Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
Roxboro Healthcare & Rehab Center
Roxboro, NC · 140 certified beds · Last Life Safety survey August 15, 2024
CMS Certification Number 345311 · first certified October 1989
Ownership
Operated by LIBERTY SENIOR LIVING · For profit - Corporation
- Ownership changed February 1, 2020 (change of ownership)to ROXBORO HEALTHCARE AND REHABILITATION CENTER from ROXBORO NURSING CENTER, INC
Position within NC
18 citations — more than 85% 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 9 citations; the earlier surveys in the window averaged 4.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
Well past the typical window (October 2025 to December 2025), and past the point by which nine in ten NC facilities have been surveyed. This facility’s last Life Safety survey was August 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
Get an email about Roxboro Healthcare & Rehab Center
One email when it happens. No account; stop it any time with one click.
3 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Physical environment (health survey)
2 physical-environment citations 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 18 Life Safety citations above. The Physical Environment Index
- F-0584 Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
- F-0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
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 | 18 |
| Median facility in NC | 9 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| August 3, 2022 | 3 |
| September 29, 2023 | 6 |
| August 15, 2024 | 9 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | 3 | 2024-08-15 |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | 2 | 2024-08-15 |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 2 | 2024-08-15 |
| K-0923 | Have proper medical gas storage and administration areas. | 2 | 2024-08-15 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 1 | 2023-09-29 |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | 1 | 2023-09-29 |
| K-0700 | Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors. | 1 | 2024-08-15 |
| K-0363 | Install corridor and hallway doors that block smoke. | 1 | 2024-08-15 |
What the citations cover
- Smoke Deficiencies 9
- Gas, Vacuum, and Electrical Systems Deficiencies 4
- Egress Deficiencies 2
- Services Deficiencies 2
- Other 1
| Category | Citations |
|---|---|
| Smoke Deficiencies | 9 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 4 |
| Egress Deficiencies | 2 |
| Services Deficiencies | 2 |
| Miscellaneous Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
August 15, 2024 — 9 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0200 | Meet other general requirements. | Deficient, Provider has date of correction (October 29, 2024) |
| 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 (October 29, 2024) |
| K-0351 | Install an approved automatic sprinkler system. | Deficient, Provider has date of correction (October 29, 2024) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (October 29, 2024) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (October 29, 2024) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (October 29, 2024) |
| K-0700 | Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors. | Deficient, Provider has date of correction (October 29, 2024) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (October 29, 2024) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (October 29, 2024) |
September 29, 2023 — 6 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (December 25, 2023) |
| 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 25, 2023) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (December 25, 2023) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (December 25, 2023) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (December 25, 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 (December 25, 2023) |
August 3, 2022 — 3 citations
| 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 (October 6, 2022) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (October 6, 2022) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (October 6, 2022) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.