Average — CMS composite of the measures below.
The next survey window likely opens around March 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 The Lodge At Rocky Mount Health And Rehabilitation during CMS and state inspections, most recent first.
Surveyors found multiple opened medications without dates and expired drugs remaining on several medication carts and in a medication room. On one cart, a nurse had undated ophthalmic ointment, inhaler, creams, eye drops, and artificial tears, all with manufacturer discard timeframes after opening. Another cart overseen by a CMA contained an opened multivitamin with iron past its expiration date, despite the CMA reporting she checks for expired meds daily. A third cart had expired Melatonin tablets and glucose gel, along with undated Fluticasone nasal sprays and Nystatin cream. In a medication room managed by a unit manager, surveyors found expired multivitamins and an undated, accessed Tuberculin PPD vial in the refrigerator. The UM, DON, and Administrator all stated that nurses, CMAs, and nursing administration were responsible for dating opened meds and routinely checking carts and rooms for expired medications.
The facility failed to accurately post daily nurse staffing information when reception staff, using schedules prepared from a master schedule, completed the public staffing report without understanding that some RNs, LPNs, and NAs were splitting shifts or working 12‑hour shifts. Receptionists counted each name on the schedule as a full staff member for the entire shift, did not receive updates on call‑outs or schedule changes, and did not revise the posted report once it was placed in the lobby. The Scheduler did not communicate staffing changes to reception, and the Administrator did not review the report for accuracy, resulting in repeated discrepancies between posted staffing levels and actual scheduled staffing across all three shifts on most days reviewed.
Surveyors found that MDS assessments were inaccurately coded for two residents: one resident receiving clopidogrel was incorrectly coded as taking an anticoagulant instead of an antiplatelet, and another resident with severe dementia who wore a wander/elopement alarm bracelet was not coded for alarm use on the quarterly MDS. The MDS nurse reported she misinterpreted an order referencing anticoagulant monitoring in the first case and did not code the alarm in the second case because there was no physician order, despite knowing the alarm was in place and it being documented in the care plan and elopement risk assessment.
A resident with significant medical needs slid out of her wheelchair during van transport after an abrupt stop, resulting in her foot becoming wedged and a subsequent ankle fracture. The transport driver, lacking specific emergency training, moved the resident without a clinical assessment and continued to the hospital, where the injury was later identified and treated. Interviews confirmed the resident was not assessed by a licensed professional prior to being moved.
A resident with right-sided hemiparesis and dependent on staff for wheelchair mobility was not properly secured in a facility van during transport, as the lap/shoulder belt was placed over the wheelchair armrest instead of directly against the body. During an abrupt stop, the resident slid out of the wheelchair, resulting in a trimalleolar ankle fracture that required a splint and opioid pain management.
The facility failed to maintain kitchen equipment in a sanitary condition, with seven out of nine baking sheets found with dark dried grease buildup. Observations revealed these unsanitary baking sheets were stacked and ready for use. The Dietary Manager and Administrator acknowledged the need for proper cleaning and adherence to the cleaning schedule.
The facility failed to implement its infection prevention and control program for droplet precautions, as observed with three staff members not adhering to protocols for residents with influenza. A Social Worker and a Nurse Aide exited rooms without removing their surgical masks, and the Maintenance Director entered a room without wearing a mask. Despite education on the procedures, these lapses occurred, highlighting a deficiency in following established infection control measures.
A resident with generalized epilepsy did not receive phenytoin for 19 days due to a mismanaged medication order. The Unit Manager mistakenly discontinued the order without proper verification, and the error went unnoticed until the resident was hospitalized for an unrelated issue. The facility lacked a robust process to ensure medication orders were correctly implemented.
A facility failed to develop a care plan for a resident with hearing impairment. The resident, with moderate cognitive impairment and hearing difficulty, was found without hearing aids, which were charging nearby. Staff interviews revealed confusion over responsibility for implementing the care plan, with the Social Worker admitting to missing it. The Administrator confirmed the oversight but could not recall if it was reviewed in meetings.
A resident with a neurogenic bladder experienced discomfort due to unsecured indwelling catheter tubing. Despite a physician's order to check catheter securement every shift, staff interviews and observations revealed inconsistent adherence to this directive, with the tubing often left unsecured and the leg strap not consistently used.
Failure to Date Opened Medications and Remove Expired Drugs From Carts and Medication Room
Penalty
Summary
The deficiency involves failure to ensure medications were properly dated when opened and that expired medications were removed from use on multiple medication carts and in a medication room. During an observation of the North Hall 3 medication cart with a nurse, surveyors found several opened and used medications without dates, including Erythromycin ophthalmic ointment, a Trilogy Elipta inhaler, Nystatin cream, Clotrimazole Betamethasone Dipropionate lotion, Rhopressa eye drops, and artificial tears, all of which had manufacturer instructions specifying discard timeframes after opening. The nurse stated that all medications in the cart were supposed to be dated when opened and that it was the responsibility of the nurse assigned to the cart to check it. On the North Hall 1 medication cart, observed with a CMA, surveyors found an opened and used bottle of multivitamin with iron with remaining pills and an expiration date that had already passed; the CMA stated she checks the cart daily for expired medications and had missed that bottle. On the South Hall medication cart, observed with another CMA, surveyors identified an opened bottle of Melatonin tablets and an unopened box of microdot glucose gel, both past their expiration dates, as well as four undated, opened bottles of Fluticasone Propionate nasal spray and one undated, opened Nystatin cream tube, all with manufacturer discard instructions after opening. In the South Hall medication room, observed with the South Unit Manager, surveyors found two unopened bottles of multivitamins past their expiration date and an undated, accessed bottle of Tuberculin PPD solution in the refrigerator. The South Unit Manager stated she was responsible for the medication room and that medication rooms were to be checked weekly by unit managers, and acknowledged that the PPD should have been dated when opened and that the refrigerator should be included in checks. The DON and Administrator both stated that nursing staff and nursing administration were responsible for checking medication carts and rooms and for dating and discarding medications, but were unsure how the identified issues were missed.
Inaccurate Posting of Daily Nurse Staffing Information
Penalty
Summary
The deficiency involves the facility’s failure to post accurate daily licensed and unlicensed nurse staffing information for the majority of days reviewed. Surveyors compared the posted “Report of Nursing Staff Directly Responsible” with the daily nursing schedules and Salaried Employee Sheets over a one‑month period and found discrepancies on 28 of 31 days. For multiple dates and shifts, the numbers of RNs, LPNs, and NAs listed on the posted report did not match the actual staffing reflected on the internal schedules and payroll-related records. Examples included days where the posted report showed more NAs or LPNs than were scheduled, days where RNs were listed on the report but were either not scheduled or marked as off on the Salaried Employee Sheet, and days where the posted counts of staff were higher or lower than the daily schedule for all three shifts. The inaccuracy was linked to how the Report of Nursing Staff Directly Responsible was prepared and the lack of understanding of split shifts and 12‑hour shifts by the staff completing the form. The Staff Development Coordinator (SDC) created the master nursing schedule, and the Scheduler generated the daily staffing schedule from it. The Scheduler then emailed the daily schedule to reception staff, who were responsible for completing and posting the report in the lobby. Receptionists reported that they had been trained by the previous Business Office Manager and other reception staff to count each name on the schedule as one staff member for the shift totals. They did not understand that when two names were listed for the same assignment, this represented two staff splitting one shift, not two full staff for the entire shift. As a result, they routinely overcounted staff when shifts were split. Reception staff also reported that they completed and posted the report in the morning and did not update it throughout the day. They stated they did not receive information about call‑outs or schedule changes and therefore did not adjust the posted staffing numbers once the form was initially completed. The Scheduler confirmed that she did not complete the posted report and did not take staff call‑outs or notify reception of changes to the daily staffing schedule. The previous Business Office Manager acknowledged that she had trained reception staff to count each person listed on the schedule as one staff member and was not aware that two people listed for the same assignment could indicate a split shift. The Administrator stated that she had not been reviewing the Report of Nursing Staff Directly Responsible for accuracy prior to its posting, which contributed to the ongoing posting of inaccurate staffing information over the review period. No specific residents, medical histories, or clinical conditions were described in relation to this deficiency. The focus of the findings was on the facility’s processes, documentation, and staff understanding related to the preparation and posting of daily nurse staffing information, and the repeated discrepancies between what was posted for public view and what was actually scheduled and recorded internally.
Inaccurate MDS Coding for Anticoagulant/Antiplatelet Use and Wander Alarm
Penalty
Summary
The facility failed to ensure accurate coding of the MDS assessments for two residents in the areas of anticoagulant/antiplatelet medication use and use of a wander/elopement alarm. For one resident admitted with hypertension, the clinical record showed a physician order and MAR documentation for daily clopidogrel, an antiplatelet medication, with no anticoagulant medication ordered or administered during the assessment period. However, the admission MDS assessment was coded to indicate the resident was receiving an anticoagulant and did not reflect antiplatelet use. In interview, the MDS nurse acknowledged that she had incorrectly coded anticoagulant use after seeing an order to monitor for signs and symptoms related to anticoagulant therapy and confirmed the assessment should have been coded for antiplatelet medication instead. For another resident with severe unspecified dementia and a history of attempting to exit the facility without alerting staff, the care plan documented a wander guard on the right ankle initiated earlier in the stay, and an elopement risk assessment completed upon readmission documented that a wander/elopement alarm bracelet was placed. A quarterly MDS assessment for this resident showed severe cognitive impairment but did not code the use of a wander/elopement alarm. Observation later confirmed the resident was wearing a wander/elopement alarm bracelet on the right ankle, and the active physician orders did not include an order for the device. The MDS nurse stated she was aware the resident had a wander/elopement alarm bracelet but believed she had not coded it because there was no physician order, and the Administrator stated the MDS nurse should have used physical observation or nursing staff input to determine if the alarm was in place to ensure accurate coding.
Failure to Assess Resident for Injury Prior to Movement After Fall During Transport
Penalty
Summary
A deficiency occurred when a resident, who had a history of stroke with right-sided hemiparesis, end-stage renal disease requiring dialysis, anxiety, and depression, was being transported to a medical appointment. During the trip, the transportation driver made an abrupt stop to avoid a collision, causing the resident to slide out of her wheelchair and wedge her left foot under the driver's seat. The driver, who was a Nursing Assistant and Medication Assistant but had not received specific training for such emergencies, pulled the resident's foot out, repositioned her in the wheelchair, and continued driving to the hospital without having the resident assessed for injury by a qualified professional prior to moving her. Upon arrival at the hospital, the resident had again slid out of the wheelchair, with her back against the legs of the wheelchair and the rest of her body on the floor of the van. The resident was observed to have a visibly swollen ankle and was in significant pain. Hospital staff assisted in moving the resident and directed that she be taken to the Emergency Department, where she was diagnosed with a nondisplaced trimalleolar fracture of the left ankle. The resident required pain management and immobilization of the ankle. Interviews with the transportation driver, the resident, the facility administrator, and the physician confirmed that the resident was not assessed by a licensed medical professional prior to being moved after the fall. The physician specifically stated that residents should always be assessed after a fall by a licensed professional before being moved, as moving without assessment could result in further injury. The transportation driver admitted to not contacting the facility immediately and to lacking training on emergency procedures during transport.
Failure to Properly Secure Resident in Transport Van Results in Injury
Penalty
Summary
A deficiency occurred when a resident was not safely secured in a facility transportation van according to the manufacturer's instructions during a trip to a medical appointment. The resident, who had a history of stroke with right-sided hemiparesis, end-stage renal disease requiring dialysis, and was dependent on staff for transfers and wheelchair mobility, was being transported by a facility driver. During the trip, the driver made an abrupt stop to avoid a collision, causing the resident to slide out of her wheelchair, with her left foot becoming wedged under the driver's seat. The driver stopped the van, repositioned the resident, and continued to the hospital. Upon arrival, the resident had again slid out of the wheelchair, with her back against the wheelchair legs and the rest of her body on the van floor. The manufacturer's instructions for the van's securement system specified that the lap and shoulder belts should be positioned directly against the passenger's body, not obstructed by wheelchair components such as armrests, and should be worn low across the pelvis. However, during a reenactment, it was demonstrated that the lap/shoulder belt had been placed over the wheelchair's armrest, preventing it from being firmly pressed against the resident's lap. This improper securement allowed the resident to slide out of the wheelchair during sudden vehicle movement. Staff interviews and observations confirmed that the resident was not secured per the manufacturer's guidelines, and the armrest of the wheelchair interfered with proper belt placement. As a result of the improper securement, the resident suffered a nondisplaced trimalleolar fracture of the left ankle, which required a splint and opioid medication for pain management. The incident was documented in medical records, and interviews with staff, the resident, and the physician confirmed the sequence of events and the resulting injury. The deficiency affected one of three residents reviewed for accidents.
Unsanitary Kitchen Equipment
Penalty
Summary
The facility failed to maintain kitchen equipment in a clean and sanitary condition, specifically concerning seven out of nine baking sheets. During an observation on February 5th, the dish drying rack in the kitchen was found to have seven stacked baking sheets with dark dried grease built up under the rim. A subsequent observation on February 6th revealed that the same baking sheets were stacked and ready for use on the rolling food preparation rack, still in the same unsanitary condition. In an interview, the Dietary Manager acknowledged that staff should have cleaned the baking sheets to remove the grease buildup. The Administrator also stated that the dietary department should adhere to their cleaning schedule and ensure a deep clean of the baking sheets.
Failure to Adhere to Droplet Precautions for Influenza
Penalty
Summary
The facility failed to implement its infection prevention and control program policies and procedures, specifically regarding droplet precautions for residents with influenza. Three staff members, including a Social Worker, Maintenance Director, and Nurse Aide, did not adhere to the established protocols. The Social Worker was observed exiting a resident's room on droplet precautions without removing her surgical mask, despite having been educated on the necessary infection control measures. She confirmed her awareness of the droplet precautions but was unaware that removing the mask upon exiting was part of the protocol. The Maintenance Director was observed entering and exiting a resident's room on droplet precautions without wearing a surgical mask. He acknowledged the oversight, stating he entered the room briefly to move a bedside table and confirmed his understanding that a mask should have been worn. The Infection Preventionist confirmed that all staff had been educated on the droplet precautions, which included wearing a mask before entering and removing it upon exiting the room. Nurse Aide #1 was also observed exiting a resident's room on droplet precautions without removing her surgical mask. She admitted to forgetting to remove the mask, despite having received education on the protocol earlier that day. The Infection Preventionist reiterated that all staff had been educated on the requirements, and the facility had posted instructions on each resident's room. The facility had also taken measures to minimize the spread of influenza, such as offering vaccines and monitoring residents for symptoms.
Medication Order Mismanagement Leads to Non-Administration of Seizure Medication
Penalty
Summary
The facility failed to clarify a physician order for phenytoin, a medication used to treat epilepsy, for a resident diagnosed with generalized epilepsy. This oversight resulted in the medication not being administered for 19 days. The resident had a physician order for phenytoin sodium extended 100 mg capsule to be given twice a day on specific days of the week. However, due to a misunderstanding, the order was discontinued by the Unit Manager without proper verification or a physician's directive to do so. The resident, who had moderate cognitive impairment and a history of phenytoin toxicity, was admitted with diagnoses including generalized epilepsy and stroke. A laboratory result indicated a sub-therapeutic phenytoin level, prompting the Nurse Practitioner to increase the dosage. However, the Unit Manager mistakenly discontinued the new order, believing it to be a duplicate, and did not verify the change with the Nurse Practitioner. This error went unnoticed until the resident was hospitalized for an unrelated incident. Interviews with facility staff revealed a lack of communication and verification processes. The Unit Manager did not review the end-of-day communication from the Nurse Practitioner, which included the medication change. The Director of Nursing and the Administrator were unaware of the discontinuation until after the resident's hospitalization. The facility lacked a triple-check process to ensure medication orders were correctly implemented, contributing to the oversight.
Failure to Implement Hearing Impairment Care Plan
Penalty
Summary
The facility failed to develop a person-centered care plan for a resident with hearing impairment. The resident, who was admitted to the facility with moderate cognitive impairment and minimal hearing difficulty requiring hearing aids, did not have a care plan addressing their hearing impairment. During an observation, the resident was found without their hearing aids, which were charging on the bedside table, and reported difficulty hearing without them. Interviews with facility staff revealed a lack of clarity and follow-through in implementing the resident's care plan. The MDS Nurse indicated that the Social Worker was responsible for implementing the care plan related to the resident's hearing impairment, but the Social Worker admitted to missing this aspect of the care plan. The Administrator confirmed that either the Social Worker or MDS Nurses were responsible for care plan implementation, but could not recall if the resident's hearing impairment care plan was reviewed in clinical meetings.
Failure to Secure Indwelling Catheter Tubing
Penalty
Summary
The facility failed to secure the indwelling urinary catheter tubing for a resident with a neurogenic bladder and urinary retention, leading to discomfort and potential risk of injury. The resident, who had moderate cognitive impairment, reported experiencing pain from the catheter when sitting in a chair, which was alleviated when a leg strap was used to secure the tubing. However, observations and interviews revealed that the catheter tubing was often left unsecured, and the leg strap was not consistently used or present in the resident's room. Interviews with staff, including a nurse aide and a nurse, indicated a lack of consistent adherence to the physician's order to check the catheter securement every shift. The nurse responsible for the resident admitted to forgetting to secure the catheter tubing on one occasion. The unit manager and the facility administrator both expressed expectations that the nursing staff would ensure the securement device was in place each shift, highlighting a gap between expected and actual practice in the facility's catheter care procedures.
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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 Rocky Mount
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Rocky Mount Rehabilitation Center | 1.7 mi | ★★★★★ | 15 | 0 |
| The Carrolton Of Nash | 1.8 mi | ★★★★★ | 2 | 0 |
| Autumn Care Of Nash | 3.5 mi | ★★★★★ | 1 | 0 |
| Longleaf Neuro-medical Treatment Center | 17.5 mi | ★★★★★ | 16 | 0 |
| Wilson Rehabilitation And Nursing Center | 17.9 mi | ★★★★★ | 3 | 0 |
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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.