Piedmont Health & Rehab Center

In the surveyor’s words

From the most serious findings on record at Piedmont Health & Rehab Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689May 13, 2026

  Based on observations, record review, and interviews with staff, Contractor for safety systems, and the Medical Director, the facility failed to effectively supervise a resident, who had diagnoses including dementia and altered mental status and a history of falls, from exiting the facility unsupervised and without staff knowledge for 1 of 3 residents reviewed for supervision to prevent accidents (Resident #1). Resident #1 was admitted to the facility on [DATE] and according to staff became increasingly confused during the shift which started at 7:00 PM. Resident #1 got out of bed multiple times and self-propelled in his wheelchair up and down the hall and was observed at the exit door looking out the window. […]

• Actual harm, isolatedF689Jul 23, 2024

  Based on record review, observations, staff, and physician interviews, the facility failed to provide care in a safe manner when a resident fell out of bed during incontinence care for 1 of 3 residents reviewed for accidents (Resident #12). Nursing assistant (NA) #1 rolled Resident #12 away from her during incontinence care and Resident #12 rolled out of bed. Resident #12 sustained a fractured tibia and fibula (bones below the right knee). Resident #12 required a 2-day hospitalization for the fracture and returned to the facility with a leg brace in place. The findings included: Resident #12 was admitted to the facility 11/24/2023 with diagnoses to include heart failure, kidney disease, lung disease, and diabetes. […]

• No harm, potential for more than minimal, widespreadF812May 20, 2021

  Based on observations and staff interviews, the facility failed to label, and date opened food and drinks in 2 of 2 coolers observed. Findings included: The kitchen was observed on [DATE] at 9:43 AM. The 2-door cooler was observed to have open and undated drinks: Thick and Easy Milk (expiration date [DATE]), [MEDICATION(S)] Thick water (expiration date [DATE]), nectar thick apple juice (expiration date [DATE]) and nectar thick ice tea (expiration date [DATE]). The 3-door cooler was observed to have open and undated food: ,d+[DATE]-gallon size Hickory Smoke BBQ sauce, 2 containers of pimento cheese (expiration date [DATE]); ½ gallon size of Ranch dressing (expiration [DATE]). The Dietary manager (DM) was interviewed on [DATE] at 10:01 AM. […]

• No harm, potential for more than minimal, patternF812Sep 11, 2025

  Based on observations, and Dietitian and staff interviews, the facility failed to label and date leftover food items stored for use in 1 of 1 walk-in cooler, 1 of 1 walk-in freezer and the dry goods storage area and failed to maintain clean food service equipment and flooring and failed to clean a thermometer probe before inserting the probe into food. These practices had the potential to affect food served to residents. The findings included:a. An observation of the walk-in refrigerator on 9/8/25 at 10:30 AM revealed an undated package of sliced ham that was not sealed. b. An observation on 9/8/25 at 10:41 AM revealed an open-to-air bag of chicken patties sitting in an open box, in the walk-in freezer and 4 bags of leftover hoagie rolls unlabeled and undated. c. […]

• No harm, potential for more than minimal, patternF755Jul 23, 2024

  Based on record review, observations, and staff interviews, the facility failed to provide routine medications for 1 of 3 residents reviewed for medication administration (Resident #2). The findings included: Resident #2 was admitted to the facility 12/1/2021 with diagnoses including diabetes and hypertension. The most recent quarterly Minimum Data Set assessment assessed Resident #2 to be moderately cognitively impaired. Review of the physician orders for Resident #2 revealed an order dated 12/1/2022 for glipizide (an oral hypoglycemic) 10 milligrams (mg) daily for diabetes. […]