Person Memorial Hospital
Roxboro, North Carolina · CCN 345004
21 surveys since 2011. The first finding at harm level was recorded in 2017.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
- Citations on record
- 117
- Surveys
- 21
- Harm or worse
- 11
- Immediate jeopardy
- 10
Findings at the most serious level CMS records.
Older surveys no longer in CMS’s monthly file or on Care Compare. They are shown here.
The facility
- Certified beds
- 56
- Ownership
- For profit - Limited Liability company
- Chain
- LIFEPOINT HEALTH
- County
- Person
- Medicare-certified since
- 1967
CMS ratings
- Overall
- 1
- Health inspection
- 2
- Staffing
- 1
- Quality measures
- 2
CMS’s own Five-Star ratings.
Compared with similar facilities
Since 2021, this facility recorded more weighted findings than most of its peer group.
Weighted by harm level, against 39 for-profit facilities with fewer than 66 beds in North Carolina.
Last survey on record
Dec 17, 2025
327 days ago.
Counts surveys with at least one finding. A clean survey leaves no record here, so the real gap may be shorter.
Staffing
| Measure | This facility | Peer median |
|---|---|---|
| Nurse hours per resident day | 3.10 | 3.57 |
| Registered-nurse hours per resident day | 0.78 | — |
As reported by the facility to CMS, beside the peer-group median.
Enforcement
- Fines
- $20,698 across 2 penalties
- Payment denials
- 1
Federal civil money penalties and remedies as CMS currently publishes them. Amounts may still be under appeal.
Severity of recent findings
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J14.5% | K— | L— |
| Actual harm | G— | H— | I— |
| No harm, potential for more than minimal | D627.3% | E940.9% | F29.1% |
| No harm, potential for minimal | A— | B29.1% | C29.1% |
Most frequently cited here
In CMS’s current monthly file.
- F7323×
Post nurse staffing information every day.
- F6792×
Provide activities to meet all resident's needs.
- F7272×
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.
- F7612×
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.
- F8122×
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
In the surveyor’s words
From the most serious findings on record at Person Memorial Hospital, in the surveyor’s own words.
- Immediate jeopardy, isolatedF689Nov 25, 2025
Based on observations, record review, and staff, Family Member, and Physician Assistant interviews, the facility failed to provide care in a safe manner when a resident rolled off the raised bed while incontinence care was being provided. The resident had a history of stroke with residual left side weakness. Nurse Aide #1 turned the resident away from her onto her left side with the resident holding the upper side rail with her right hand. While care was being provided Resident #1 stated she could not hold on anymore and rolled out of the bed landing on her knees and immediately complained of pain in her knees, back and legs. […]
- No harm, potential for more than minimal, widespreadF727Sep 19, 2024
Based on record reviews and staff interviews, the facility failed to schedule a Registered Nurse (RN) for at least 8 consecutive hours a day for 2 of the 33 days reviewed for staffing. The findings included: A review of the daily posted nursing staff forms, daily nursing staff assignment sheets, and staff clock-in sheets from 8/17/24 through 9/18/24 was conducted on 9/19/24. A. On 8/24/24 the daily staff posting indicated 1 RN working day shift (7 AM - 3PM). Daily posting also indicated 2 Licensed Practical Nurse (LPN) and 2 NA working night shift (11PM - 7 AM). Review of the nursing staff assignment sheet for 8/24/24 indicated the RN, Nurse #9, working from 7 AM - 7 PM. The RN, Nurse #9, was also assigned to work as a Nurse Aide from 11 PM to 7 AM. […]
- No harm, potential for more than minimal, widespreadF732Sep 19, 2024
Based on observation and staff interviews, the facility failed to post the daily nurse staffing information for residents and visitors on 1 of the 4 days of the survey period. The facility also failed to update the daily staffing information to reflect actual staffing changes for 6 of 33 days reviewed for posted nurse staffing information. Finding included: 1. On 9/15/24 (Sunday) during the facility initial tour at 9:20 AM and for multiple observations throughout the day including 1:30 PM and 3 PM, the daily nurse staffing sheet posted near the facility elevator was dated 9/13/24 (Friday). The posting was not updated to reflect the current date, census, and staffing information. […]
- No harm, potential for more than minimal, widespreadF880Jan 7, 2022
Based on observations, staff, family interviews, and record review, the facility failed to set up screening stations for signs and symptoms of COVID-19 near each entrance or provide clear instruction how to reach the screening room for 3 facility State Surveyors and 1 Federal Surveyor before entering the facility for 1 of 4 on-site survey days. This failure occurred during a global COVID-19 pandemic. Findings included: Record review revealed the Standard Operation Procedure, updated on 11/4/21, indicated that for indoor visits, all visitors will receive instructions regarding visitation protocols and will be screened for COVID-19 symptoms prior to each visit. On 1/4/22 at 6:10PM, during the observation of the hospital ' s main entrance, the door was automatically opened. […]
- No harm, potential for more than minimal, patternF605Dec 17, 2025
Based on record reviews, and staff and physician interviews, the facility failed to limit the duration of psychotropic medications (any drug that affects brain activities associated with mental processes and behavior) ordered on an as-needed (PRN) basis to 14 days and/or indicate the duration and rationale for extending the PRN order beyond 14 days. This occurred for 1 of 5 residents whose medications were reviewed (Resident #36). Findings Included:Resident #36 was admitted to the facility on [DATE] with diagnoses that included anxiety disorder.On 5/9/25, the physician ordered one (1) milliliter (ml) of Lorazepam Intensol Oral Concentrate (Lorazepam) 2 milligrams/milliliter (mg/ml) to be administered via Percutaneous Endoscopic Gastrostomy (PEG) tube every 2 hours as needed (PRN) for… […]
Read 30 findings in full →The most serious and the most recent: 30 of 117 on record.
Every survey on record
FindingsAt actual harm or above
- Dec 17, 2025Standard4 findings
- Nov 25, 2025Complaint1 finding · 1 harm
- Sep 19, 2024Standard and complaint7 findings
- Aug 23, 2023Standard10 findings
- Jan 7, 2022Standard and complaint5 findings
- Nov 26, 2019Complaint1 finding · 1 harm
- Aug 16, 2019Complaint1 finding
- Aug 8, 2019Standard6 findings
Show the 13 earlier surveys
- Aug 30, 2018Standard3 findings
- Sep 12, 2017Standard27 findings · 9 harm
- Jul 20, 2017Complaint1 finding
- Oct 6, 2016Standard and complaint12 findings
- Nov 6, 2015Standard7 findings
- Aug 29, 2015Complaint3 findings
- Mar 24, 2015Complaint1 finding
- Jan 29, 2015Complaint2 findings
- Dec 18, 2014Standard7 findings
- Sep 6, 2013—8 findings
- Aug 1, 2013—1 finding
- Jul 19, 2012—9 findings
- Aug 18, 2011—1 finding
Surveys that found no deficiencies are not in CMS’s files and do not appear here.
Comparable facilities
The nearest facilities to this one in the same peer group, by weighted findings.
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