PERSON MEMORIAL HOSPITAL
615 RIDGE ROAD, ROXBORO, NC 27573
At or above the 2024 benchmark — average inspection record.
Quality Breakdown
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RN Staffing
Registered nurse time each resident receives daily. 2024 federal benchmark: 0.55 hrs. Repealed February 2026.
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0.63 — At or above the repealed 0.55 hr benchmark |
The 0.55 hour RN standard was repealed effective February 2, 2026 and is not currently enforced. We still grade against it. Why |
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Health Deficiencies (last 3 survey cycles)
Violations found during federal inspections, with how many remain open and how many involved actual harm.
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Total
22
Outstanding
3
Actual harm or worse (G–L)
1
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CMS Ratings
Overall and Staffing quality ratings from CMS (1-5 stars).
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Quality: ★★★☆☆ (3/5)
Staffing: ★★☆☆☆ (2/5)
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NursingHomeGrade Score
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53/100 |
Loaded into NursingHomeGrade on April 12, 2026. This is the load date, not the date CMS published the underlying survey data — see release dates.
Inspection Deficiencies
Health inspections identify violations of federal standards. Severity ranges from no actual harm (A–F) to immediate jeopardy (J–L).
1 immediate jeopardy issue found among 22 total deficiencies. 19 corrected. — 3 still outstanding
Most recent inspection (December 17, 2025)
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected January 14, 2026
Post nurse staffing information every day.
Nursing and Physician Services Deficiencies — No revisit needed, corrected January 14, 2026
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected January 14, 2026
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected January 14, 2026
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected November 26, 2025
Inspection cycle 2 (September 19, 2024)
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Resident Rights Deficiencies — Deficient, Provider has plan of correction, corrected October 17, 2024
Post nurse staffing information every day.
Nursing and Physician Services Deficiencies — Deficient, Provider has date of correction, corrected October 17, 2024
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Nursing and Physician Services Deficiencies — Deficient, Provider has date of correction, corrected October 17, 2024
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected October 17, 2024
Provide care and assistance to perform activities of daily living for any resident who is unable.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected October 17, 2024
Provide activities to meet all resident's needs.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected October 17, 2024
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected October 17, 2024
Inspection cycle 3 (August 23, 2023)
Post nurse staffing information every day.
Nursing and Physician Services Deficiencies — Deficient, Provider has plan of correction, corrected October 8, 2023
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has plan of correction, corrected October 8, 2023
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Administration Deficiencies — Deficient, Provider has date of correction, corrected October 8, 2023
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Nursing and Physician Services Deficiencies — Deficient, Provider has date of correction, corrected October 8, 2023
Observe each nurse aide's job performance and give regular training.
Nursing and Physician Services Deficiencies — Deficient, Provider has date of correction, corrected October 8, 2023
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected October 8, 2023
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected October 8, 2023
Provide activities to meet all resident's needs.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected October 8, 2023
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected October 8, 2023
Honor the resident's right to organize and participate in resident/family groups in the facility.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected October 8, 2023
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