01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2025-12-04 | 3 | 2024-08-15 | 9 |
| Cycle 2 | 2024-08-15 | 9 | 2023-09-29 | 6 |
| Cycle 3 | 2023-09-29 | 8 | 2022-08-03 | 3 |
CMS CCN 3453112026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Roxboro Healthcare & Rehab Center
901 Ridge Road · Roxboro, NC 27573 · Person County
Certified beds140CMS provider file
Recent citation rows38current CMS citation release
Penalty rows2current 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
38 rows in the current release
2 rows carry G–L scope/severity codes; 0 carry J–L. 6 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2025-12-04 · HEALTHF0584Severity E · pattern; potential for more than minimal harm
Resident Rights Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2025-12-262025-12-04 · HEALTHF0657Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Correction field: Deficient, Provider has date of correction · 2025-12-262025-12-04 · 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 · 2025-12-262024-08-15 · HEALTHF0554Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Allow residents to self-administer drugs if determined clinically appropriate.
Correction field: Deficient, Provider has date of correction · 2024-09-042024-08-15 · HEALTHF0656Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Correction field: Deficient, Provider has date of correction · 2024-09-042024-08-15 · 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 · 2024-09-04 · complaint2024-08-15 · HEALTHF0688Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Correction field: Deficient, Provider has date of correction · 2024-09-042024-08-15 · HEALTHF0690Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Correction field: Deficient, Provider has date of correction · 2024-09-042024-08-15 · HEALTHF0759Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure medication error rates are not 5 percent or greater.
Correction field: Deficient, Provider has date of correction · 2024-09-042024-08-15 · HEALTHF0761Severity D · isolated; 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 · 2024-09-042024-08-15 · HEALTHF0842Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Correction field: Deficient, Provider has date of correction · 2024-09-04 · complaint2024-08-15 · HEALTHF0921Severity E · pattern; potential for more than minimal harm
Environmental Deficiencies
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Correction field: Deficient, Provider has date of correction · 2024-09-04 · complaint2024-08-15 · FIREK0200Severity D · isolated; potential for more than minimal harm
Egress Deficiencies
Meet other general requirements.
Correction field: Deficient, Provider has date of correction · 2024-10-292024-08-15 · FIREK0321Severity E · pattern; 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 · 2024-10-292024-08-15 · FIREK0351Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Install an approved automatic sprinkler system.
Correction field: Deficient, Provider has date of correction · 2024-10-292024-08-15 · FIREK0363Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Install corridor and hallway doors that block smoke.
Correction field: Deficient, Provider has date of correction · 2024-10-292024-08-15 · FIREK0374Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Correction field: Deficient, Provider has date of correction · 2024-10-292024-08-15 · FIREK0521Severity E · pattern; potential for more than minimal harm
Services Deficiencies
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Correction field: Deficient, Provider has date of correction · 2024-10-292024-08-15 · FIREK0700Severity E · pattern; potential for more than minimal harm
Miscellaneous Deficiencies
Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors.
Correction field: Deficient, Provider has date of correction · 2024-10-292024-08-15 · FIREK0918Severity E · pattern; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Have generator or other power source capable of supplying service within 10 seconds.
Correction field: Deficient, Provider has date of correction · 2024-10-292024-08-15 · FIREK0923Severity E · pattern; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Have proper medical gas storage and administration areas.
Correction field: Deficient, Provider has date of correction · 2024-10-292024-07-12 · HEALTHF0686Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Correction field: Deficient, Provider has date of correction · 2024-08-15 · complaint2024-07-12 · HEALTHF0697Severity G · isolated actual harm
Quality of Life and Care Deficiencies
Provide safe, appropriate pain management for a resident who requires such services.
Correction field: Deficient, Provider has date of correction · 2024-08-15 · complaint2024-07-12 · HEALTHF0755Severity G · isolated actual harm
Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Correction field: Deficient, Provider has date of correction · 2024-08-15 · complaint03 / 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 |
|---|---|---|---|
| 2024-07-12 | Fine | $56,778 | 0 |
| 2024-07-12 | Payment Denial | $0 | 29 |
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- LIBERTY HEALTHCARE GROUP LLCOrganization · 5% OR GREATER DIRECT OWNERSHIP INTEREST100% · since 02/01/2020
- WILSON, JEFFREYIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 02/01/2020
- LONG TERM CARE MANAGEMENT SERVICES LLCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 02/01/2020
- CALCUTT, JOSEPHIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 02/01/2020
- WILSON, JEFFREYIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 02/01/2020
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 hours3.13per resident day
RN hours0.37per resident day
Weekend nurse hours2.93per resident day
Staff turnover58.9%CMS reported field
06 / LOCAL RECORDS
Open the Roxboro ledger →