine pancreatic insufficiency was observed self-administering Creon capsules without an active physician's order or care plan indicating it was clinically appropriate. The facility's interim DON confirmed that the resident had not been assessed or care-planned for self-administration, revealing a deficiency in medication management.
A resident with hemiplegia and contractures did not have a comprehensive care plan addressing the application and removal of splints. Despite receiving occupational therapy and recommendations for splint management, the care plan lacked necessary interventions. Interviews with facility staff confirmed that the interdisciplinary team missed including splint use in the care plan.
A resident with hemiplegia and contractures did not receive the prescribed splint application to prevent further contracture, as nursing staff failed to follow the physician's order. Despite education from the occupational therapist, staff were unaware of their responsibility, and the care plan lacked necessary details, leading to non-compliance with the order.
A resident with a history of UTIs and an indwelling urinary catheter was observed with the catheter bag touching the floor multiple times, contrary to infection control protocols. Despite staff involvement, the issue persisted until the bed was adjusted to prevent the bag from resting on the floor. The DON confirmed the expectation that catheter bags should not touch the floor.
The facility reported a medication error rate of 7.1% during a Medication Administration Observation, exceeding the acceptable threshold of 5%. Two residents were affected: one received the wrong formulation of aspirin, and another received an incorrect dosage of a calcium/Vitamin D combination. The errors were confirmed by the staff involved, and the interim DON emphasized the importance of following medication orders.
The facility failed to manage medication storage properly, with a stock bottle of cetirizine found with an illegible expiration date on the 200 Hall Med Cart and five loose, unidentified tablets discovered on the 100 Hall Med Cart. The interim DON acknowledged that nurses were responsible for checking expiration dates, yet these deficiencies were observed.
A resident with severely impaired cognition and a history of cerebral infarction and recurrent UTIs had consistently dirty fingernails, despite requiring substantial assistance for personal hygiene. Observations showed a dark brown/black substance under the nails over several days. The nurse aide responsible did not notice the issue, leaving the resident's family member to clean the nails. The interim DON confirmed that nail care should occur on shower days and as needed, indicating a lapse in care.
The facility failed to document the pharmacist's Monthly Medication Reviews and the physician's responses for two residents. The consultant pharmacist's recommendations were not uploaded into the electronic records, as they were kept in the DON's office. The interim DON noted that the previous DON did not ensure the recommendations were reviewed by the physician or uploaded, leading to missing documentation.
The facility failed to provide timely pain management for three residents, including one with a hip replacement, another with a severe ankle fracture, and a hospice patient with cancer. Delays in medication delivery, miscommunication, and incorrect allergy documentation led to unmanaged pain and inadequate care.
The facility failed to provide timely access to pain medications for three residents due to issues with backup supply access, prescription faxing errors, and untimely reordering. One resident experienced pain after hip surgery due to delayed Oxycodone administration, another faced a three-day delay due to allergy miscommunication, and a third ran out of medication due to untimely reordering.
A resident with multiple health conditions, including diabetes and Alzheimer's, had a reopened pressure sore on their thigh. The facility failed to document the sore's reopening and apply a dressing without obtaining orders. The treatment nurse discovered the issue and obtained necessary orders, but concerns about wound care practices were not addressed by the administration, leading to her resignation.
Failure to Maintain Clean and Intact Ceiling Vents in Dining Room
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment in the dining room by not keeping nine ceiling vents free from dust buildup and chipped paint. Observations over several days revealed that all nine ceiling vents above resident dining tables had visible dust and chipped paint, with particles being blown into the air directly over areas where residents were eating. These conditions were consistently observed during multiple meal services, with staff serving meals to groups of residents while dust and paint chips were visibly airborne in the dining area. However, there was no observation of dust or paint chips directly in the residents' food. Interviews with the Maintenance Director, Regional Consultant, and Administrator confirmed the presence of dust and chipped paint on the vents. Maintenance logs showed that while HVAC filters had been changed regularly, there was no documentation of vent cleaning or maintenance. Both the Maintenance Director and Administrator acknowledged that the vents required cleaning and that the maintenance department was responsible for this task, but no cleaning schedule or records were provided.
Failure to Maintain Clean Kitchen Vents and Fans
Penalty
Summary
Surveyors observed that seven ceiling vents, two ceiling fans, and two industrial fans in the kitchen and dishwashing areas had visible dust particles on their blades and vent grates. During meal preparation, dust was seen blowing from these fixtures over the steam table, food preparation areas, uncovered dishes, and an uncovered pan of vegetables. In the dishwashing area, dust from the vents and fans was observed blowing over clean dishes. The Dietary Manager confirmed the presence of dust and stated that the maintenance department was responsible for cleaning these fixtures, but was unaware of when the last deep cleaning had occurred. The kitchen cleaning checklist did not assign responsibility for cleaning vents and fans to kitchen staff. A review of maintenance logs for the previous 90 days showed documentation of filter changes but no records of vent or fan cleaning. The Maintenance Director stated that vents were cleaned monthly, but could not provide documentation or a cleaning schedule for the ceiling vents, ceiling fans, or industrial fans. The Administrator also confirmed the need for cleaning and presented reports that documented filter inspections and changes, but not vent cleaning. These findings indicate that the facility failed to maintain kitchen ventilation and fan fixtures free of dust, resulting in dust particles blowing onto clean surfaces and food preparation areas.
Failure to Involve Resident and Representative in Care Planning Process
Penalty
Summary
The facility failed to involve a resident and/or their representative in the care planning process as required. Specifically, a resident with diagnoses including type 2 diabetes mellitus, congestive heart failure, and atrial fibrillation, who had moderate cognitive impairment at one assessment and was later assessed as cognitively intact, did not have a care plan meeting conducted or documented since January 2025. Although a care plan meeting was scheduled and an invitation was sent to the resident's representative for a meeting in May 2025, there was no evidence that the resident was invited, and the meeting did not occur due to lack of response from the representative. The resident expressed that it had been a long time since any care plan meeting occurred and indicated a desire to participate in the development of his care plan and receive updates on his medical issues. Interviews with facility staff revealed that the Social Worker was responsible for scheduling care plan meetings and typically sent invitations to representatives based on the MDS assessment calendar. The Social Worker acknowledged that she missed scheduling the care plan meetings for this resident and that the resident, who was cognitively intact, could have participated in the meeting. The Administrator confirmed that care plan meetings and notifications should follow regulations and that residents and/or their representatives should be involved in care plan meetings, but acknowledged that the required meetings had not been held for this resident since January 2025.
HVAC Vent Condensation and Ceiling Damage in Kitchen
Penalty
Summary
The facility failed to prevent a buildup of dust and condensation on and around the kitchen HVAC vent, leading to moisture damage to the ceiling. Observations revealed a puddle of water on the kitchen floor, directly beneath the HVAC vent, which had a visible buildup of dust and a brownish-black discoloration around its edges. The condensation from the vent was dripping onto the floor, contributing to the water puddle. The Dietary Manager acknowledged that the vent dripped water during high humidity and had been doing so for several months. Despite being aware of the issue, the Dietary Manager had not reported it to maintenance, and the facility Administrator was also aware of the problem. Further observations showed that the ceiling paint near the vent was loose and sagging, with visible condensation and water stains. The Maintenance Manager, who was recently hired, stated he had not received any work orders or notifications about the vent or ceiling issues. He noted that the kitchen air conditioning thermostat was set too low, causing the equipment to run nonstop and contributing to the condensation problem. The Administrator confirmed that the low thermostat setting and frequent opening of the back door increased humidity, leading to the condensation and subsequent ceiling damage.
Failure to Assess Appropriateness of Self-Administration of Medication
Penalty
Summary
The facility failed to determine whether the self-administration of medications was clinically appropriate for a resident who was observed to have a medication at bedside. The resident, who had intact cognition, was admitted with diagnoses including diabetes and exocrine pancreatic insufficiency. Upon re-entering the facility after a hospital stay, the resident had physician's orders for Creon capsules to be taken with meals and snacks. However, there were no active physician's orders or care plans indicating that it was clinically appropriate for the resident to self-administer the Creon capsules. Observations revealed that the resident had a bubble-pack card of Creon capsules on his nightstand, within reach, and was seen self-administering the medication without staff inquiry. Interviews with the resident and the facility's interim DON confirmed that the resident had not been assessed or care-planned for self-administration, and there was no active physician's order for this practice. The DON acknowledged that a resident should be assessed and care-planned for self-administration of medication, highlighting a deficiency in the facility's medication management process.
Failure to Include Splint Management in Resident Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with contractures and the need for splint application and removal. The resident, who was admitted with hemiplegia following a cerebral infarction affecting the right side, had contractures in the right elbow, wrist, hand, and fingers. Occupational therapy was provided, and upon discharge, recommendations were made for nursing staff to assist with self-care needs and perform a functional maintenance program for the resident's right hand and elbow splints. However, the resident's care plan did not include any interventions related to the contractures or the application and removal of splints. Interviews with the facility's MDS Nurse and Rehabilitation Director revealed that the interdisciplinary team was responsible for developing and revising care plans, which were updated quarterly. The Rehabilitation Director confirmed that the use of splints should have been included in the care plan, indicating that this intervention was overlooked. The deficiency was identified during a review of the resident's care plan, which lacked necessary information and interventions for managing the resident's contractures and splint use.
Failure to Apply Splints as Ordered for Resident with Contractures
Penalty
Summary
The facility failed to follow a physician's order to apply two splints to a resident's right hand and elbow to prevent further contracture. The resident, who was admitted with hemiplegia following a cerebral infarction affecting his right side, was assessed to have contractures in his right elbow, wrist, hand, and fingers. Occupational therapy services were provided, and upon discharge, the nursing staff was instructed to apply and remove the splints daily. However, observations revealed that the splints were not applied as ordered. During multiple observations, the resident was seen without the required splints on his right arm. Interviews with staff members, including nurse aides and the hall nurse, indicated a lack of awareness and responsibility regarding the application of the splints. The nurse aide assigned to the resident was unaware of the splint requirement, and the hall nurse incorrectly believed it was the rehabilitation department's responsibility. The occupational therapist confirmed that the nursing staff had been educated on the splint application process, and the splints were to be applied in the morning and removed in the afternoon. Further investigation revealed that the resident's care plan and Kardex did not include information about the splint application, leading to confusion among the staff. The interim Director of Nursing acknowledged the oversight and clarified that the responsibility for applying the splints had been transferred to the nursing staff. Despite this, the splints were not consistently applied, resulting in a failure to adhere to the physician's order and potentially compromising the resident's care.
Failure to Maintain Infection Control for Urinary Catheter
Penalty
Summary
The facility failed to prevent a urinary catheter bag from touching the floor, which is a deficiency in maintaining infection control standards. This issue was observed in the case of a resident who was admitted with a history of cerebral infarction and recurrent urinary tract infections. The resident required substantial assistance for daily activities and had an indwelling urinary catheter due to urinary retention. Observations revealed that the urinary catheter bag was repeatedly found resting on the floor, which was not in compliance with infection control protocols. The deficiency was noted during multiple observations where the urinary catheter bag was seen touching the floor, despite the expectation that it should be attached to the bed frame and positioned off the floor. The nursing staff, including a nurse aide and a nurse, were involved in the care of the resident, but the issue persisted until it was addressed by raising the bed slightly. The interim Director of Nursing confirmed the expectation that catheter bags should not touch the floor, indicating a lapse in adherence to this protocol.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in a 7.1% error rate during a Medication Administration Observation. This deficiency was identified through observations, staff interviews, and record reviews involving two residents. The first incident involved a nurse administering an 81 mg chewable aspirin tablet to a resident instead of the prescribed 81 mg enteric-coated delayed-release aspirin. The nurse confirmed the error after reviewing the medication orders and comparing the formulations available in the medication cart. The second incident involved a medication aide administering a combination medication of 600 mg calcium and 400 units of Vitamin D to a resident, contrary to the prescribed dosage of 600 mg calcium and 200 units of Vitamin D. The medication aide acknowledged the discrepancy after reviewing the stock bottle and stated she would report the issue to her Unit Manager. The interim Director of Nursing, along with the Unit Manager, discussed the findings and expressed the expectation that nursing staff should adhere to medication orders and seek clarification when necessary.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to properly manage medication storage on two medication carts, leading to deficiencies in drug labeling and identification. On the 200 Hall Med Cart, a stock bottle of cetirizine was found with an illegible expiration date. The bottle, which was opened on 6/11/24, contained approximately 20 tablets, but the manufacturer's expiration date was not readable. Both the Medication Aide and the Unit Manager confirmed the expiration date could not be determined, indicating a failure to ensure drugs were labeled in accordance with professional principles. Additionally, on the 100 Hall Med Cart, five loose, unidentified tablets of varying sizes were discovered in the top drawer. Neither the nurse nor the Unit Manager could identify these tablets, which included two large, two small, and one medium-sized white round tablets. The interim Director of Nursing acknowledged that nurses were responsible for checking expiration dates and that nurse management staff routinely followed up on medication storage, yet these deficiencies were still observed.
Failure to Maintain Resident's Nail Hygiene
Penalty
Summary
The facility failed to ensure proper nail hygiene for a resident with severely impaired cognition and a history of cerebral infarction and recurrent UTIs. The resident required substantial assistance for personal hygiene, as indicated in her care plan. Observations over several days revealed that the resident's fingernails were consistently dirty, with a dark brown/black substance underneath them. Despite the resident's need for assistance, the nurse aide responsible for her care did not notice the dirty nails and did not clean them, leaving the task to the resident's family member. The family member, upon visiting, found the resident's nails unclean and took it upon herself to clean them. The nurse aide later stated that she would clean nails when noticed or on scheduled bath days, but she had not observed the need in this case. The interim DON confirmed that nail care should be performed on shower days and as needed, indicating a lapse in the expected care routine. This deficiency highlights a failure in maintaining the resident's personal hygiene as per the care plan and facility expectations.
Failure to Document Medication Reviews and Physician Responses
Penalty
Summary
The facility failed to maintain proper documentation of the pharmacist's Monthly Medication Reviews (MMRs) and the physician's review and response to the pharmacist's findings for two residents. For one resident, the electronic medical record did not include the MMRs for specific months, nor did it contain the signed provider's review and response to the pharmacist's recommendations. Similarly, for another resident, the electronic medical record was missing MMRs and the signed provider's review and response for certain months. The consultant pharmacist stated that all recommendations after the monthly MMRs were sent via email to the Director of Nursing (DON), Administrator, and Pharmacy Nurse Consultant. However, these recommendations were not uploaded into the residents' electronic records, as they were kept in the DON's office. The interim DON, who was hired later, indicated that the previous DON did not ensure that the recommendations were reviewed by the physician or uploaded into the electronic records, leading to inconsistencies and missing documentation. Interviews with the Nurse Consultant and Administrator revealed that they were made aware of the pharmacy's concerns and discussed the issue with relevant staff. However, the plan of correction did not address the missing recommendations for the two residents involved in the deficiency.
Deficiencies in Pain Management for Residents
Penalty
Summary
The facility failed to provide appropriate pain management for three residents, resulting in deficiencies in care. Resident #10, who had undergone hip replacement surgery, did not receive her prescribed Oxycodone in a timely manner due to a delay in the medication's arrival and a lack of access to the facility's backup supply. Despite being in pain, the resident was not offered alternative pain relief, such as Acetaminophen, until the Oxycodone was available. The nursing staff failed to communicate effectively, leading to a delay in pain management. Resident #15, who had a history of substance abuse and had undergone multiple surgeries for a severe ankle fracture, also experienced a delay in receiving Oxycodone. The resident's allergy to Oxycodone was mistakenly noted, causing further delays in obtaining the medication. Despite the resident's reports of pain, the staff did not administer the prescribed Oxycodone until three days after admission, relying instead on Acetaminophen, which was not sufficient for the resident's pain management needs. Resident #5, who was on hospice care for colon cancer and chronic pain, missed doses of Oxycodone due to the facility running out of the medication. The staff failed to reorder the medication in a timely manner, resulting in the resident experiencing unmanaged pain. Although alternative pain medications were available, the resident reported that the Oxycodone was specifically effective for her cancer pain, highlighting the importance of timely medication management.
Deficiency in Pain Medication Management
Penalty
Summary
The facility failed to ensure that nurses had access to backup pain medications and that these medications were replenished and available for administration. This deficiency affected three residents who required narcotic pain medications. One resident, who had undergone hip replacement surgery, did not receive Oxycodone until several hours after admission due to the unavailability of the medication in the facility's backup supply. The resident experienced pain during this period, and the staff was not aware of the procedures to obtain the medication from the backup supply. Another resident, who had a history of substance abuse and depression, did not receive Oxycodone for three days following admission due to a miscommunication regarding an allergy and a delay in faxing the prescription to the pharmacy. The resident had been receiving Oxycodone in the hospital and clarified the allergy issue with the staff, but the medication was still not available in the facility's backup supply. The pharmacy records indicated that the prescription was not received until two days after the resident's admission. A third resident, with a history of chronic pain and opioid disorder, ran out of Oxycodone because the facility did not reorder the medication in a timely manner. The resident's Oxycodone was held until it arrived from the pharmacy, and the facility's backup supply was not utilized. The pharmacy manager reported that the facility had not replenished its backup supply of Oxycodone since March, and a required form for reordering was not properly submitted. The facility's accounting system for controlled substances did not accurately reflect the number of tablets on hand.
Failure to Document and Obtain Orders for Pressure Sore Care
Penalty
Summary
The facility failed to ensure proper documentation and orders for the care of a reopened pressure sore on a resident's right posterior thigh. The resident, who had a history of diabetes, Alzheimer's disease, stroke, neuropathy, and peripheral vascular disease, was under hospice care and required substantial assistance with hygiene and bed mobility. Despite being at risk for skin impairment, the resident's care plan was not followed when a dressing was applied to the reopened pressure sore without obtaining orders or documenting the change in the resident's record. The treatment nurse discovered the issue on June 26th when a Nurse Aide informed her of a dressing on the resident's thigh that needed changing. Upon inspection, the nurse found the dressing had drainage and an odor, indicating it needed attention. However, there was no record of the pressure sore reopening or any orders for the dressing. The nurse obtained the necessary orders and ensured the Wound Physician evaluated the resident the following day. Despite reporting the issue to the facility's resource nurse and the Director of Nursing, the treatment nurse felt her concerns about wound care practices were not addressed, leading to her resignation. Interviews with facility staff, including the DON, Administrator, and Nurse Consultant, revealed a lack of awareness about the dressing being applied without orders. The Wound Physician noted the resident's skin was prone to breakdown due to sweating and previous skin issues, and the Medical Director emphasized the importance of obtaining treatment orders when skin breakdown is first observed. The facility's failure to document and obtain orders for the pressure sore dressing led to a deficiency in the care provided to the resident.
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What surveyors actually found near you
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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) |
|---|---|---|---|---|
| Person Memorial Hospital | 0.2 mi | ★★★★★ | 5 | 1 |
| Yanceyville Rehabilitation And Healthcare Center | 20.2 mi | ★★★★★ | 1 | 0 |
| Berry Hill Nursing Home | 20.3 mi | ★★★★★ | 0 | 0 |
| Oxford Health And Rehabilitation Center | 22.2 mi | ★★★★★ | 14 | 0 |
| Brantwood Nh & Retirement Center | 22.4 mi | ★★★★★ | 2 | 0 |
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