01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2025-12-17 | 5 | 2024-09-19 | 1 |
| Cycle 2 | 2024-09-19 | 7 | 2023-08-23 | 5 |
| Cycle 3 | 2023-08-23 | 10 | 2022-01-07 | 1 |
CMS CCN 3450042026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Person Memorial Hospital
615 Ridge Road · Roxboro, NC 27573 · Person County
Certified beds56CMS provider file
Recent citation rows29current CMS citation release
Penalty rows6current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
29 rows in the current release
1 rows carry G–L scope/severity codes; 1 carry J–L. 6 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2025-12-17 · HEALTHF0605Severity E · pattern; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Correction field: Deficient, Provider has date of correction · 2026-01-142025-12-17 · HEALTHF0732Severity C · widespread; potential for minimal harm
Nursing and Physician Services Deficiencies
Post nurse staffing information every day.
Correction field: No revisit needed · 2026-01-142025-12-17 · HEALTHF0756Severity E · pattern; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Correction field: Deficient, Provider has date of correction · 2026-01-142025-12-17 · HEALTHF0812Severity E · pattern; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Correction field: Deficient, Provider has date of correction · 2026-01-142025-11-25 · HEALTHF0689Severity J · isolated immediate jeopardy
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Deficient, Provider has date of correction · 2025-11-26 · complaint2024-09-19 · HEALTHF0577Severity C · widespread; potential for minimal harm
Resident Rights Deficiencies
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Correction field: Deficient, Provider has plan of correction · 2024-10-172024-09-19 · HEALTHF0585Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2024-10-17 · complaint2024-09-19 · HEALTHF0677Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Correction field: Deficient, Provider has date of correction · 2024-10-17 · complaint2024-09-19 · HEALTHF0679Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide activities to meet all resident's needs.
Correction field: Deficient, Provider has date of correction · 2024-10-17 · complaint2024-09-19 · HEALTHF0727Severity F · widespread; potential for more than minimal harm
Nursing and Physician Services Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2024-10-17 · complaint2024-09-19 · HEALTHF0732Severity F · widespread; potential for more than minimal harm
Nursing and Physician Services Deficiencies
Post nurse staffing information every day.
Correction field: Deficient, Provider has date of correction · 2024-10-172024-09-19 · HEALTHF0761Severity E · pattern; potential for more than minimal harm
Pharmacy Service Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2024-10-172024-09-19 · FIREK0321Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Correction field: Deficient, Provider has date of correction · 2024-12-202023-08-23 · FIREE0004Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Develop and maintain an Emergency Preparedness Program (EP).
Correction field: Deficient, Provider has date of correction · 2023-10-08 · complaint2023-08-23 · HEALTHF0565Severity E · pattern; potential for more than minimal harm
Resident Rights Deficiencies
Honor the resident's right to organize and participate in resident/family groups in the facility.
Correction field: Deficient, Provider has date of correction · 2023-10-082023-08-23 · HEALTHF0636Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Correction field: Deficient, Provider has date of correction · 2023-10-082023-08-23 · HEALTHF0640Severity B · pattern; potential for minimal harm
Resident Assessment and Care Planning Deficiencies
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Correction field: Deficient, Provider has plan of correction · 2023-10-082023-08-23 · HEALTHF0679Severity E · pattern; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide activities to meet all resident's needs.
Correction field: Deficient, Provider has date of correction · 2023-10-082023-08-23 · HEALTHF0727Severity D · isolated; potential for more than minimal harm
Nursing and Physician Services Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2023-10-082023-08-23 · HEALTHF0730Severity D · isolated; potential for more than minimal harm
Nursing and Physician Services Deficiencies
Observe each nurse aide's job performance and give regular training.
Correction field: Deficient, Provider has date of correction · 2023-10-082023-08-23 · HEALTHF0732Severity B · pattern; potential for minimal harm
Nursing and Physician Services Deficiencies
Post nurse staffing information every day.
Correction field: Deficient, Provider has plan of correction · 2023-10-082023-08-23 · HEALTHF0761Severity E · pattern; potential for more than minimal harm
Pharmacy Service Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2023-10-082023-08-23 · HEALTHF0812Severity E · pattern; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Correction field: Deficient, Provider has date of correction · 2023-10-082023-08-23 · HEALTHF0867Severity E · pattern; potential for more than minimal harm
Administration Deficiencies
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Correction field: Deficient, Provider has date of correction · 2023-10-0803 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| 2025-11-25 | Fine | $16,153 | 0 |
| 2025-11-25 | Payment Denial | $0 | 1 |
| 2023-10-02 | Fine | $4,545 | 0 |
| 2023-09-11 | Fine | $13,635 | 0 |
| 2023-08-28 | Fine | $4,545 | 0 |
| 2023-08-21 | Fine | $4,196 | 0 |
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- DLP HEALTHCARE LLCOrganization · 5% OR GREATER DIRECT OWNERSHIP INTEREST100% · since 10/01/2011
- DLP PARTNER LLCOrganization · 5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED · since 10/01/2011
- HISTORIC LIFEPOINT HOSPITALS, LLCOrganization · 5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED · since 10/01/2011
- LEGACY LIFEPOINT HEALTH LLCOrganization · 5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED · since 01/01/2014
- LIFEPOINT HOLDINGS 2 LLCOrganization · 5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED · since 10/01/2011
- LIFEPOINT HOSPITALS HOLDINGS LLCOrganization · 5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED · since 10/01/2011
- BROWN, ELLIOTTIndividual · CORPORATE OFFICERNOT APPLICABLE · since 04/02/2026
- LAWRENCE, CHARLOTTEIndividual · CORPORATE OFFICERNOT APPLICABLE · since 03/24/2022
- MONTE, CHRISTOPHERIndividual · CORPORATE OFFICERNOT APPLICABLE · since 10/01/2011
- POLITE, ELMERIndividual · CORPORATE OFFICERNOT APPLICABLE · since 12/14/2020
- POPPELL, MARCUSIndividual · CORPORATE OFFICERNOT APPLICABLE · since 11/16/2018
- SENSING, PHILLIPIndividual · CORPORATE OFFICERNOT APPLICABLE · since 05/04/2026
- BEARD, BERTRANDIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 05/01/2022
- SENSING, PHILLIPIndividual · ADP OF THE SNFNOT APPLICABLE · since 05/04/2026
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours3.10per resident day
RN hours0.78per resident day
Weekend nurse hours2.84per resident day
Staff turnover—%CMS reported field
06 / LOCAL RECORDS
Open the Roxboro ledger →