Deficiency Records for Piedmont Hills Center For Nursing and Rehab
Updated as of March 01, 2024
A list of the most recent deficiencies for Piedmont Hills Center For Nursing and Rehab. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Meet other general requirements. | Fire Safety | 2024-01-02 | 2024-03-16 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2024-01-02 | 2024-03-16 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2024-01-02 | 2024-03-16 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-01-02 | 2024-03-16 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-01-02 | 2024-03-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-01-02 | 2024-03-16 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-01-02 | 2024-03-16 | N |
| Install properly constructed windows in hallway walls or doors. | Fire Safety | 2024-01-02 | 2024-03-16 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2024-01-02 | 2024-03-16 | N |
| Use approved construction type or materials. | Fire Safety | 2024-01-02 | 2024-02-16 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-01-02 | 2024-02-16 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2024-01-02 | 2024-02-16 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-01-02 | 2024-02-16 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2024-01-02 | 2024-02-16 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-01-02 | 2024-02-16 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2024-01-02 | 2024-02-16 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-01-02 | 2024-02-16 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-01-02 | 2024-02-16 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-12-04 | 2024-01-04 | Y |
| Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency. | Health | 2023-12-04 | 2024-01-01 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-12-04 | 2024-01-01 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-12-04 | 2024-01-01 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-12-04 | 2024-01-01 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-12-04 | 2024-01-01 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-12-04 | 2024-01-01 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2023-12-04 | 2024-01-01 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-12-04 | 2024-01-01 | N |
| Ensure a qualified health professional conducts resident assessments. | Health | 2023-12-04 | 2024-01-01 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-12-04 | 2024-01-01 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-12-04 | 2024-01-01 | N |
| 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. | Health | 2023-12-04 | 2024-01-01 | N |
| Post nurse staffing information every day. | Health | 2023-12-04 | 2024-01-01 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-12-04 | 2024-01-01 | N |
| 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. | Health | 2023-12-04 | 2024-01-01 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2023-12-04 | 2024-01-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-12-04 | 2024-01-01 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-12-04 | 2024-01-01 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-12-04 | 2024-01-01 | N |
| Provide bedrooms that don't allow residents to see each other when privacy is needed. | Health | 2023-12-04 | 2024-01-01 | N |
| Conduct mandatory training, for all staff, on the facility?s Quality Assurance and Performance Improvement Program. | Health | 2023-12-04 | 2024-01-01 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2023-12-04 | 2024-01-01 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-12-04 | 2024-01-01 | Y |
| 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. | Health | 2023-12-04 | 2024-01-01 | Y |
| 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. | Health | 2023-12-04 | 2024-01-01 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-12-04 | 2024-01-01 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2023-12-04 | 2024-01-01 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-12-04 | 2024-01-01 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-12-04 | 2024-01-01 | Y |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-12-04 | 2024-01-01 | Y |
| Provide or obtain dental services for each resident. | Health | 2023-12-04 | 2024-01-01 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-11-23 | 2022-12-12 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-11-23 | 2022-12-12 | Y |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2022-09-15 | 2022-10-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-09-15 | 2022-10-10 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-09-15 | 2022-10-10 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-08-19 | 2022-09-14 | N |
| 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. | Health | 2022-08-19 | 2022-09-14 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-08-19 | 2022-09-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-08-19 | 2022-09-14 | N |
| Dispose of garbage and refuse properly. | Health | 2022-08-19 | 2022-09-14 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-08-19 | 2022-09-14 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-08-19 | 2022-09-14 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-08-19 | 2022-09-14 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-08-19 | 2022-09-14 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-08-19 | 2022-09-14 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2021-12-13 | 2022-01-31 | N |
| 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. | Health | 2021-12-13 | 2022-01-31 | N |
| Post nurse staffing information every day. | Health | 2021-12-13 | 2022-01-31 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2021-12-13 | 2022-01-31 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-12-13 | 2022-01-31 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-12-13 | 2022-01-31 | Y |
| 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. | Health | 2021-12-13 | 2022-01-31 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-12-13 | 2022-01-31 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-12-13 | 2022-01-31 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-12-13 | 2022-01-31 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-12-13 | 2022-01-31 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-12-13 | 2022-01-31 | Y |
