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Person Memorial Hospital
615 Ridge Road, Roxboro, NC 27573 · CMS Certification Number (CCN) 345004
At a glance
- CMS overall rating
- ★☆☆☆☆ 1 of 5
- Health inspection citations
- 22 in the last 3 inspection cycles (1 immediate jeopardy, 0 actual harm, 5 from complaints)
- Fire safety citations
- 7
- Fines (last 3 years)
- 2 fines, total $20,698
- Payment denials
- 1
- Most recent standard inspection
- December 17, 2025
- Official record
- Medicare Care Compare page for this facility
Source: CMS Nursing Home Provider Information: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
CMS star ratings
CMS rates every Medicare- and Medicaid-certified nursing home from 1 to 5 stars. Health inspection stars are relative to other homes in the same state: the top 10% get 5 stars and the bottom 20% get 1 star. CMS says to use the ratings together with other information, including a visit. Technical Users’ Guide
| Rating | This facility | North Carolina average | U.S. average |
|---|---|---|---|
| Overall | ★☆☆☆☆ 1 of 5 | 2.9 | 3 |
| Health inspections | ★★☆☆☆ 2 of 5 | 2.9 | 2.8 |
| Staffing | ★☆☆☆☆ 1 of 5 | 2.7 | 2.9 |
| Quality measures | ★★☆☆☆ 2 of 5 | 3.3 | 3.6 |
| Long-stay quality | ★★☆☆☆ 2 of 5 | Not published | Not published |
| Short-stay quality | ★★★☆☆ 3 of 5 | Not published | Not published |
Averages: CMS State and US Averages: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Health inspections
| Inspection cycle | Standard survey date | Health citations | From standard survey | From complaints |
|---|---|---|---|---|
| Cycle 1 (most recent) | December 17, 2025 | 5 | 4 | 1 |
| Cycle 2 | September 19, 2024 | 7 | 7 | 4 |
CMS weighted health inspection score: 87.25 (lower is better; it counts citation severity, complaints and repeat revisits). Citations from infection control inspections: Not published. How to read these citations
22 health citations across 4 inspection dates, newest first. The letter is CMS’s scope/severity code: A–C means potential for minimal harm, D–F potential for more than minimal harm, G–I actual harm, and J–L immediate jeopardy.
December 17, 2025: 4 citations (Standard)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| E | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies | Standard | Deficient, Provider has date of correction Corrected 01/14/2026 |
| E | F-0756 | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Pharmacy Service Deficiencies | Standard | Deficient, Provider has date of correction Corrected 01/14/2026 |
| C | F-0732 | Post nurse staffing information every day. Nursing and Physician Services Deficiencies | Standard | No revisit needed Corrected 01/14/2026 |
| E | F-0605 | Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. Freedom from Abuse, Neglect, and Exploitation Deficiencies | Standard | Deficient, Provider has date of correction Corrected 01/14/2026 |
November 25, 2025: 1 citation (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| J | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 11/26/2025 |
September 19, 2024: 7 citations (Standard + Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| E | F-0761 | 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. Pharmacy Service Deficiencies | Standard | Deficient, Provider has date of correction Corrected 10/17/2024 |
| F | F-0732 | Post nurse staffing information every day. Nursing and Physician Services Deficiencies | Standard | Deficient, Provider has date of correction Corrected 10/17/2024 |
| F | F-0727 | 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. Nursing and Physician Services Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 10/17/2024 |
| D | F-0679 | Provide activities to meet all resident's needs. Quality of Life and Care Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 10/17/2024 |
| D | F-0677 | Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 10/17/2024 |
| D | F-0585 | 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. Resident Rights Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 10/17/2024 |
| C | F-0577 | Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. Resident Rights Deficiencies | Standard | Deficient, Provider has plan of correction Corrected 10/17/2024 |
August 23, 2023: 10 citations (Standard)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| E | F-0867 | Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Administration Deficiencies | Standard | Deficient, Provider has date of correction Corrected 10/08/2023 |
| E | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies | Standard | Deficient, Provider has date of correction Corrected 10/08/2023 |
| E | F-0761 | 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. Pharmacy Service Deficiencies | Standard | Deficient, Provider has date of correction Corrected 10/08/2023 |
| B | F-0732 | Post nurse staffing information every day. Nursing and Physician Services Deficiencies | Standard | Deficient, Provider has plan of correction Corrected 10/08/2023 |
| D | F-0730 | Observe each nurse aide's job performance and give regular training. Nursing and Physician Services Deficiencies | Standard | Deficient, Provider has date of correction Corrected 10/08/2023 |
| D | F-0727 | 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. Nursing and Physician Services Deficiencies | Standard | Deficient, Provider has date of correction Corrected 10/08/2023 |
| E | F-0679 | Provide activities to meet all resident's needs. Quality of Life and Care Deficiencies | Standard | Deficient, Provider has date of correction Corrected 10/08/2023 |
| B | F-0640 | Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Resident Assessment and Care Planning Deficiencies | Standard | Deficient, Provider has plan of correction Corrected 10/08/2023 |
| D | F-0636 | Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. Resident Assessment and Care Planning Deficiencies | Standard | Deficient, Provider has date of correction Corrected 10/08/2023 |
| E | F-0565 | Honor the resident's right to organize and participate in resident/family groups in the facility. Resident Rights Deficiencies | Standard | Deficient, Provider has date of correction Corrected 10/08/2023 |
Source: CMS Health Deficiencies: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Fire safety inspections
7 fire safety citations across 3 inspection dates
| Date | Severity | Tag | What was cited | Status |
|---|---|---|---|---|
| 09/19/2024 | D | K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 12/20/2024 |
| 08/23/2023 | F | K-0918 | Have generator or other power source capable of supplying service within 10 seconds. Gas, Vacuum, and Electrical Systems Deficiencies | Deficient, Provider has date of correction Corrected 11/05/2023 |
| 08/23/2023 | F | K-0916 | Have a battery powered remote alarm panel in a location accessible by operating personnel. Gas, Vacuum, and Electrical Systems Deficiencies | Deficient, Provider has date of correction Corrected 11/05/2023 |
| 08/23/2023 | D | K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. Services Deficiencies | Deficient, Provider has date of correction Corrected 11/05/2023 |
| 08/23/2023 | D | K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. Egress Deficiencies | Deficient, Provider has date of correction Corrected 11/05/2023 |
| 08/23/2023 | F | E-0004 | Develop and maintain an Emergency Preparedness Program (EP). Emergency Preparedness Deficiencies | Deficient, Provider has date of correction Corrected 10/08/2023 |
| 01/07/2022 | D | K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. Egress Deficiencies | Deficient, Provider has date of correction Corrected 03/25/2022 |
Automatic sprinklers in all required areas: Yes. CMS does not count fire safety citations in the health inspection star rating.
Source: CMS Fire Safety Deficiencies: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Penalties
| Date | Type | Fine amount | Payment denial |
|---|---|---|---|
| November 25, 2025 | Fine | $16,153 | — |
| November 25, 2025 | Payment Denial | — | Starting November 25, 2025, 1 days |
| October 2, 2023 | Fine | $4,545 | — |
Source: CMS Penalties: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Staffing
| Measure | This facility | North Carolina average | U.S. average |
|---|---|---|---|
| Total nurse staff hours per resident per day | 3.1 | 3.85 | 3.86 |
| Registered nurse (RN) hours per resident per day | 0.78 | 0.62 | 0.69 |
| LPN/LVN hours per resident per day | 0.59 | Not published | Not published |
| Nurse aide hours per resident per day | 1.72 | Not published | Not published |
| Total nurse staff hours per resident per day, weekends | 2.84 | Not published | Not published |
| RN hours per resident per day, weekends | 0.62 | Not published | Not published |
| Total nursing staff turnover (%) | Staffing data not submitted or invalid for calculating turnover. | 49 | 45.8 |
| Registered nurse turnover (%) | Staffing data not submitted or invalid for calculating turnover. | Not published | Not published |
| Administrators who have left | Staffing data not submitted or invalid for calculating turnover. | Not published | Not published |
Reported hours come from the Payroll-Based Journal (PBJ) staffing data that facilities submit to CMS each quarter.
Source: CMS Provider Information; State and US Averages: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Facility details
- Legal business name
- Dlp Person Memorial Hospital LLC
- Ownership type
- For profit - Limited Liability company
- Chain
- Lifepoint Health (8 facilities)
- Ownership changed in last 12 months
- No
- Certified beds
- 56
- Average residents per day
- 46.9
- Participates in
- Medicare and Medicaid
- Located inside a hospital
- Yes
- Continuing care retirement community
- No
- Resident and family council
- Resident
- First approved for Medicare/Medicaid
- January 1, 1967
- County/parish
- Person
Source: CMS Provider Information: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Owners and managers reported to CMS
14 ownership and management records
| Name | Role | Type | Ownership % | Since |
|---|---|---|---|---|
| DLP HEALTHCARE LLC | 5% OR GREATER DIRECT OWNERSHIP INTEREST | Organization | 100% | undefined undefined, NaN |
| DLP PARTNER LLC | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | Organization | NO PERCENTAGE PROVIDED | undefined undefined, NaN |
| HISTORIC LIFEPOINT HOSPITALS, LLC | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | Organization | NO PERCENTAGE PROVIDED | undefined undefined, NaN |
| LEGACY LIFEPOINT HEALTH LLC | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | Organization | NO PERCENTAGE PROVIDED | undefined undefined, NaN |
| LIFEPOINT HOLDINGS 2 LLC | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | Organization | NO PERCENTAGE PROVIDED | undefined undefined, NaN |
| LIFEPOINT HOSPITALS HOLDINGS LLC | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | Organization | NO PERCENTAGE PROVIDED | undefined undefined, NaN |
| BROWN, ELLIOTT | CORPORATE OFFICER | Individual | NOT APPLICABLE | undefined undefined, NaN |
| LAWRENCE, CHARLOTTE | CORPORATE OFFICER | Individual | NOT APPLICABLE | undefined undefined, NaN |
| MONTE, CHRISTOPHER | CORPORATE OFFICER | Individual | NOT APPLICABLE | undefined undefined, NaN |
| POLITE, ELMER | CORPORATE OFFICER | Individual | NOT APPLICABLE | undefined undefined, NaN |
| POPPELL, MARCUS | CORPORATE OFFICER | Individual | NOT APPLICABLE | undefined undefined, NaN |
| SENSING, PHILLIP | CORPORATE OFFICER | Individual | NOT APPLICABLE | undefined undefined, NaN |
| BEARD, BERTRAND | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| SENSING, PHILLIP | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
Source: CMS Ownership: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Check it yourself
- Medicare Care Compare: Person Memorial Hospital. Full inspection reports, quality measures and staffing.
- DHSR Complaint Intake Unit: File a Complaint. The state agency also takes nursing home complaints.
- Ask the facility to show you its most recent inspection report and plan of correction.
Page built from CMS data files processed September 1, 2026 (CMS refreshes monthly). Last checked October 26, 2026. Not a ranking or endorsement.