Piedmont Hills Center for Nursing and Rehab

In the surveyor’s words

From the most serious findings on record at Piedmont Hills Center for Nursing and Rehab, in the surveyor’s own words.

• Immediate jeopardy, patternF726Jul 17, 2024

  Based on observations, record review, Nurse Practitioner and staff interviews, the facility failed to verify competency for cleaning and disinfecting glucometers according to the manufacturer's instructions. Medication Aide (MA) #1 was observed to conduct a finger stick blood sugar (FSBS) check on Resident #1 and using the same shared glucometer proceeded to check blood sugar levels on Resident #2, Resident #3, and Resident #4 without disinfecting the glucometer between any of the residents. MA #1 was interviewed and reported she worked at the facility for approximately 2 years and her competencies for cleaning and disinfecting glucometers per the manufacturer's instructions had never been verified. She stated she never cleaned and disinfected the glucometer between residents. […]

• Immediate jeopardy, patternF880Jul 17, 2024

  Based on record reviews, observations, and staff and Nurse Practitioner (NP) interviews, the facility staff failed to disinfect a shared blood glucose meter (glucometer) between residents whose blood glucose levels required monitoring. Medication Aide (MA) #1 was observed to conduct a finger stick blood sugar (FSBS) check on Resident #1 and using the same glucometer proceeded to check blood sugar levels on Resident #2, Resident #3, and Resident #4 without disinfecting the glucometer between any of the residents. This occurred while there were no residents with known bloodborne pathogens, such as Hepatitis and Human Immunodeficiency Virus (HIV), in the facility. […]

• Immediate jeopardy, patternF684Aug 19, 2022

  Based on record review and interviews with staff, Physician Assistant and the Medical Director, the facility failed to implement an order from the hospital discharge summary to test blood sugar twice daily for Resident #72. The facility administered injectable and oral diabetes medication to Resident #72 who was diagnosed with diabetes without monitoring the resident's blood sugar from admission to the facility until admission to the hospital. On 8/13/22, Resident #72's blood sugar registered HI on the glucometer. Resident #72 was sent to the emergency department (ED) due to being lethargic and staff were unable to obtain vital signs. […]

• Immediate jeopardy, patternF756Aug 19, 2022

  Based on record review, Consultant Pharmacist, Medical Director and staff interviews, the facility failed to complete an evaluation of Resident #72's medication regimen that identified the need to monitor injectable and oral diabetes medications for 4 of 4 medication regimen reviews. Resident #72 received weekly injectable and daily oral diabetes medication without blood sugar testing as ordered and experienced critically high blood sugars identified at the hospital. This deficient practice occurred for 1 of 6 sampled residents reviewed for medication regimen review (Resident #72). […]

• Immediate jeopardy, isolatedF689Jun 11, 2025

  Based on observations, record review, and staff, Medical Director and Nurse Practitioner interviews, the facility failed to ensure the necessary supervision was provided to a severely cognitively impaired resident to prevent an avoidable accident. Resident #1 was prescribed a puree diet and had a history of choking. On 3/19/25 Resident #1, who was known to have poor safety awareness, had a choking episode in the main lobby. Staff performed a back blow that produced a piece of bread from his mouth. He was assessed by the Nurse Practitioner (NP) and determined to return to his baseline. Following the 3/19/25 choking incident, all facility staff were educated on the importance of providing residents with diets per the physician order. […]