Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Piedmont Health & Rehab Center during CMS and state inspections, most recent first.
A resident with dementia, altered mental status, and recurrent falls was repeatedly observed wandering in a wheelchair and looking out the exit door window, but staff lost track of him overnight. No one heard the 300-Hall alarm, and the door lock/wander alarm was later found unplugged, allowing the resident to exit unsupervised and be found outside on a dark, sloped embankment wearing only a brief.
Surveyors identified multiple deficiencies in food storage, labeling, and sanitation practices, including unlabeled and undated food items in storage areas, dirty plate covers, improper cleaning of a thermometer probe before food temperature checks, and unclean beverage machines and storage area floors. The Dietary Manager and Administrator acknowledged lapses in staff adherence to required procedures.
A cognitively intact resident voiced the need for privacy during a council meeting, but the Activity Assistant responded in a condescending manner, telling the resident to 'calm down' and rolling her eyes. The resident felt frustrated and disrespected, reporting that staff did not listen and spoke in a childlike manner. The incident left the resident and others confused and silent.
Two residents had inconsistencies in their advance directive documentation, with mismatches between physician orders, face sheets, and MOST/DNR forms. In both cases, staff did not update the physician's orders to reflect changes in code status, resulting in conflicting information about whether to perform life-saving measures.
Three dependent residents with various medical conditions, including heart disease, stroke, and diabetes, were found with long, unclean fingernails. Staff responsible for their care either failed to notice the need for nail care or did not provide it, with some citing restrictions related to diabetes. Nursing leadership confirmed that nail care should be performed during hygiene routines and as needed, but this was not consistently done.
Two residents receiving oxygen therapy did not have required 'oxygen in use' signage posted outside their rooms while oxygen was being administered. Multiple staff, including the DON and ADON, confirmed that signage was expected but had not been posted, despite physician orders for continuous or as-needed oxygen for respiratory conditions.
A resident with multiple health conditions fell out of bed during incontinence care, resulting in a fractured tibia and fibula. The resident, who was cognitively intact, required one-person assistance for bed mobility. During care, the nursing assistant rolled the resident away, causing her to fall. The resident was hospitalized and returned with a leg brace, now requiring two-person assistance.
A resident with diabetes and hypertension did not receive routine doses of glipizide due to the facility's failure to contact the pharmacy for refills and utilize the automatic medication dispensing system. Despite having an automated system in place, the staff did not follow procedures to ensure the medication was available and administered as ordered.
A resident with diabetes and hypertension did not receive prescribed glipizide on multiple occasions due to unavailability, and the physician was not notified. Nursing notes documented the medication was unavailable, but there was no record of physician notification. Interviews revealed a lack of awareness and follow-up by nursing staff and the former DON.
The facility failed to ensure the use of PPE when handling soiled linens in the laundry room. A Laundry Aide was observed transferring soiled linens to the washing machine without PPE, despite having received training. The Infection Control Nurse and DON confirmed the requirement for PPE use, but the Aide did not comply.
Unsupervised Resident Elopement After Door Alarm Was Disabled
Penalty
Summary
The facility failed to effectively supervise a resident with dementia, altered mental status, recurrent falls, and worsening confusion so that he exited the building unsupervised and without staff knowledge. The resident was admitted for skilled nursing care after a hospital stay for recurrent falls and acute on chronic altered mental status. On admission, staff documented that he required moderate assistance with transfers, bed mobility, and activities of daily living, and he was described as intermittently confused. The admission elopement screening did not identify him as having elopement risk factors, despite his cognitive impairment and history of falls. During the night shift, staff observed the resident repeatedly getting out of bed, moving about the 300 Hall in a wheelchair, and sitting at the exit door looking out the window. Staff redirected him back to bed multiple times, and he was also brought to the nurse’s station for close observation. The nurse reported that she last saw him in bed around 4:00 a.m., and the nurse aide discovered him missing between 4:00 and 4:30 a.m. No staff members recalled hearing the 300-Hall door alarm that night. After the resident was found outside, staff determined that the 300-Hall door alarm power cord had been unplugged, which disabled both the lock and wander-alarm system. The resident was located outside on a gravel embankment at the edge of the parking lot, wearing only an adult incontinence brief, with his gown on the ground beside him. He told staff he had fallen and needed help getting up. The area was dark and dimly lit, and the embankment sloped down from the parking lot toward a nearby street. EMS transported him to the hospital for evaluation, where imaging and laboratory studies showed no acute findings, and a contusion to the right hand was treated. The event was documented by staff as an elopement from the facility, and the report states the noncompliance had a high likelihood of causing serious injury or serious bodily harm.
Food Storage, Sanitation, and Equipment Cleaning Deficiencies Identified
Penalty
Summary
The facility failed to properly label and date leftover food items in the walk-in cooler, walk-in freezer, and dry goods storage area. Observations revealed an undated and unsealed package of sliced ham in the refrigerator, an open bag of chicken patties and four bags of unlabeled and undated hoagie rolls in the freezer, and a bag of breadcrumbs in the dry storage area that was also unlabeled and undated. The Dietary Manager confirmed that staff are expected to label and date items when opened and inspect boxes before placing them in storage. Additionally, plate covers used prior to serving were found to be dirty with food crumbs. Further observations showed that a staff member used a thermometer with visible food particles to check the temperature of creamed corn without cleaning the probe beforehand. The staff member admitted to forgetting to clean the probe due to nervousness and time constraints. The tea and coffee machines were found to have dried stains and sticky substances, and the dry goods storage area floor had dirt, food debris, and dust under the shelves. The Dietary Manager acknowledged that cleaning was not done adequately by weekend staff and that the dry goods storage area floors were supposed to be cleaned daily. The Administrator stated an expectation for correct procedures and careful attention to food service to ensure food safety and sanitation.
Failure to Ensure Resident Dignity During Council Meeting
Penalty
Summary
A cognitively intact resident, who had no documented behavioral issues, expressed concern during a resident council meeting that the door to the meeting room should be closed for privacy. The resident attempted to communicate this need to the Activity Assistant, who responded by telling the resident to 'calm down' in a condescending tone and did not close the door. The resident was visibly upset, shaking his head, furrowing his brow, and raising his voice to express frustration at being spoken to like a child. The Activity Assistant further responded by rolling her eyes and again telling the resident to calm down, which left the resident and others confused and silent. Following this interaction, the Activity Assistant excused herself from the meeting and closed the door, allowing the residents to continue privately. In interviews, the resident reported feeling frustrated and disrespected, stating that the Activity Assistant did not listen to concerns and spoke in a childlike manner. The Activity Assistant stated she was unaware of her undignified tone or actions and explained her response as being caught off guard. The Administrator confirmed expectations that staff treat residents with dignity and respect and avoid unprofessional responses.
Failure to Consistently Update and Match Advance Directive Documentation
Penalty
Summary
The facility failed to ensure that advance directive information was consistently updated and matched across all relevant documentation for two residents. For one resident, there was a discrepancy between the physician's order, which indicated Do Not Resuscitate (DNR), and both the face sheet and Medical Orders for Scope of Treatment (MOST) form, which indicated full code status. Staff interviews revealed that the resident's code status had recently changed from DNR to full code, but the physician's order was not updated to reflect this change. Both the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) acknowledged that the orders should have been updated to match the resident's current wishes as documented on the MOST form and face sheet. For another resident, the physician's order indicated full code status, while the face sheet, DNR form, and MOST form all indicated DNR status. This resident was cognitively intact at the time of admission. Staff interviews confirmed that the advance directive information in the physician's order was not updated when the DNR form was signed by the physician. Both the ADON and DON stated that all documentation should have matched to accurately reflect the resident's advance directive wishes, but the necessary updates were not made in the system.
Failure to Provide Nail Care for Dependent Residents
Penalty
Summary
The facility failed to provide adequate nail care for three residents who were dependent on staff for personal hygiene. One resident, admitted with heart disease and weakness, was observed with long fingernails and a dark brown substance under his nails. He reported receiving showers or bed baths but stated that staff did not clean under his nails or trim them, and he did not like having long, dirty nails. The nurse aide assigned to him confirmed that she had not noticed the condition of his nails and had not been informed by the resident that his nails needed attention. Facility leadership, including the DON and Administrator, stated that nail care should be performed with each shower and as needed. Another resident, admitted with a right humerus fracture, stroke, and hemiplegia, was also found with fingernails extending approximately 1/4 inch beyond the fingertips. He stated his nails had not been trimmed since admission and expressed a preference for short nails. The nurse aide responsible for his care was unaware of the length of his nails and had not provided nail care, stating the resident had not requested it. Interviews with nursing leadership reiterated that nurse aides are responsible for nail care during showers and as needed. A third resident, with diagnoses including diabetes, kidney failure, and muscle weakness, was observed with long fingernails and a brown substance underneath. He reported having asked staff to trim his nails without result and stated that nurse aides would not trim his nails due to his diabetes. The nurse aide confirmed she did not perform nail care for diabetic residents and would have reported long nails to a nurse if noticed. The ADON stated that the activity director, who normally performed nail care, had been absent, and that nurse aides should have reported the need for nail care to nursing staff. The DON was not aware that this resident's nails had not been trimmed.
Failure to Post Oxygen in Use Signage for Residents Receiving Oxygen Therapy
Penalty
Summary
The facility failed to post required cautionary signage indicating oxygen was in use for two residents who were receiving oxygen therapy. For one resident with a diagnosis of respiratory disease and a physician's order for continuous oxygen via nasal cannula, observations on multiple dates confirmed that no oxygen signage was posted on the resident's room door while the resident was receiving oxygen. Interviews with nursing staff, the hospice nurse, the Director of Nursing, and the Administrator all confirmed that signage should have been present and that nursing staff were responsible for ensuring its placement. Similarly, another resident with diagnoses including acute lower respiratory infection, cough, wheezing, and congestive heart failure was observed on multiple occasions receiving oxygen via nasal cannula without the required signage posted outside the room. Staff interviews, including with the Assistant Director of Nursing and the Director of Nursing, revealed that they were unaware the signage was missing and acknowledged that it was expected for all residents receiving oxygen to have appropriate signage posted.
Resident Falls During Incontinence Care Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide care in a safe manner when a resident fell out of bed during incontinence care. The incident involved a resident who was admitted with diagnoses including heart failure, kidney disease, lung disease, and diabetes. The resident was assessed to be cognitively intact and required one-person substantial assistance with bed mobility. However, during incontinence care, the nursing assistant rolled the resident away from her, resulting in the resident rolling out of bed and sustaining a fractured tibia and fibula. The nursing assistant involved in the incident reported that she had previously provided care to the resident, who required only one staff member's assistance at that time. During the incident, the nursing assistant was on the left side of the bed and helped the resident turn away from her for incontinence care. The resident leaned further to the right, causing her legs to slip off the mattress and slide to the floor. The nursing assistant called for help, and other staff members arrived to assist the resident, who was found on her knees holding onto the bed rail and expressing knee pain. The resident was subsequently sent to the hospital for evaluation, where x-ray results confirmed fractures in the right leg. The resident returned to the facility with a leg brace and required two-person total assistance for bed mobility and transfers. The incident highlighted a failure in providing adequate supervision and assistance during incontinence care, leading to the resident's fall and injury.
Failure to Administer Routine Medications
Penalty
Summary
The facility failed to provide routine medications for a resident diagnosed with diabetes and hypertension, who was moderately cognitively impaired. The resident had physician orders for several hypoglycemic medications, including glipizide, which was not administered on multiple occasions in December 2023. The medication administration record indicated that glipizide was not given on specific dates, and nursing notes documented the medication as unavailable without any record of the pharmacy being contacted for refills. Interviews with staff revealed that the facility had an automatic medication dispensing system that should have been stocked with routine medications. However, the former Director of Nursing and a nurse involved in the case did not recall the resident missing doses of glipizide. The facility physician noted that while the resident was on other hypoglycemic medications, missing the doses of glipizide should not have harmed the resident, but the medication should have been administered as ordered. The pharmacist explained that the facility used an automated refill system that required a completed form for refills, which was not done for October and November 2023, leading to the cancellation of refills. The pharmacist also noted that glipizide was available in the automatic medication dispensing system, but no calls were made from the facility to request a refill, and no medications were removed from the system for the resident during the period in question.
Failure to Notify Physician of Missed Medication Administration
Penalty
Summary
The facility failed to notify the physician of missed medication administration for a resident diagnosed with diabetes and hypertension. The resident had a physician's order for glipizide, an oral hypoglycemic medication, to be administered daily. However, the medication was not given on several occasions as documented in the medication administration record, specifically on five different dates. The nursing notes indicated that the medication was unavailable, but there was no documentation that the physician had been notified about the missed doses. Interviews with the nursing staff and the former Director of Nursing revealed that the facility had an automatic medication dispensing system that should have been stocked with routine medications. The former Director of Nursing was unaware of the missed doses and the lack of physician notification. Nurse #1, who documented one of the missed doses, could not recall the incident or why the physician was not contacted. Attempts to interview Nurse #2, who documented the other missed doses, were unsuccessful. The facility physician confirmed that he was not informed about the unavailability of glipizide for the resident. He stated that if he had been notified, he would have ordered a replacement medication. Although the physician believed that missing the doses likely did not harm the resident due to other hypoglycemic medications being administered, he emphasized that the resident should have received the medication and that he should have been notified of the issue.
Failure to Use PPE in Laundry Room
Penalty
Summary
The facility failed to handle soiled linens in a manner that prevents the spread of infection, as observed during a survey of the laundry room. During the observation, it was noted that the Laundry Aide did not use personal protective equipment (PPE) when handling soiled linens. The Laundry Aide was seen removing soiled linens from a tied plastic bag and placing them directly into the washing machine without wearing any PPE. This action was contrary to the facility's policy on transmission-based precautions and isolation, which requires the use of standard precautions when handling resident care laundry. Interviews with the Infection Control Nurse and the Director of Nursing revealed that the Laundry Aide had been trained to use PPE when handling soiled linens, but she did not follow this protocol. The Infection Control Nurse confirmed that PPE should be used in such situations and expressed uncertainty as to why the Laundry Aide did not comply. The Director of Nursing was unaware of the non-compliance and stated that she expected the use of PPE to prevent infection spread. The Administrator also confirmed that the Laundry Aide had received training on PPE use but was unsure why it was not being utilized.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Salisbury
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Salisbury Rehabilitation And Nursing Center | 1.5 mi | ★★★★★ | 17 | 1 |
| Nc State Veterans Home - Salisbury | 1.8 mi | ★★★★★ | 12 | 1 |
| Autumn Care Of Salisbury | 1.8 mi | ★★★★★ | 6 | 0 |
| Trinity Oaks | 1.8 mi | ★★★★★ | 0 | 0 |
| Compass Healthcare And Rehab Rowan, Llc | 1.9 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.