Piedmont Hills Nursing: Delayed Notifications After Injury - NC
Not the on-call nurse practitioner. Not the attending provider. Nobody.
Federal inspectors cited the facility in October after interviewing the Director of Nursing, two nurses, and the facility's administrator. What emerged was a picture of two separate clinical warning signs, two separate nurses, and the same failure to act on either one.
Nurse #3 was the first to observe that Resident #5's pulse had dropped below 60 beats per minute. A pulse that low, in a nursing home resident, is a change in condition. The Director of Nursing, interviewed by inspectors on October 23, said plainly that she would have wanted Nurse #3 to notify the provider at the time it happened.
Nurse #3 did not.
At around 6:40 that evening, Nurse #4 entered Resident #5's room and saw what the Director of Nursing later described as a bump over the resident's left eye. That discovery, too, required an immediate call, this time to the on-call nurse practitioner. The Director of Nursing said she would have wanted Nurse #4 to make that call the moment the injury was observed.
Nurse #4 did not make that call either. Instead, Nurse #4 summoned the Director of Nursing to the room.
The Director of Nursing came. She saw the bump above Resident #5's left eye. She spoke with the resident's responsible party for roughly ten minutes. The conversation covered hospice and hospitalization. What the inspection record does not reflect is any explanation for why, at that point, with the Director of Nursing present and a visible head injury in front of her, the on-call provider was not contacted then.
The administrator, interviewed later the same morning inspectors were on site, offered no ambiguity about what should have happened. Nurse #3 and Nurse #4, the administrator said, should have notified the provider immediately of any change in condition.
The citation carries a harm level of minimal harm or potential for actual harm, and inspectors noted it affected few residents. The regulatory tag is F0580, which covers the requirement that facilities notify a resident's physician and responsible party of changes in condition.
What the record does not say is what caused the bump above Resident #5's left eye, whether she was on hospice at the time, or what ultimately happened to her after that September evening. The inspection was a complaint survey, meaning someone, a resident, a family member, or a staff member, contacted authorities before inspectors arrived.
What the record does say is this: a resident's heart rate fell to a dangerous level, and then she was later found with a visible injury to her head, and the nurses who observed each of those things decided, in the moment, that neither one required a phone call.
The Director of Nursing was eventually summoned to the room. She discussed hospice with the family. Whether a provider was ever reached that night, and when, is not reflected in the portion of the inspection report made available.
Piedmont Hills Center for Nursing and Rehab operates at 109 S. Holden Road in Greensboro. The inspection was completed October 23, 2025.
Resident #5's responsible party spent ten minutes in that room talking to the Director of Nursing about hospice and hospitalization while a bump sat above their loved one's left eye. Whether anyone with prescribing authority was ever told about it that night remains, in the public record, unanswered.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Piedmont Hills Center For Nursing and Rehab from 2025-10-23 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 7, 2026 · Our methodology
Piedmont Hills Center for Nursing and Rehab in Greensboro, NC was cited for violations during a health inspection on October 23, 2025.
Not the on-call nurse practitioner.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.