Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Rocky Mount Health & Rehab Center during CMS and state inspections, most recent first.
Staff failed to promptly notify a provider of abnormal lab results for a resident with cognitive impairment, resulting in delayed treatment for infection, and did not administer the full prescribed course of Tamiflu to another resident with multiple diagnoses. These deficiencies were identified through interviews, record reviews, and facility policy checks, and were discussed with facility leadership.
Staff failed to ensure accurate and complete clinical documentation for multiple residents, including sending incorrect paperwork to the ED, not correcting a significant weight discrepancy, failing to document bathing care accurately, and not discontinuing IV orders after removal. These deficiencies were confirmed through record review, resident interviews, and staff discussions.
Staff failed to maintain infection control standards, including improper positioning of a urinary catheter drainage tube for a resident with cognitive impairment, inadequate disinfection of glucometers by LPNs using alcohol swabs instead of approved wipes, and failure to follow PPE protocols and communication regarding isolation precautions for residents with infectious diseases.
A resident with multiple medical conditions and a clear preference for three showers per week did not consistently receive the requested number of showers, as confirmed by both resident interviews and documentation review. Despite a care plan and physician's order supporting the resident's preference, showers were inconsistently provided, and records were incomplete or delayed, indicating a failure to support resident choice in accordance with facility policy.
Facility staff did not ensure that a DDNR form for a resident with intact cognition was signed by the ordering medical provider, as required. The form was present in the clinical record but lacked the necessary provider signature at the time of review.
A resident with multiple complex diagnoses experienced significant weight loss, but staff failed to notify the provider and responsible party of this change in condition. Although a new nutritional supplement was ordered and communicated, the actual weight loss was not disclosed as required by facility policy.
A resident with multiple chronic conditions, including neuromuscular bladder dysfunction, was not accurately coded for an indwelling catheter on the MDS assessment, despite clear documentation and observation of a Foley catheter in use. LPNs were unable to find any evidence that the catheter had been discontinued or that a voiding trial had occurred, and acknowledged the MDS was coded incorrectly.
Facility staff did not fully complete required PASRR Level I forms for several residents, leaving sub-questions unanswered and omitting key information regarding mental illness and related conditions. In one case, a resident with multiple neurocognitive and mood disorder diagnoses had an incomplete screening and lacked documentation of a Level II assessment, contrary to facility policy.
A resident reported that a bathroom handrail detached while she was attempting to stand, which she stated led to a fall and decreased mobility in her right leg and left arm. Despite the facility's policy requiring documentation and assessment of such incidents, there was no record of the event or any post-incident assessment in the resident's clinical file. Staff and maintenance confirmed the handrail detachment but stated the resident did not fall, and the incident was not documented as required.
Staff failed to administer supplemental oxygen at the rate ordered by the provider for a resident with cognitive impairment and multiple diagnoses. The resident was repeatedly observed receiving oxygen at 2.0 l/m instead of the ordered 3.0 l/m, despite documentation that the concentrator setting was checked. A nurse confirmed the discrepancy and corrected the setting after it was brought to her attention.
A resident with multiple chronic conditions did not receive a required monthly drug regimen review by a licensed pharmacist, and there was no evidence that a medical provider reviewed pharmacy recommendations as outlined in facility policy. The resident's care plan called for routine pharmacy review due to psychoactive medication use, but documentation and staff interviews confirmed the review was missed and recommendations were not properly addressed.
Staff failed to administer insulin medications as ordered for two residents with diabetes and multiple comorbidities, giving insulin on several occasions when blood glucose levels were below the provider-specified thresholds for holding the medication. Facility policy required verification of orders and adherence to provider instructions, but these were not followed, resulting in significant medication errors.
Failure to Promptly Notify Provider of Abnormal Labs and Incomplete Medication Administration
Penalty
Summary
Facility staff failed to provide timely and appropriate care for two residents, resulting in deficiencies related to communication of abnormal laboratory results and medication administration. For one resident with significant cognitive impairment and memory problems, staff did not promptly notify the medical provider of abnormal laboratory findings, including elevated white blood cell count, urea nitrogen, creatinine, and urinalysis results suggestive of infection. The laboratory results were available late in the evening, but there was no documentation of provider notification until nearly two days later, despite the resident exhibiting symptoms such as emesis, poor appetite, and abnormal behavior. The delay in notification led to a late initiation of antibiotics and subsequent transfer to the hospital, where the resident was diagnosed with sepsis due to a urinary tract infection. For another resident with mild cognitive impairment, dysphagia, hydrocephalus, and severe intellectual disabilities, staff failed to administer the full prescribed course of Tamiflu following a positive test for Influenza A. The provider had ordered a 5-day course of Tamiflu, but the medication administration record showed that only 8 out of 10 doses were given. Two capsules remained in the medication cart, and the LPN responsible for administration could not explain the discrepancy. The facility's own policy required verification of medication orders and administration, but this was not followed in this instance. Both deficiencies were identified through staff interviews, clinical record reviews, and facility document reviews. The survey team discussed these findings with facility leadership, including the Administrator, DON, and Regional Director of Clinical Services, noting the failure to ensure prompt response to abnormal laboratory results and adherence to medication administration protocols.
Failure to Maintain Accurate and Complete Clinical Records
Penalty
Summary
Facility staff failed to maintain complete and accurate clinical records for several residents, resulting in multiple documentation deficiencies. For one resident, the clinical record inaccurately indicated that a DNR/Advanced Directive was sent to the emergency department, despite the resident being a full code and not having a DNR order. Another resident's weight was incorrectly documented as nearly 100 pounds less than the previous month, with no evidence that this significant discrepancy was addressed or corrected by staff. Additionally, staff did not properly document bathing and shower care for a resident who was dependent on staff for these activities. The clinical record did not reflect the actual care provided, as shown by discrepancies between point of care documentation and separate shower sheets. The resident also reported not receiving a shower for a week, further highlighting the inconsistency in documentation. For another resident, physician's orders related to intravenous (IV) access were not discontinued in the clinical record after the IV was removed. Progress notes and staff interviews confirmed that the IV had been dislodged and was not reinserted, but the orders remained active in the record. These failures were discussed with facility leadership during surveyor meetings, and no additional information was provided prior to the exit conference.
Infection Control Failures in Catheter Care, Glucometer Disinfection, and Isolation Precautions
Penalty
Summary
Facility staff failed to maintain proper infection prevention and control practices for multiple residents, resulting in several deficiencies. For one resident with an indwelling urinary catheter, the drainage tube was repeatedly observed in contact with the floor beside the bed on multiple occasions throughout the day. The resident was assessed as having significant cognitive impairment, being rarely able to make themselves understood or understand others, and having both long- and short-term memory problems. Despite these vulnerabilities, staff did not ensure the catheter drainage system was positioned to minimize infection risk, and the issue persisted until it was brought to the attention of a nurse, who acknowledged the problem and stated she would change the collection bag. In another instance, staff failed to follow proper disinfection procedures for blood glucometers used for residents on isolation precautions. One LPN was observed using an alcohol swab to clean a glucometer after use, contrary to the facility's policy and the manufacturer's instructions, which require specific EPA-registered disinfectant wipes. The LPN also placed the glucometer and its storage bag on various surfaces, including the medication cart and her pocket, without appropriate cleaning of those surfaces afterward. The infection preventionist later confirmed that alcohol swabs were not sufficient and that approved disinfectant wipes were available but not used as required. Additionally, staff did not consistently adhere to transmission-based precautions for residents with confirmed infectious diseases. One nurse entered the room of a resident on droplet precautions for Flu A without donning the required personal protective equipment (PPE), due to a lack of communication during shift change about the resident's isolation status. The nurse administered medications to the roommate, passing by the resident on precautions, and only later clarified the need for PPE. Another LPN failed to clean the medication cart after placing a potentially contaminated glucometer on it following use in an isolation room. These lapses were observed and discussed with facility leadership, but no further information was provided prior to the survey exit.
Failure to Consistently Honor Resident Bathing Preferences
Penalty
Summary
Facility staff failed to honor a resident's right to self-determination and support of resident choice regarding bathing preferences. The resident, who was cognitively intact and had multiple medical diagnoses including pneumonia, respiratory failure, hypertension, diabetes, COPD, and muscle weakness, expressed a preference and had a physician's order for showers three times per week. Interviews with the resident revealed that showers were inconsistently provided, often depending on which aide was working, and the resident reported usually receiving only one or two showers per week rather than the three requested. The resident also indicated that the lack of showers was not always due to staffing shortages but rather staff willingness. Record review showed discrepancies between assignment sheets and the clinical record, with documentation indicating that the resident did not consistently receive three showers per week as ordered and preferred. The care plan acknowledged the resident's preferences and included an approach to allow choice of bath if desired. However, documentation for February and March showed that the resident received only one shower in some weeks, and additional shower records were only provided after repeated requests from the surveyor. Facility policy required honoring resident bathing preferences, but the evidence demonstrated that this was not consistently followed for this resident.
Unsigned DDNR Form by Medical Provider
Penalty
Summary
Facility staff failed to ensure that a Durable Do Not Resuscitate (DDNR) form for one resident was signed by the ordering medical provider. The resident was assessed as having intact or borderline cognition, with a Brief Interview for Mental Status (BIMS) score of 14 out of 15, and was able to make self understood and understand others. The clinical record included a DDNR order form that was completed and dated, but it lacked the required medical provider signature at the time of review. This omission was identified during staff interviews and clinical record review, and the unsigned form was presented to surveyors as evidence of the deficiency.
Failure to Notify Provider and Responsible Party of Significant Weight Loss
Penalty
Summary
Facility staff failed to notify the provider and the responsible party of a significant change in condition for one resident who experienced an 8.38% weight loss within a month. The resident had multiple diagnoses, including late-onset Alzheimer's disease, seizures, dysphagia, secondary Parkinsonism, frontotemporal neurocognitive disorder, and muscle weakness. The resident's care plan identified increased nutritional risk and required supplements as ordered. Despite these risks and the significant weight loss, the provider and responsible party were not informed of the weight loss itself, only of a new supplement order. A review of the facility's policy confirmed that both the provider and responsible party should be notified of significant weight loss, defined as 5% in 30 days or 10% in 180 days. Staff interviews revealed that the nurse who implemented the new supplement order was unaware of the weight loss and did not communicate the reason for the new order to the provider or responsible party. Documentation showed that only the new order was communicated, not the underlying change in condition, which was contrary to facility policy.
Failure to Accurately Code Indwelling Catheter on MDS Assessment
Penalty
Summary
Facility staff failed to ensure an accurate Minimum Data Set (MDS) assessment for one resident by not coding the presence of an indwelling catheter, despite clear evidence of its use. The resident had multiple diagnoses, including congestive heart failure, vascular dementia, chronic kidney disease, neuromuscular dysfunction of the bladder, and chronic respiratory failure. The resident was observed with a Foley catheter in place, and medical records, including provider orders, medication administration records, and progress notes, all documented the presence and care of the catheter during the assessment period. Despite this documentation, the MDS assessment did not reflect the use of an indwelling catheter in Section H. Interviews with LPNs revealed no evidence that the catheter had been discontinued or that a voiding trial had occurred during the relevant period. The staff acknowledged the MDS was coded incorrectly after reviewing the records and failing to find any documentation supporting the absence of the catheter.
Incomplete PASRR Level I Documentation for Multiple Residents
Penalty
Summary
Facility staff failed to properly complete the Preadmission Screening and Resident Review (PASRR) Level I forms for multiple residents, as required by document guidance. For two residents, the main questions in sections regarding serious mental illness and related conditions were answered 'No' without completing the required sub-questions. The social worker confirmed that these sub-questions were left blank when the main answer was 'No,' and stated she would have marked 'Yes' if appropriate, but did not complete the sub-questions otherwise. This incomplete documentation was identified during record review and confirmed in staff interviews. Additionally, for another resident with multiple diagnoses including Alzheimer's disease, seizure disorder, and mood disorders, the PASRR Level I screening was found to be incomplete, with a key question regarding the need for a Level II assessment left blank. There was also no Level II PASRR in the resident's record, despite policy indicating that such information should be maintained. These deficiencies were discussed with facility leadership during the survey process.
Failure to Document and Assess Resident After Handrail Incident
Penalty
Summary
Facility staff failed to provide adequate supervision and monitoring in response to an incident involving a resident and a bathroom handrail. The resident reported that the handrail detached from the wall while she was attempting to stand from the toilet, which she stated resulted in a fall and subsequent decreased ability to use her right leg and left arm. The resident was assessed as having intact or borderline cognition and was able to communicate her needs. However, there was no documentation in her clinical record regarding the incident, nor was there evidence of an assessment being completed following the event. Interviews with staff and maintenance personnel confirmed the occurrence of the handrail detachment, but staff reported that the resident did not fall and instead sat back down on the toilet. The exact date of the incident could not be confirmed, and the event was not documented in the resident's records. Review of the facility's Incident/Accident Policy indicated that all incidents or accidents involving residents should be recorded in the electronic health record and assessed as soon as possible, but no later than the end of the shift. Despite this policy, the incident involving the handrail was not documented, and no post-incident assessment was completed for the resident. The failure to document and assess the resident after the incident was confirmed by the facility's administration during interviews with the survey team.
Failure to Administer Oxygen at Ordered Rate
Penalty
Summary
Facility staff failed to provide respiratory care consistent with medical provider orders for one resident. The resident, who had diagnoses including senile degeneration of the brain, insomnia, hypertension, pain, restlessness and agitation, and anxiety disorder, was assessed as being severely impaired in decision-making with short and long-term memory problems. The resident had a provider order for continuous oxygen at 3.0 liters per minute (l/m) via nasal cannula, with instructions to check the concentrator for proper function and setting every shift. Despite these orders, the resident was observed on multiple occasions receiving oxygen at a delivery rate of 2.0 l/m, as indicated by the oxygen concentrator setting. The medication administration record showed that staff documented checking the concentrator for the correct setting, but the actual observed setting did not match the provider's order. When questioned, a registered nurse initially stated the resident was receiving three liters, but upon inspection, confirmed the concentrator was set to two liters and adjusted it to the correct rate. The facility's policy required licensed clinicians to administer oxygen as ordered and to set the flow meter to the correct rate.
Failure to Complete and Document Monthly Drug Regimen Review
Penalty
Summary
Facility staff failed to ensure that a licensed pharmacist performed a monthly drug regimen review for one resident, as required. Specifically, there was no evidence that a drug regimen review was completed for the resident in January 2025, and the facility was unable to provide documentation of a medical provider's review of the pharmacist's recommendations from July 2024. The July 2024 drug regimen review included a clinical priority recommendation regarding the concomitant use of daptomycin and atorvastatin, but the recommendation was not signed by the medical provider and was not found in the resident's clinical record. The resident involved had multiple diagnoses, including Type 2 Diabetes Mellitus, Chronic Obstructive Pulmonary Disease, Obstructive and Reflux Uropathy, Anxiety Disorder, and Major Depressive Disorder, and was assessed as cognitively intact. The resident's care plan included pharmacy review of psychoactive medication use as a routine intervention. Despite this, the facility's documentation and staff interviews confirmed that the required monthly drug regimen review was missed for January 2025, and the process for ensuring provider review of pharmacy recommendations was not followed according to facility policy.
Failure to Administer Insulin Medications as Ordered
Penalty
Summary
Facility staff failed to ensure that two residents were free from significant medication errors by not administering insulin medications according to provider orders. For one resident with diagnoses including Type 2 Diabetes Mellitus, chronic kidney disease, and hypertension, staff administered Novolin insulin on multiple occasions despite blood glucose readings below the ordered threshold for holding the medication. The resident's care plan required medications to be administered as ordered, and facility policy mandated verification of medication orders prior to administration. Another resident, also with Type 2 Diabetes Mellitus and additional complex medical conditions, received Lantus, Humalog, and Insulin Glargine on several occasions when blood glucose levels were below the parameters specified in the provider's orders. The resident's care plan similarly required medications to be administered as ordered. Facility documentation and policy required staff to verify medication orders and adhere to provider instructions, but these procedures were not followed, resulting in the administration of insulin outside of prescribed parameters.
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 61 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 Rocky Mount
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Franklin Health And Rehabilitation Center | 1 mi | ★★★★★ | 1 | 0 |
| Friendship Health And Rehab Center - South | 15.5 mi | ★★★★★ | 0 | 0 |
| Pheasant Ridge Nursing And Rehabilitation | 16.3 mi | ★★★★★ | 7 | 0 |
| South Roanoke Nursing And Rehabilitation | 17.1 mi | ★★★★★ | 0 | 0 |
| King's Grant Lacy Health Center | 18.2 mi | ★★★★★ | 0 | 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.