Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
PERSON MEMORIAL HOSPITAL
ROXBORO, NC · 56 certified beds · Last Life Safety survey September 19, 2024
CMS Certification Number 345004 · first certified January 1967
Ownership
Operated by LIFEPOINT HEALTH · For profit - Limited Liability company
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within NC
7 citations — more than 29% of the 419 certified nursing homes in NC. Compared within NC rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 1 citation; the earlier surveys in the window averaged 3.7. With 4 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
Well past the typical window (November 2025 to January 2026), and past the point by which nine in ten NC facilities have been surveyed. This facility’s last Life Safety survey was September 2024. Facilities in NC are typically surveyed 14–16 months after the last one (median 15), measured over 412 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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Emergency preparedness
1 of the 7 citations on file is Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
1 physical-environment citation on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 7 Life Safety citations above. The Physical Environment Index
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
How that compares
Compared with the median facility in NC, and nationally. Surveyors differ markedly between states, so the NC figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 7 |
| Median facility in NC | 9 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| January 7, 2022 | 1 |
| August 23, 2023 | 5 |
| August 23, 2023 | 5 |
| September 19, 2024 | 1 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | 2 | 2023-08-23 |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 1 | 2023-08-23 |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | 1 | 2023-08-23 |
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | 1 | 2023-08-23 |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | 1 | 2024-09-19 |
| K-0916 | Have a battery powered remote alarm panel in a location accessible by operating personnel. | 1 | 2023-08-23 |
What the citations cover
- Egress Deficiencies 2
- Gas, Vacuum, and Electrical Systems Deficiencies 2
- Smoke Deficiencies 1
- Emergency Preparedness Deficiencies 1
- Other 1
| Category | Citations |
|---|---|
| Egress Deficiencies | 2 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 2 |
| Smoke Deficiencies | 1 |
| Emergency Preparedness Deficiencies | 1 |
| Services Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
September 19, 2024 — 1 citation
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (December 20, 2024) |
August 23, 2023 — 5 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (October 8, 2023) |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (November 5, 2023) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (November 5, 2023) |
| K-0916 | Have a battery powered remote alarm panel in a location accessible by operating personnel. | Deficient, Provider has date of correction (November 5, 2023) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (November 5, 2023) |
January 7, 2022 — 1 citation
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (March 25, 2022) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.