Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
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 Signature Healthcare Of Roanoke Rapids during CMS and state inspections, most recent first.
MDS assessment was not accurately coded for anticoagulant use for a resident with CVA who had an active order for dabigatran. The MAR showed the medication was given as ordered during the MDS look-back period, but the MDS did not reflect the anticoagulant use. The MDS nurse confirmed she missed the medication when completing the assessment, and the Administrator stated the MDS nurse was responsible for coding it correctly.
Missing oxygen-in-use signage for two residents: Two residents with COPD and dependence on supplemental O2 were observed in bed with NC oxygen in place, but their room doors did not have the required oxygen-in-use signs posted. Staff stated the signs should be posted for all residents using supplemental O2 and indicated the signs likely were missed after recent room changes.
Medication Error Rate Exceeded Threshold: The facility had 3 medication errors out of 39 opportunities, resulting in a 7.69% error rate. One nurse failed to administer ordered cholecalciferol and fenofibrate to a resident with vitamin D deficiency and hyperlipidemia because the stock dose did not match the order and one medication was unavailable. Another nurse administered a fluticasone propion-salmeterol inhaler to a resident with COPD but did not prompt the resident to rinse and spit as directed by the manufacturer.
The facility failed to accurately document and reconcile controlled medications for multiple residents, including those receiving hydrocodone-acetaminophen, oxycodone, and Oxycontin for pain. For one resident with metastatic cancer and severe pain, controlled drug records showed more doses removed from locked storage than were documented as administered on the MAR, and several nurses admitted to forgetting MAR documentation, misdating removals, or signing out doses without times to correct off-counts. On one unit, the controlled substance count sheets over several days lacked required dual signatures, omitted counts of cards and sheets, and contained undocumented additions and subtractions of medication cards, with some shifts showing no recorded reconciliation at all. For another resident on chronic Oxycontin, the pharmacy’s dispense and return records did not match the facility’s controlled drug records, and neither the pharmacist nor the corporate nurse consultant could reconcile the discrepancies. A third resident on scheduled Oxycontin and PRN oxycodone had MAR entries indicating doses were given without corresponding removals on the controlled drug record, and nurses later reported holding doses without correcting the MAR, giving PRN oxycodone instead of scheduled Oxycontin without clear documentation, or being unable to explain mismatched records.
The facility failed to maintain accurate and complete medical records for two residents, including documentation of bowel movements and administration of controlled pain medications. One resident with advanced cancer had bowel movements under-documented despite staff acknowledging more frequent occurrences, and multiple doses of hydrocodone-acetaminophen and oxycodone were signed out on the controlled drug record without corresponding entries on the MAR, even though nurses stated the medications were given. Another resident with vertebral osteomyelitis and chronic low back pain had a scheduled Oxycontin dose documented as administered when it was actually held due to sedation, and the nurse involved did not know how to correct the electronic MAR. The DON and interim Administrator both acknowledged that these records were incomplete or inaccurate.
A resident with Stage IV cancer and Stage IV kidney disease was admitted from the hospital with a discharge summary listing multiple scheduled follow-up appointments, including a PET scan and oncology and nephrology visits. The facility’s process required nursing staff to review the discharge summary and provide it to the Transportation Nurse Aide to arrange transport, but this did not occur. The family member went to the oncology appointment expecting to meet the resident, believing transportation had been arranged, but the resident never arrived and all appointments were missed. The Transportation Nurse Aide and Social Worker reported they were unaware of the appointments, and the DON confirmed the discharge summary had not been given to the Transportation Nurse Aide as expected.
A resident with metastatic cancer, an open malignant shoulder wound, neuropathy, and a history of spine surgery had PRN hydrocodone, PRN oxycodone, and scheduled gabapentin ordered for pain and was care-planned to request and receive pain meds as needed. On one evening shift, the resident requested pain medication early in the shift, but the assigned nurse did not administer any opioid analgesic, could not be located by the NA, and was later found asleep in a car with the med cart keys. Another nurse, working on a different unit, and other staff repeatedly attempted to wake the assigned nurse and contacted the DON, but the resident’s first documented oxycodone dose on that shift was not given until the early morning hours, at which time the resident was tearful and reported extreme pain. The MAR showed no hydrocodone given that shift and no documented time for the evening gabapentin dose, demonstrating a significant delay in providing ordered pain management.
A resident with multiple comorbidities and severely impaired cognition experienced two falls in one day. After the second fall, an RN assessed new left leg pain and obtained a STAT order for x‑rays of the left hip and femur, but the mobile x‑ray was not completed that night due to access issues and lack of staff response. The next morning, the resident’s representative reported the resident was in pain and requested Tylenol before dialysis; an RN performed a limited assessment, relied on the prior evaluation and pending STAT x‑ray, and allowed the resident to attend dialysis, while the DON, seeing the resident laughing in a wheelchair, did not assess pain. When the x‑ray technician arrived later, the resident was already at dialysis, and the exam was again delayed. Dialysis documentation showed ongoing left lower extremity pain and early termination of treatment, and the resident was later found to have a hip fracture requiring surgery. The deficiency centers on the failure to ensure timely completion of the ordered STAT x‑ray and prompt diagnostic evaluation of the resident’s post‑fall leg pain.
Surveyors identified significant medication errors involving two residents who did not receive scheduled rapid-acting insulin doses due to a staffing shortage, and another resident who continued to receive prednisone despite a pulmonologist's recommendation to discontinue it. The errors were linked to missed medication administration, lack of timely communication, and failure to implement consultation recommendations.
Due to insufficient nursing staff coverage, two residents with diabetes did not receive their scheduled morning doses of rapid-acting insulin. The absence of a medication aide and a unit manager resulted in delayed medication administration, and communication lapses among staff further contributed to the missed doses. The incident was confirmed through medication records and staff interviews.
A resident with hemiplegia and transfer dependence was manually transferred from a wheelchair to bed by an agency CNA without the required mechanical lift, despite clear care plan instructions and available assistance. The resident reported being handled roughly and experienced severe pain, later found to be due to a comminuted, displaced femur fracture. Staff interviews and documentation confirmed the transfer was not performed per protocol.
The facility did not update its facility-wide assessment to reflect the needs of all residents, including two who required tracheostomy care. The assessment inaccurately stated no residents needed such care, and the Administrator admitted to not reviewing the assessment in the previous year.
The facility failed to accurately code MDS assessments for several residents, leading to discrepancies in medical records. A resident with improved kidney function was incorrectly coded for dialysis, another with vascular dementia was not coded for a wander guard alarm, and a diabetic resident was not coded for hypoglycemic medication. Additionally, a resident dependent on dialysis was not correctly coded upon readmission. The MDS Nurse was responsible for these inaccuracies.
The facility failed to properly label and store medications, with an insulin pen and albuterol inhaler found unlabeled on Unit 3, and a netarsudil solution unrefrigerated on Unit 1. Additionally, a wound treatment cart on Unit 3 was left unattended and unlocked, containing resident treatment supplies. The DON confirmed that all staff were responsible for ensuring proper labeling, storage, and security of medications and treatment carts.
The facility failed to maintain sanitary conditions in the kitchen, with observations revealing unclean equipment such as a plate dispenser with dried food particles and a steam table shelf covered in food debris. Despite having a cleaning schedule, these areas were overlooked, as confirmed by the dietary managers and the Administrator.
The facility failed to properly dispose of garbage in the dumpster area, with observations of an open dumpster lid, scattered litter, and uncollected waste. The Dietary District Manager noted the area was cleaned earlier, but the waste company did not pick up dropped items. The Administrator stated all staff were responsible for maintaining cleanliness, and the Corporate Administrator suggested daily inspections.
A facility failed to complete a Minimum Data Set (MDS) Significant Change in Status Assessment for a resident who was admitted with a diagnosis of malignant neoplasm and later admitted to hospice. Despite a physician order indicating the resident's terminal status and hospice admission, no MDS assessment was completed to reflect this change. Interviews with the MDS Nurse and Administrator confirmed the oversight.
A resident with severe cognitive impairment and specific activity preferences did not have a person-centered care plan developed by the facility. Despite expressing interest in activities like reading and music, the resident's care plan lacked these provisions. Observations showed the resident often in their room with the TV on, and interviews revealed confusion among staff about responsibility for care plan development.
A facility failed to obtain a physician order for tracheostomy care for a resident with a tracheostomy. Although nursing staff provided care, including cleaning and suctioning, there was no documented physician order for tracheostomy site care. The Unit Manager acknowledged the oversight, and the DON could not explain how the order was missed.
A facility failed to ensure a resident receiving dialysis had a physician's order for the service. The resident, dependent on renal dialysis, was readmitted from the hospital without the dialysis order being reinstated. Staff interviews confirmed the oversight, with the Unit Manager and DON acknowledging the failure to reestablish the order. The Administrator also noted that staff should have ensured the presence of a physician's order.
The facility failed to notify the Ombudsman of hospital transfers for two residents. The Social Service Director was running incorrect reports, leading to missed notifications. Interviews revealed that the Director of Nursing and interim Administrator were unaware of the issue, which was identified through record reviews and staff interviews.
MDS Assessment Not Coded for Anticoagulant Use
Penalty
Summary
Ensure each resident receives an accurate assessment was not met when the facility failed to accurately code the Minimum Data Set (MDS) admission assessment for the use of an anticoagulant medication for Resident #17. Resident #17 was admitted with diagnoses including CVA and had an active physician order for dabigatran 150 mg by mouth twice daily; the order was on hold for 4/18/26 and 4/19/26, and the Medication Administration Record showed the medication was administered twice daily on 4/20/26, 4/21/26, 4/22/26, and 4/23/26. However, the MDS admission assessment did not code the resident for anticoagulant use during the 7-day look-back period. During interview, the MDS Nurse reviewed the electronic health record and confirmed the medication had been administered during the look-back period and stated she missed the anticoagulant use when completing the MDS and did not code the assessment accurately. The Administrator stated the MDS Nurse was responsible for ensuring the assessment was coded correctly.
Missing oxygen-in-use signage for two residents
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not met when the facility failed to post cautionary and safety signs indicating supplemental oxygen was in use for 2 residents. Resident #1 had diagnoses including COPD and dependence on supplemental oxygen, with a physician order for oxygen via nasal cannula at 3 liters per minute continuous every shift for hypoxia. Resident #17 had diagnoses including chronic respiratory failure with hypoxia, COPD, and dependence on supplemental oxygen, with a physician order for oxygen at 2 liters per minute via nasal cannula continuous every shift for hypoxia. Both residents were observed in bed with supplemental oxygen in place, and neither room had the required oxygen-in-use signage posted. The record review showed both residents had recent room changes, with Resident #1 moved on 4/26/26 and Resident #17 moved on 4/29/26. During interviews, Unit Manager #2 stated that all residents using supplemental oxygen should have the safety oxygen-in-use sign posted on the door frame and that the signs likely were not moved during the room changes. The DON stated the oxygen-in-use signage must have been missed when the room changes occurred. The Administrator stated that when a resident is admitted and requires supplemental oxygen, the safety signage should be posted on the resident's door.
Medication Error Rate Exceeded Threshold
Penalty
Summary
The facility failed to keep the medication error rate below 5%, with 3 medication errors out of 39 opportunities for a rate of 7.69% during medication administration observations for 2 of 4 residents. The deficiency was based on observations, record reviews, manufacturer recommendations, and staff interviews involving Resident #26 and Resident #6. Resident #26 had diagnoses including vitamin D deficiency and hyperlipidemia. Physician orders showed cholecalciferol 25 mcg daily and fenofibrate 40 mg daily. During a medication pass, Nurse #1 administered nine medications to the resident but did not give cholecalciferol or fenofibrate. When questioned, Nurse #1 confirmed the orders and stated the cholecalciferol stock bottle contained 20 mcg, so it was not administered, and fenofibrate was not available for administration. The nurse stated he would follow up with pharmacy regarding delivery of the fenofibrate. Resident #6 had COPD and was ordered fluticasone propion-salmeterol 500-50 mcg twice daily. The manufacturer's instructions stated that after inhalation the patient should rinse the mouth with water without swallowing. During observation, Nurse #6 administered the inhaler but did not prompt the resident to rinse and spit afterward. When interviewed, Nurse #6 confirmed the manufacturer’s instruction and acknowledged she did not prompt the resident to rinse and spit.
Failure to Accurately Document and Reconcile Controlled Medications
Penalty
Summary
The deficiency involves the facility’s failure to accurately document and reconcile controlled medications for multiple residents, and to follow its system for accounting for controlled substances between shift changes and upon receipt or removal from locked storage. For one resident with metastatic cancer, open malignant wound, neuropathy, and a history of spine surgery, hydrocodone-acetaminophen and oxycodone orders were in place for pain management. The hydrocodone-acetaminophen controlled drug record showed 11 removals from storage, while the MAR reflected only one administered dose. The oxycodone controlled drug record showed 13 removals, while the MAR reflected 11 administered doses. Several nurses signed out controlled medications without corresponding MAR documentation, left times blank, or misdated removals. One nurse reported he arrived late for his shift, did not believe a narcotic count was done at shift change, and later signed out additional doses without times to correct an off count, intending another nurse to fill in the times. Another nurse admitted she often became busy and forgot to document administrations on the MAR after removing doses from storage, and another nurse stated she administered a dose but forgot to sign the MAR. The facility’s unit-level controlled substance count sheets also showed multiple deficiencies in reconciliation practices. On one unit, over a period of several days, the controlled substance count sheet documented 20 instances where medication cards were added to or subtracted from the total count. For 11 of these, only one nurse’s signature was present, and for seven there were no nurse signatures at all. In two instances, there was only a notation of “+1” without any information about which medication, which resident, or which nurse was involved. Across multiple days and shifts, required signatures of off-going or on-coming nurses were missing, the number of cards/containers and count sheets was left blank, and there were gaps of up to 36 hours with no documented count or reconciliation. The DON later reported that a count had been reconciled in her presence during one of these undocumented periods, but this reconciliation was not reflected on the count sheet. For another resident with chronic pain receiving Oxycontin twice daily, discrepancies existed between the pharmacy’s records and the facility’s records regarding dispensed and returned doses. The pharmacy’s system showed that 28 Oxycontin tablets were dispensed on one date, that 17 doses from that fill were returned the following day, and that another 28 tablets were sent on the same day as the recorded return. The pharmacist stated they had no record of returned Oxycontin from the later dispense and were still awaiting unused doses. In contrast, the facility’s controlled drug records showed all 28 doses from the first fill were used with none returned, and that 17 doses from the second fill remained after discharge and were returned on a later date. The Corporate Nurse Consultant stated that the facility’s return documentation was pulled directly from the pharmacy’s system and could not explain why the pharmacy’s internal records and the facility’s records could not be reconciled. A third resident with vertebral osteomyelitis and low back pain had orders for scheduled Oxycontin and PRN oxycodone. For this resident, the March MAR and Oxycontin controlled drug record did not consistently match. On one date, a nurse initialed the 10:00 AM Oxycontin dose as given on the MAR, but no corresponding removal was documented on the controlled drug record; the nurse later stated she had not administered the dose because the resident appeared sedated, and that she had signed the MAR before deciding to hold the dose and did not know how to correct the entry. On another date, a nurse documented administration of PRN oxycodone and placed initials with an asterisk and the comment “RC” by the 10:00 PM Oxycontin dose, but no Oxycontin removal was documented; the nurse later stated she had not realized the resident had Oxycontin ordered, gave oxycodone instead, and did not document an explanation for not giving the Oxycontin. On a separate date, another nurse initialed the 10:00 AM Oxycontin dose as administered on the MAR, but there was no corresponding removal on the controlled drug record, and the nurse could not recall why the documentation did not match. The DON stated she expected removal documentation from locked storage to coincide with MAR documentation of administration.
Inaccurate Documentation of Bowel Movements and Controlled Medications
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate and complete medical records for two residents, specifically regarding bowel movement documentation and controlled medication administration. One resident with Stage IV basal cell carcinoma had only three bowel movements documented over a nineteen-day stay, despite nursing staff and the DON acknowledging that the resident had more bowel movements than recorded. The facility’s system was designed to flag when a resident went three days without a bowel movement so that medications could be administered if needed, but the actual frequency of bowel movements was not accurately reflected in the medical record. For the same resident, record review showed multiple instances where hydrocodone-acetaminophen and oxycodone were removed from controlled drug storage, as documented on the Controlled Drug Record, but there was no corresponding documentation of administration on the MAR. Nurse #1 confirmed that she had administered both hydrocodone-acetaminophen and oxycodone at the times she signed out the medications but failed to document these administrations on the MAR. Another nurse (Nurse #6) also reported administering a dose of hydrocodone-acetaminophen that she removed from storage but forgot to sign for on the MAR. The DON stated that the resident was at risk for constipation due to pain medications and acknowledged that the record was incomplete and did not accurately reflect the resident’s status. A second resident with vertebrae osteomyelitis and low back pain had an order for scheduled Oxycontin and PRN oxycodone for breakthrough pain. Review of this resident’s MAR and Oxycontin Controlled Drug Record showed that a nurse (Nurse #13) initialed that a scheduled Oxycontin dose was given, even though she did not administer it because the resident appeared sedated. Nurse #13 explained that she had signed the MAR before deciding to hold the dose and was unfamiliar with how to correct the electronic MAR to show that the medication was not actually administered. She confirmed that the medical record was therefore not accurate. The interim Administrator stated an expectation that medical records be complete regarding documentation of bowel movements and controlled medications.
Failure to Arrange Transportation for Critical Follow-Up Appointments
Penalty
Summary
The facility failed to ensure that transportation was arranged for a resident’s scheduled follow-up oncology and nephrology appointments after discharge from the hospital and admission to the facility. The resident had Stage IV basal cell carcinoma with metastatic disease to the lung and bone, as well as Stage IV kidney disease. The hospital discharge summary included multiple diagnostic and physician appointments for a specific date, including a preclinical PET scan and visits with an oncologist and nephrologist, with times, departments, and locations clearly listed. A physician progress note documented that the resident’s family member informed the physician that an oncology follow-up was scheduled in about 10 days and asked whether transportation could be arranged. On the day of the scheduled appointments, the family member went to the oncology appointment expecting to meet the resident there, believing the facility had arranged transportation, but the resident did not arrive and all appointments were missed. Interviews and record review showed that the facility’s internal process for reviewing hospital discharge summaries and arranging transportation was not followed for this resident. The Transportation Nurse Aide stated that nursing staff are supposed to read the discharge summary for new admissions and then give it to her so she can identify and arrange transportation for any listed appointments. She reported that she never received this resident’s discharge summary, was not informed of the scheduled appointments, and therefore did not arrange transport, although she could have taken the resident if she had known. The Social Worker stated she was unaware of the missed appointments and that the Transportation Nurse Aide routinely checked discharge summaries and arranged transport, with the Social Worker assisting if the aide was absent. The DON confirmed that the Transportation Nurse Aide should have been given the discharge summary to arrange transportation but this did not occur, and the admitting nurse who might have provided further information was unavailable for interview due to a personal emergency.
Failure to Provide Timely Pain Medication to Resident With Metastatic Cancer
Penalty
Summary
The deficiency involves the facility’s failure to provide timely, ordered pain management to a cognitively intact resident with stage IV basal cell carcinoma metastatic to lung and bone, an open malignant wound to the posterior left shoulder, neuropathy, and a history of cervical and thoracic spine surgery. The resident’s admission MDS documented frequent moderate pain interfering with daily activities, with reported pain up to 7/10, and the care plan directed staff to encourage the resident to request PRN pain medication and to offer it as ordered. Physician orders included hydrocodone 5-325 mg every four hours PRN, oxycodone 10 mg every six hours PRN, and gabapentin 800 mg three times daily. The resident’s family member reported that the resident had told him it often took a couple of hours after calling before staff administered pain medication, describing this as a general problem rather than a single incident. On the evening in question, assignment sheets showed that one nurse was assigned to the resident beginning at 7:00 PM. The MAR for that date showed the evening gabapentin dose was documented with another nurse’s initials, with no time of administration, and the first oxycodone dose on that shift was not given until 1:48 AM the following day, with no hydrocodone documented for that shift. A nurse aide who cared for the resident that evening reported that during initial rounds between 7:00 PM and 7:30 PM, the resident requested pain medication, and she relayed this to the assigned nurse, who said she would get to it. Around 8:30 PM, the resident again reported he still had not received pain medication, and the aide stated she could not locate the assigned nurse despite repeatedly looking for her and observing that the nurse’s medication cart remained in the same place. The aide reported the resident repeatedly called out that he was in pain and that he did not go to sleep because he was hurting. Another nurse, assigned to a different unit, reported being alerted by staff that the assigned nurse was asleep in her car while residents on that unit, including this resident, needed medications. She stated she could not access the resident’s medications because the assigned nurse had the keys to the medication cart. She contacted the on-call nurse and the DON for assistance and was instructed multiple times to try to awaken the assigned nurse in her car. She and other staff attempted to wake the assigned nurse, who briefly cracked the car door but did not return to the building and went back to sleep. The DON reported receiving calls about the situation later that night, directing staff to awaken the assigned nurse and instructing her to return inside, and then ultimately coming to the facility after midnight, having the assigned nurse reconcile controlled substances, and sending her home. The assisting nurse stated that by the time the DON arrived, the resident still had not received pain medication, and that she was only able to administer oxycodone around 2:00 AM, at which time the resident had tears in his eyes and rated his pain as 20/10. The assigned nurse later stated she had not been feeling well, had gone to her car for a break, and was not aware the resident was in pain or that he had not received pain medication.
Failure to Complete STAT X‑Ray After Fall With New Left Leg Pain
Penalty
Summary
The deficiency involves the facility’s failure to obtain a STAT mobile x‑ray as ordered after a resident fall and subsequent complaint of left leg pain. The resident had multiple significant diagnoses, including end stage renal disease, pulmonary hypertension, COPD, chronic respiratory failure, CHF, atrial fibrillation, sick sinus syndrome with pacemaker, hypertension, Type 2 diabetes, osteoarthritis, gait difficulty, muscle weakness, and disability-related activity limitations. An admission MDS showed severely impaired cognition but ability to understand and be understood, no prior falls since admission, and receipt of dialysis and multiple therapies. The care plan identified the resident as at risk for falls related to debility and difficulty walking, with a goal to remain free from falls with major injury. On the morning of 02/16, the resident was found on the floor by nurse aides after reportedly sliding off the bed while trying to sit on the edge. The wound care nurse (Nurse #2) assessed the resident, documented no injuries, and the resident denied pain; range of motion of all extremities was reportedly normal, and the resident was talking about going shopping. Nurse aides who assisted confirmed that the resident did not complain of pain and was able to move all extremities. Nurse #2 stated she notified the resident’s representative (RR) about this first fall, although the event report erroneously documented notification of the resident instead of the RR. Later that day, the NP assessed the resident for gout pain in the left great toe and also checked her leg because of the earlier fall, finding normal range of motion and no signs of pain or suspicion of hip fracture at that time. Late that night on 02/16, a second fall was documented by Nurse #1 as a late entry. Nurse #1 recorded that the resident was found on the floor at the bedside, denied hitting her head, and had no bruising or bleeding, but did complain of left leg pain on assessment with range of motion, though no deformity was noted. Nurse #1 notified the on‑call physician and obtained a STAT order for x‑rays of the left femur and hip related to the fall, and documented notifying the RR. The DON later stated that STAT mobile x‑rays were normally completed within four hours. However, the ordered STAT x‑ray was not completed that night. The DON reported that the mobile x‑ray company indicated the responding technician was new, did not have the door code, and was unable to reach staff by doorbell or phone, so the exam was not performed. On the morning following the second fall, the RR arrived and reported the resident was moaning in pain and requested Tylenol before dialysis. Nurse #3 stated she initially did not perform a full assessment because she relied on Nurse #1’s prior assessment and the existing STAT x‑ray order, but later recalled that, after the RR voiced concern about pain, she assessed the resident by listening to lungs, palpating the abdomen and both hip areas, and bending both legs at the knees. She reported the resident denied pain, did not verbalize pain during the assessment, and only grimaced or closed her eyes with movement; she stated she administered Tylenol but failed to document it on the MAR, and she considered the resident appropriate to attend dialysis. The DON stated she saw the resident sitting in a wheelchair laughing while waiting for transport and did not assess pain at that time, and that she contacted the NP, who reportedly said that if the resident was not in distress it was acceptable to proceed with dialysis and obtain the x‑ray later. The mobile x‑ray technician arrived later that day to perform the STAT x‑ray but the resident had already left for dialysis, and the technician indicated the exam would be rescheduled. Nurse #3 documented that the RR reported the resident was having left leg pain when being repositioned before dialysis, that the resident grimaced with movement, and that Tylenol was given. The DON stated she had delegated a call to the dialysis unit to check on the resident’s status; the dialysis nurse reportedly told facility staff that the resident was sleeping and had no complaints of pain, although the dialysis provider’s documentation showed the resident continued to complain of left lower extremity pain during dialysis and requested to end treatment early. The NP later reviewed the case and noted that, given the resident’s diagnoses and the presence of a hip fracture, she had been at risk for shortness of breath or a cardiovascular event during transfer to dialysis, but that she had not experienced these outcomes. The RR reported she believed the resident should have been sent to the hospital after the second fall and that she learned at the hospital that the resident required surgery for a hip fracture. The facility’s failure to ensure that the ordered STAT x‑ray was obtained promptly after the second fall, and to complete timely diagnostic evaluation of the resident’s reported left leg pain, constituted the deficiency.
Significant Medication Errors Due to Missed Insulin Doses and Failure to Discontinue Steroid
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by missed doses of scheduled rapid-acting insulin for two residents and a failure to discontinue a steroid medication as recommended for another resident. For two residents with diabetes, scheduled doses of insulin aspart were not administered in the morning due to a staffing issue. The Medication Administration Records (MAR) indicated that the morning doses were missed, and there was no documentation of blood sugar readings prior to the scheduled administration times. The nurse on duty reported that he was only notified of the need to pass medications after arriving late, and by that time, it was already time for the next scheduled insulin doses. The physician was informed and directed staff to hold the missed doses and proceed with the next scheduled administration. Both residents did not experience adverse events from the missed doses, but the medications were not given as ordered. Another resident with a diagnosis of pulmonary sarcoidosis continued to receive prednisone, a corticosteroid, despite a pulmonologist's consultation recommending discontinuation of the medication. The consultation report was signed by the unit manager, but the order to discontinue prednisone was not implemented until several months later. The MAR showed that the resident continued to receive prednisone every other day until the order was finally discontinued. Interviews with the previous DON and medical directors revealed that the consultation report was either not reviewed with the physician or the recommendation was not acted upon in a timely manner. The administrator was unaware that the consultation report had not been reviewed and that the medication had not been discontinued as recommended. These deficiencies were identified through record review, staff and resident interviews, and review of consultation reports. The facility's failure to administer medications as ordered and to follow up on consultation recommendations resulted in significant medication errors for three residents. The events were attributed to staffing issues, lack of communication, and failure to implement physician recommendations in a timely manner.
Insufficient Nursing Staff Leads to Missed Insulin Doses
Penalty
Summary
The facility failed to ensure sufficient nursing staff were present to meet the needs of all residents, resulting in significant medication errors for two residents with diabetes. On the morning in question, two of three assigned staff members, a Medication Aide and a Unit Manager, did not report to work as scheduled. This left only one nurse on duty for the three units, and the absence of staff was not promptly addressed, leading to a delay in medication administration. As a result, two residents who required scheduled morning doses of rapid-acting insulin did not receive their medication as ordered. One resident, who was cognitively intact, reported not receiving his insulin after breakfast due to the absence of the assigned staff member. The other resident, who had severe cognitive impairment, also missed the scheduled insulin dose. The Medication Administration Records confirmed that the insulin was not administered, and notes indicated the missed doses were due to overlapping doses from late administration, with the physician being made aware. Interviews with staff revealed that the scheduler was aware of the staffing shortage early in the shift and attempted to find replacements but was unsuccessful. The previous DON and other nursing staff arrived later in the day, but by that time, the morning medications had already been missed. Communication lapses among staff contributed to the delay in addressing the staffing issue, and the absence of key personnel directly led to the failure to administer critical medications as scheduled.
Failure to Follow Care Plan for Safe Transfer Results in Resident Fracture
Penalty
Summary
A deficiency occurred when a resident, who had a history of cerebral vascular accident, hemiplegia, hemiparesis, heart failure, and diabetes mellitus, was transferred from a wheelchair to a bed by a nurse aide without the use of a mechanical lift, as required by the resident's care plan. The resident was documented as cognitively intact but dependent on staff for transfers and had range of motion impairment on one side. The care plan specifically indicated the need for a mechanical lift for all transfers. On the day of the incident, the agency nurse aide performed a one-person assist transfer, lifting the resident manually from the wheelchair to the bed. The aide did not use the mechanical lift, despite being instructed by another nurse aide to do so and being informed that assistance was available if needed. The resident reported being picked up and thrown onto the bed, resulting in immediate pain. The aide acknowledged performing the transfer alone and stated that the resident complained of mild pain, which was reportedly relieved with repositioning. Following the transfer, the resident experienced significant pain and swelling in the left knee, which was assessed by nursing staff. The pain persisted despite administration of acetaminophen and other interventions. The resident was eventually sent to the emergency department, where imaging revealed a comminuted and displaced fracture of the distal femur. The incident was confirmed through interviews with staff and review of documentation, which showed that the transfer was not performed according to the resident's care plan and that the required mechanical lift was not used.
Failure to Update Facility Assessment for Tracheostomy Care
Penalty
Summary
The facility failed to annually review and update its facility-wide assessment, which is necessary to determine the resources required to care for residents competently during both day-to-day operations and emergencies. This oversight had the potential to affect all 80 residents in the facility. Specifically, the facility assessment inaccurately indicated that there were no residents requiring tracheostomy care, despite medical records showing that two residents had tracheostomies and required such care. The facility was unable to provide documentation demonstrating that the facility assessment had been reviewed and updated since 2023. During an interview, the Administrator acknowledged that it was her responsibility to ensure the facility assessment was current and admitted she was unaware that the assessment was outdated, having forgotten to conduct a review in 2024.
Inaccurate MDS Coding for Residents
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for several residents, leading to discrepancies in their medical records. Resident #15, who was admitted with end-stage renal disease and initially required dialysis, had improved kidney function and no longer needed dialysis upon discharge back to the facility. However, the MDS assessment incorrectly indicated that the resident was still receiving dialysis due to an assumption made by MDS Nurse #1 based on a physician order for monitoring the shunt site. Resident #57, diagnosed with vascular dementia, had an active physician order for a wander guard alarm, which was in place as per the Medication Administration Record (MAR). Despite this, the MDS quarterly assessment failed to reflect the use of the wander guard alarm. MDS Nurse #1 acknowledged missing this detail during the assessment process. Similarly, Resident #44, who had diabetes and was on insulin glargine, was not coded for the use of hypoglycemic medication in the MDS assessment, an oversight admitted by MDS Nurse #1. Resident #70, who was readmitted to the facility with end-stage renal disease and dependence on dialysis, was not correctly coded in the MDS assessment to reflect his dialysis treatment. The resident had been hospitalized for sepsis and returned without dialysis orders, but the MDS should have indicated the ongoing need for dialysis. The Director of Nursing noted that the dialysis order was not reinstated upon the resident's return from the hospital. In all cases, the Administrator confirmed that the MDS Nurse was responsible for ensuring accurate coding of resident assessments.
Medication Management and Security Deficiencies
Penalty
Summary
The facility failed to properly label and store medications on two separate medication carts, leading to deficiencies in medication management. On Unit 3, an insulin lispro injector pen was found open without a date or resident identifiers, and an albuterol inhaler was similarly unlabeled. The Unit Manager confirmed these findings, and the Director of Nursing acknowledged that all nurses were responsible for ensuring medications were labeled and dated. Additionally, on Unit 1, a netarsudil ophthalmic solution was found unrefrigerated, contrary to the manufacturer's storage recommendations. The Director of Nursing stated that nurses were responsible for checking medication storage. Furthermore, the facility failed to secure a wound treatment cart on Unit 3, which was found unattended and unlocked. The cart contained resident creams, ointments, medicated dressings, and treatment supplies. The Administrator and Nurse #2 were present at the nursing station but did not notice the unlocked cart until it was pointed out by the surveyor. The Director of Nursing confirmed that the cart should have been locked when unattended, and all nursing staff were aware of this requirement.
Failure to Maintain Sanitary Kitchen Conditions
Penalty
Summary
The facility failed to maintain kitchen equipment in a clean and sanitary condition, which could potentially lead to cross-contamination of food served to residents. During a lunch meal observation, the two-cylinder plate dispenser was found with dark dried food particles at the bottom of both cylinders, and the plate tray had dried liquid stains. This condition was observed on two consecutive days, indicating a lack of regular cleaning. The District Dietary Manager acknowledged that the plate dispenser was kept plugged in at all times, and staff had overlooked cleaning inside the cylinders. Additionally, the shelf under the steam table was observed to be covered with dark dried food particles during kitchen inspections. Despite having a weekly cleaning schedule that included the steam table, the Certified Dietary Manager admitted that the cleaning was not adequately performed. The Administrator confirmed that the dietary staff should maintain cleanliness in all kitchen areas, including the plate dispenser and steam table shelves, but these areas were neglected in the cleaning routine.
Improper Garbage Disposal in Dumpster Area
Penalty
Summary
The facility failed to ensure proper disposal of garbage and refuse, as observed in the dumpster area. On the morning of January 7, 2024, a large bag of garbage was seen hanging out of the lid of Dumpster #1, and two disposable gloves were found on the ground behind it. Later that afternoon, the lid and right-side door of Dumpster #1 were open, with additional litter, including three disposable gloves, a soda bottle, and straw papers, scattered around the area. The Dietary District Manager confirmed that the area had been cleaned earlier that day, but the waste company did not pick up the dropped items. The facility's Administrator stated that all staff were responsible for maintaining the cleanliness of the dumpster area, and the Corporate Administrator suggested assigning a staff member to inspect the area daily.
Failure to Complete MDS Significant Change Assessment for Hospice Admission
Penalty
Summary
The facility failed to complete a Minimum Data Set (MDS) Significant Change in Status Assessment for a resident who was admitted with a diagnosis of malignant neoplasm. The resident was initially identified as cognitively intact, had a tracheotomy, and was not receiving hospice services at the time of admission. However, a physician order dated 11/21/24 indicated that the resident was to be admitted to hospice due to the terminal diagnosis, with a life expectancy of six months or less. Despite this significant change in the resident's status, there was no documentation in the medical record that an MDS significant change in status assessment had been completed to reflect the initiation of hospice services. Interviews with the MDS Nurse and the Administrator confirmed that the assessment should have been completed when the resident began receiving hospice services. The MDS Nurse acknowledged the oversight, and the Administrator stated that the MDS Nurse should have reviewed the resident for a significant change in status assessment upon the election of hospice services.
Failure to Develop Person-Centered Care Plan for Resident
Penalty
Summary
The facility failed to develop a person-centered care plan for a resident with severe cognitive impairment, who had expressed specific activity preferences. The resident, admitted with diagnoses including stroke and dementia, indicated that activities such as reading, listening to music, attending religious services, and being outdoors were very important. However, the resident's care plan, last reviewed in early January 2025, did not include any provisions related to these activity preferences. Observations over several days showed the resident consistently in their room with the television on, and the responsible party was unaware of any activities provided by the facility. Interviews with facility staff revealed a lack of clarity and responsibility regarding the development and implementation of the resident's activity care plan. The Activity Director, who had been in the role for over a year, admitted to not having created care plans previously and only recently being shown how to do so. The MDS Nurse indicated that the Activity Director was responsible for the activity-focused care plan, while the Administrator expected the MDS Nurses to assist when needed. This lack of coordination and clear responsibility led to the deficiency in providing a person-centered care plan for the resident.
Failure to Obtain Physician Order for Tracheostomy Care
Penalty
Summary
The facility failed to obtain a physician order for tracheostomy care for a resident who was admitted with a tracheostomy. The resident, identified as Resident #35, was admitted with a diagnosis that included a tracheostomy and had physician orders for oxygen via tracheostomy collar and suctioning needs. However, there was no physician order documented for tracheostomy site care, and the Treatment Administration Record for December 2024 and January 2025 lacked documentation of such care. Interviews with nursing staff revealed that tracheostomy care was being provided at least once per shift, including cleaning around the tracheostomy site and suctioning as needed. Despite this, the Unit Manager confirmed that a physician order for tracheostomy care was not entered upon the resident's admission, and the Director of Nursing was unable to explain how this oversight occurred. The deficiency was identified during a survey, highlighting a lapse in ensuring proper documentation and physician orders for necessary respiratory care.
Failure to Ensure Physician's Order for Dialysis
Penalty
Summary
The facility failed to ensure that a resident receiving dialysis had a physician's order for dialysis. This deficiency was identified for a resident who was admitted with end-stage renal disease and was dependent on renal dialysis. The resident's care plan included specific instructions for managing dialysis-related care, such as coordinating with the dialysis center and monitoring the shunt site. However, after the resident was readmitted from the hospital, the dialysis order was not reinstated, and this oversight was confirmed through staff interviews. The deficiency was further highlighted when the resident was sent to dialysis without a documented physician's order. Interviews with the Unit Manager and the Director of Nursing revealed that the staff failed to reestablish the dialysis order upon the resident's return from the hospital. The Administrator also acknowledged that the staff should have ensured the presence of a physician's order for dialysis. This lapse in documentation and communication led to the deficiency being cited during the survey.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to notify the Ombudsman in writing of resident transfers to the hospital for two residents. Resident #35 was transferred to the hospital on two occasions, but the Ombudsman was not notified of these transfers. The Social Service Director, who started in the position in July 2024, was running the wrong report, which did not show any resident transfers or discharges. This error was discovered during interviews with the Ombudsman and the Social Service Director, who admitted to not knowing how to run the correct report until recently. Similarly, Resident #11 was transferred to the Emergency Department on two occasions due to changes in condition, but there was no documentation that the Ombudsman was notified of these transfers. The Director of Nursing and the interim Administrator confirmed that it was the responsibility of the Social Service Director to send these notifications, but they were unaware that the notifications were not sent. The deficiency was identified through record reviews and staff interviews, highlighting a lapse in the facility's notification process to the Ombudsman.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 16 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Roanoke Rapids
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Liberty Commons Nursing And Rehabilitation Center | 3.5 mi | ★★★★★ | 1 | 0 |
| Northampton Nursing And Rehabilitation Center | 15.5 mi | ★★★★★ | 3 | 0 |
| Emporia Rehabilitation And Healthcare Center | 18.5 mi | ★★★★★ | 3 | 0 |
| Greensville Health And Rehabilitation Center | 18.5 mi | ★★★★★ | 0 | 0 |
| Rich Square Nursing & Rehabilitation Center | 24 mi | ★★★★★ | 9 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Signature Healthcare Of Roanoke Rapids.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.