Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Piney Grove Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors found that PTAC units in eight resident rooms, each occupied by two residents, had visible black, raised residue on the vent slats and accumulations of brown, white, and black particles on the internal surfaces behind the slats. The dirty conditions, including slats and internal bases partially to largely covered with residue and debris, were still present when rechecked with the maintenance director. Interviews with the maintenance and housekeeping directors showed that staff relied on an electronic work order system for problem reporting, that PTAC units were only routinely checked during monthly filter changes, and that housekeeping cleaned only the perimeter surfaces. Both departments considered different parts of the PTAC units to be the other’s responsibility and could not describe a defined inspection or cleaning schedule for the slats and internal base areas, while the administrator acknowledged the units were unacceptably dirty and that there was confusion over cleaning responsibilities.
A resident in an LTC facility did not receive her prescribed pain medication for several days due to misappropriation, leading to increased pain. The facility's narcotic count sheets were altered, and 30 tablets were unaccounted for. Staff interviews revealed a lack of awareness about the missing medications, and the pharmacy confirmed delivery. The issue was not detected by the facility's inspection process, and the DON suggested the medications were likely taken by someone with access.
A resident with chronic pain did not receive prescribed pain medication for several days, leading to increased pain levels. The facility's staff failed to communicate the unavailability of the medication, and no alternative pain management was provided. Interviews revealed a lack of awareness and follow-up by the medical team.
The facility failed to provide scheduled showers to three residents, impacting their right to self-determination. A resident with arthritis did not receive showers as scheduled, affecting her comfort. Another resident, moderately cognitively impaired, received partial or bed baths instead of showers, which she preferred. A third resident, also moderately cognitively impaired, did not receive any scheduled showers over a month. Staffing issues and frequent schedule changes were cited as reasons for the missed showers.
The facility failed to address and communicate resolutions to concerns raised by residents during Resident Council meetings over several months. Recurring issues such as missed showers, unresponsive staff, and poor customer service were documented without evidence of follow-up actions. Residents expressed dissatisfaction with vague responses from staff, and the Activity Director confirmed a lack of feedback on resolutions. The current Administrator acknowledged the absence of a formal grievance process during the period reviewed.
The facility did not notify the Regional Ombudsman of resident discharges or transfers for six months, affecting 149 residents. The Social Worker, unaware of the requirement, failed to send notifications, and the Administrator confirmed the oversight.
The facility failed to develop discharge care plans for three residents who wished to return to the community. Despite having intact cognition and clear discharge goals, these residents were not involved in discussions about their discharge plans or progress. The Social Worker and MDS Coordinator did not complete the necessary discharge care plans, leading to a lack of communication and documentation. The Administrator acknowledged the need for a discharge planning process, but it was not implemented, resulting in resident and family frustration.
A facility failed to maintain accurate TARs for a resident with a sacral pressure ulcer. Despite physician orders for daily wound care, documentation was missing on several occasions, indicating treatments may not have been completed. Interviews with nursing staff revealed uncertainty about whether treatments were performed, and the DON confirmed that undocumented treatments are considered not done.
A long-term care facility failed to implement infection control policies, as staff did not adhere to guidelines during wound care, incontinence care, and while following Enhanced Barrier Precautions (EBP). The Wound Nurse reused contaminated gauze, and a Nurse Aide did not perform hand hygiene after incontinence care. Additionally, staff did not wear required PPE for residents with indwelling medical devices, and proper signage was missing.
A resident missed 14 doses of prescribed narcotic pain medication over 4 1/2 days due to the facility's failure to notify the NP and MD about the medication shortage. The resident experienced increased pain levels, and interviews revealed that staff did not take appropriate action to address the issue. The DON expected staff to ensure medication orders were fulfilled and to notify medical staff when issues arose.
A resident with dementia and hemiplegia did not receive proper personal hygiene care, including nail trimming and chin hair shaving, due to staff inaction and lack of awareness. Despite the resident's ability to communicate her needs, staff failed to address these issues, leaving the tasks to the resident's family member, who was unable to visit due to injury. The facility's Unit Manager and DON were unaware of the situation, highlighting a gap in routine ADL care.
A resident with lymphedema did not receive daily compression wraps as ordered by the physician. Despite the resident's intact cognition and need for assistance, staff failed to apply the wraps consistently, and documentation was inaccurate. Interviews revealed that the Wound Nurse and other staff were unsure or forgot to apply the wraps, and the DON was unaware of these lapses.
Two residents with intact cognition were not invited to participate in their care planning meetings following their admission to the facility. The Social Worker, due to a lack of training and process, failed to schedule these meetings, and the residents confirmed not being invited. The Administrator expected these meetings to occur within 72 hours of admission and quarterly, with input from the Interdisciplinary Team.
A facility failed to secure an indwelling urinary catheter tubing for a resident with benign prostatic hyperplasia, leading to potential tension or trauma. The resident, who was moderately cognitively impaired, was observed without a stabilizing device for the catheter tubing. Staff confirmed the absence of the device and applied a sure lock tape to secure the tubing. The DON confirmed that every catheter should have a stabilizing device to prevent trauma.
Unclean PTAC Units and Unclear Cleaning Responsibilities in Multiple Resident Rooms
Penalty
Summary
The deficiency involves the facility’s failure to maintain Packaged Terminal Air Conditioner (PTAC) units in a safe, clean, and comfortable condition in 8 of 26 resident rooms. Surveyors observed multiple PTAC units with patchy black, raised residue on the vent slats and accumulations of brown, white, and black particles on the internal surfaces behind the slats. In one room, 4 of 5 slats had black residue covering 50% of the left side of each slat, while in another room all 5 slats had black, raised residue covering 75% of the entire surface of each slat and the internal surface behind the vents. Additional rooms showed similar conditions, with varying degrees of residue and particle buildup on both the slats and the base behind the slats. These observations were made in rooms that were all occupied by two residents each, indicating that multiple residents were living in rooms with visibly dirty PTAC units. In one room, the base of the internal surface behind the slats was 75% covered with brown, white, and black particles, and in another room, 50% of that area was covered with similar debris. Other rooms had all 5 slats covered 25–50% with patchy black, raised residue, and in one room the base behind the vent slats was 75% covered with brown and black particles. The conditions remained unchanged when re-observed with the Director of Maintenance two days later. Interviews with facility staff revealed a lack of clear responsibility and routine processes for cleaning and inspecting the affected areas of the PTAC units. The Director of Maintenance stated that staff were expected to report issues through an electronic work order system, and he had not received any notifications about PTAC problems in the affected rooms. He reported that he inspected each room weekly but only looked at PTAC units during monthly filter changes, and he attributed the residue and particles to condensation and housekeeping activities. The Director of Housekeeping stated that housekeeping cleaned high- and low-touch areas daily, including only the perimeter of PTAC units, and performed monthly deep cleans, but considered the slats and base behind the slats to be outside areas that fell under Maintenance. Both the Maintenance and Housekeeping Directors were unable to describe a routine inspection or cleaning schedule for the slats and internal base of the PTAC units, and the Administrator acknowledged that the dirty PTAC units were unacceptable and that there was confusion between departments about cleaning responsibilities.
Misappropriation of Resident's Pain Medication
Penalty
Summary
The facility failed to protect a resident's right to be free from misappropriation of controlled medications, specifically affecting one resident who did not receive her prescribed pain medication for several days. The resident, who was admitted with diagnoses including debility, arthritis, and chronic pain, had a physician's order for oxycodone-acetaminophen to be administered three times daily. However, discrepancies in the narcotic count sheets revealed that 30 tablets were unaccounted for, and the resident missed 14 doses over a period of several days, leading to an increase in her pain level. Interviews with staff and pharmacy personnel indicated that the medication was delivered to the facility, but the declining count sheets were altered, and one sheet was missing, suggesting possible diversion of the medication. The resident reported increased pain and was not offered alternative pain management during this period. The pharmacy confirmed that the medication was sent and should have lasted until a later date, but early refill requests were made, indicating a potential issue with medication management. The facility's staff, including the former Director of Nursing and the Medical Director, were unaware of the missing medications until the investigation. The Consultant Pharmacist noted that their inspection process might not have detected such an error, as it involved spot-checking rather than a comprehensive review. The Director of Nursing acknowledged the expectation that medications should not be unaccounted for and suggested that the missing medications and sheet were likely taken by someone with access.
Failure to Administer Pain Medication
Penalty
Summary
The facility failed to ensure that a resident's pain was adequately assessed and managed, resulting in the resident experiencing increased pain levels. Resident #17, who was admitted with diagnoses including debility, arthritis, and chronic pain, had a physician's order for oxycodone-acetaminophen to be administered three times daily. However, the Medication Administration Record (MAR) indicated that the resident did not receive her prescribed doses for several consecutive days in early August 2024, leading to an increase in her pain level to 8 out of 10, compared to her usual level of 0 to 3 when medicated. Interviews with staff revealed a lack of communication and follow-up regarding the unavailability of the resident's pain medication. Nurse #3, who was responsible for administering the medication on several occasions, was no longer employed, and attempts to contact her were unsuccessful. Medication Aide #2 and Nurse #2 both indicated that they would typically report medication unavailability to a supervising nurse or contact the pharmacy, but neither recalled specific actions taken in this case. The facility's Emergency Medication Kit did not contain the necessary medication, and the pharmacy confirmed that a refill was not due until later in the month, leading to a delay in medication delivery. The resident reported significant pain and discomfort due to the lack of medication, which affected her daily activities and sleep. Despite the resident's complaints, there was no documentation of alternative pain management strategies being offered. Interviews with the Medical Director and Nurse Practitioner revealed that they were unaware of the missed doses and emphasized the importance of clear communication regarding medication availability. The Director of Nursing and Administrator acknowledged the expectation that medications should be administered as ordered, highlighting a breakdown in the facility's processes for managing and communicating medication needs.
Failure to Provide Scheduled Showers to Residents
Penalty
Summary
The facility failed to honor the residents' right to self-determination by not providing showers according to the residents' preferences and schedules. Resident #17, who was cognitively intact and required assistance with showering, did not receive showers as scheduled on multiple occasions. Despite being scheduled for showers twice a week, there were several instances where no shower was provided, and the resident expressed dissatisfaction with the lack of showers, which she preferred due to her arthritis. The facility's staff, including agency nurse aides, cited frequent schedule changes and staffing issues as reasons for missed showers. Resident #64, who was moderately cognitively impaired and required assistance with bathing, also did not receive showers as scheduled. The resident was scheduled for showers twice a week but often received partial or bed baths instead. The resident expressed a preference for showers, stating that they made her feel cleaner. Interviews with agency nurse aides revealed that frequent assignment changes and staffing shortages contributed to the failure to provide scheduled showers. Resident #189, who was moderately cognitively impaired but could make her needs known, did not receive any showers as scheduled over a month-long period. The resident was scheduled for showers twice a week but often received partial or bed baths instead. The resident expressed a preference for showers, stating that they made her feel cleaner and helped with her dry skin. Interviews with agency nurse aides indicated that frequent assignment changes and staffing shortages were factors in the missed showers. The facility's management, including the Unit Manager and Director of Nursing, were unaware of the issue and emphasized the need for staff to report missed showers to adjust schedules accordingly.
Failure to Address Resident Council Concerns
Penalty
Summary
The facility failed to effectively address and communicate resolutions to concerns raised by residents during Resident Council meetings over a period of several months. The Resident Council meeting minutes from January to August 2024 consistently documented recurring issues such as residents not receiving showers, staff turning off call lights without providing care, and poor customer service. Despite these concerns being repeatedly noted in the meeting minutes, there was no evidence of the facility's response or resolution to these issues, as the minutes lacked any indication of follow-up actions or communication back to the residents. Interviews with residents who regularly attended the Resident Council meetings revealed their dissatisfaction with the facility's handling of their concerns. They expressed that the responses from staff were vague, often stating that issues were being addressed without providing specific details or satisfactory resolutions. The residents, including the Resident Council President, emphasized their desire for clear communication and feedback from the administration regarding the efforts made to resolve their concerns. The Activity Director, responsible for recording the minutes, confirmed that she was instructed to document concerns and inform the administration, but she never received concrete feedback on how these issues were resolved. The current Administrator, who began in August 2024, acknowledged the lack of a formal process for addressing grievances and suggested implementing a system where concerns from Resident Council meetings would be documented on grievance forms and tracked through a formal resolution process. However, this process was not in place during the period reviewed, contributing to the deficiency in addressing resident concerns.
Failure to Notify Regional Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to notify the Regional Ombudsman of resident discharges or transfers over a six-month period from April 2024 to September 2024. A review of the facility's Admission/Discharge report revealed that 149 residents were discharged home, transferred to the hospital, or transferred to another nursing facility during this time. The Social Worker, who began employment in October 2023, admitted during an interview that she had not been sending notifications to the Regional Ombudsman and was unaware of the requirement to do so. The Administrator confirmed in an interview that the Social Worker had not been contacting the Regional Ombudsman regarding resident discharges or transfers. Both the Administrator and the Social Worker acknowledged that there was no excuse for the lack of notifications, and they recognized that notifications should be sent whenever a resident is discharged or transferred from the facility.
Failure to Develop Resident Discharge Plans
Penalty
Summary
The facility failed to implement a discharge planning process that involved residents in developing a discharge care plan addressing their goals and post-discharge needs. This deficiency was identified for three residents who expressed a desire to return to the community. Despite having intact cognition and clear discharge goals, these residents did not have a discharge care plan documented in their comprehensive care plans. Interviews with the residents revealed that they had not been engaged in discussions about their discharge goals, plans, or progress. The Social Worker (SW) and MDS Coordinator were responsible for developing discharge care plans, but neither had completed this task for any resident. The SW conducted initial assessments and 72-hour care plan meetings but did not document ongoing conversations with residents. The MDS Coordinator stated that discharge care plans were typically the responsibility of the SW, but none had been developed. The lack of documentation and communication resulted in residents being uninformed about their discharge plans and progress. The facility's Administrator acknowledged that the discharge planning process should begin upon admission and be updated based on the resident's progress. However, this process was not followed, as evidenced by the absence of discharge care plans and the lack of communication with residents and their families. This oversight led to frustration among residents and their families, who were left uncertain about discharge timelines and financial implications of extended stays.
Failure to Document Pressure Ulcer Treatments
Penalty
Summary
The facility failed to maintain accurate Treatment Administration Records (TAR) for a resident with a sacral pressure ulcer. The resident had a physician order for specific wound care treatments, but there were multiple instances where documentation was missing, indicating that the treatments may not have been completed as ordered. On several dates across February, March, April, and May 2024, there was no documentation in the TAR to confirm that the prescribed treatments were administered. Interviews with the wound nurse and other nursing staff revealed uncertainty about whether the treatments were performed, as they could not recall specific details or confirm their actions on the missing dates. The Director of Nursing (DON) stated that if a treatment is not documented, it is considered not done, emphasizing the importance of proper documentation. The lack of documentation was attributed to possible oversight by the staff responsible for the treatments. The facility was unable to identify the nurse responsible for the treatment on one of the dates, further complicating the issue. This deficiency highlights a failure in maintaining accurate medical records and ensuring that prescribed treatments are consistently administered and documented.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement infection control policies and procedures, as evidenced by multiple staff members not adhering to established guidelines. The Wound Nurse did not follow proper procedures during a dressing change for a resident with a wound. Specifically, the nurse did not clean the overbed table before placing supplies, failed to use a clean chuck pad under the resident, and reused gauze that had fallen onto a soiled brief. These actions were contrary to the facility's policy on clean dressings, which outlines specific steps for maintaining a sterile environment during wound care. Additionally, a Nurse Aide (NA) did not follow hand hygiene protocols after providing incontinence care to the same resident. The NA failed to remove soiled gloves and perform hand hygiene before touching the resident's bed linens, bed controls, and catheter bag. This was a direct violation of the facility's handwashing policy, which requires personnel to wash their hands after contact with bodily fluids and before touching other surfaces or residents. The facility also did not adhere to Enhanced Barrier Precautions (EBP) for residents with indwelling medical devices. Several staff members, including a nurse and a wound nurse, did not wear the required gowns and gloves when providing care to residents with central venous catheters and urinary catheters. The lack of proper signage and personal protective equipment (PPE) on residents' doors further contributed to the failure to follow EBP guidelines, as staff were not adequately informed of the necessary precautions.
Failure to Notify Medical Staff of Medication Shortage
Penalty
Summary
The facility failed to notify the Nurse Practitioner (NP) and Medical Director (MD) that a resident was completely out of her narcotic pain medication, resulting in the resident missing 14 consecutive doses over 4 1/2 days. The resident, who was admitted with diagnoses including debility, arthritis, and chronic pain, had a physician's order for oxycodone-Acetaminophen to be administered three times daily. However, the Medication Administration Record (MAR) for August 2024 showed that the resident did not receive her medication on multiple occasions, with different nurses failing to administer the doses. Interviews with the involved staff revealed a lack of communication and action to address the medication shortage. Agency Nurse #3 and Nurse #2 did not notify the NP or MD about the medication being out of stock, and attempts to contact Agency Nurse #4 were unsuccessful. The resident reported increased pain levels during the period without medication, and both the MD and NP were unaware of the situation until interviewed. The Director of Nursing (DON) stated that it was expected for residents to receive their medications as ordered and for staff to contact the NP or MD to obtain necessary orders.
Failure to Provide Adequate Personal Hygiene Care
Penalty
Summary
The facility failed to provide adequate personal hygiene care for a dependent resident, identified as Resident #43, who required assistance with activities of daily living (ADL) due to her medical conditions, including dementia, hemiplegia, and osteoporosis. Observations revealed that the resident's nails were long with brown debris underneath, and she had visible chin hairs, which were not addressed by the facility staff. Despite the resident's ability to communicate her needs, she reported that her family member usually had to trim her nails and chin hairs, but the family member had been unable to visit due to a personal injury. Interviews with staff members, including Agency Nurse Aide (NA) #8 and Nurse Aide (NA) #11, indicated a lack of awareness and action regarding the resident's personal hygiene needs. Agency NA #8 admitted to noticing the long nails but did not trim them or report the issue to the Unit Manager, citing unfamiliarity with the resident's care routine. Similarly, NA #11 did not notice the resident's long nails or chin hairs and did not provide a bath or report the need for nail trimming to the Unit Manager, assuming it would be handled during scheduled showers. The Unit Manager and Director of Nursing (DON) were unaware of the resident's unmet hygiene needs and emphasized that nail trimming and shaving should be part of routine ADL care. The DON stated that NAs should report any diabetic residents needing nail trimming to nurses or Unit Managers. The resident's family member confirmed that the facility staff had not offered to trim the resident's nails or shave her chin hairs, leading to the family member performing these tasks despite their own physical limitations.
Failure to Apply Compression Wraps as Ordered
Penalty
Summary
The facility failed to apply compression wraps daily for a resident with lymphedema, as per the physician's order. The resident, who had intact cognition and required substantial assistance with lower body dressing, was observed without compression wraps on multiple occasions. The resident reported that staff did not consistently apply the wraps and that she never refused the treatment. The Treatment Administration Record (TAR) indicated that the wraps were not applied on specific dates, and there were discrepancies in the documentation by the nursing staff. Interviews with the nursing staff revealed inconsistencies in the application of the compression wraps. The Wound Nurse could not recall if he had offered to apply the wraps on one of the days in question, and Nurse #5 admitted to forgetting to document a supposed refusal by the resident. Additionally, Nurse #6 did not have the resident on her treatment list for one of the days, and Nurse #5 mistakenly initialed the TAR as if the treatment had been completed. The Director of Nursing was unaware of the lapses in treatment and stated that the physician's order should have been followed.
Failure to Include Residents in Care Planning Process
Penalty
Summary
The facility failed to invite two residents to participate in their care planning process, which is a requirement following the completion of their admission Minimum Data Set (MDS) assessments. Resident #82, who was admitted with diagnoses including gout, hypertension, severe protein-calorie malnutrition, and osteoarthritis, was not invited to a care plan meeting despite having intact cognition. The facility's records showed no evidence of a care plan meeting being scheduled for Resident #82, and the resident confirmed not being invited to any such meetings since admission. Similarly, Resident #13, admitted with conditions such as rhabdomyolysis, hemiplegia, hemiparesis following a stroke, and diabetes, was also not invited to participate in a care plan meeting. The resident's electronic medical record lacked evidence of an invitation to discuss and provide input on their care plan. The facility's schedule did not list a care plan meeting for Resident #13 until much later, and the resident confirmed not being invited to any meetings since admission. Interviews with the Social Worker (SW) revealed a lack of training and a process for scheduling care plan meetings, which contributed to the oversight. The SW admitted to not inviting residents based on family requests and was unaware of the requirement to invite residents to participate in their care planning. The Administrator confirmed that the SW was responsible for scheduling these meetings and expected them to occur within 72 hours of admission and quarterly thereafter, with the entire Interdisciplinary Team (IDT) present or providing input if unable to attend.
Failure to Secure Indwelling Urinary Catheter Tubing
Penalty
Summary
The facility failed to secure an indwelling urinary catheter tubing to prevent tension or trauma for a resident diagnosed with benign prostatic hyperplasia, which can cause urinary obstruction. The resident, who was moderately cognitively impaired, was observed without a stabilizing device for the catheter tubing while sitting in a wheelchair. The catheter tubing was threaded down the resident's left pant leg, and the catheter bag was hooked to the wheelchair bars. During an interview, the resident confirmed that a stabilizing device was not always in place. Further observations revealed that during morning care, the resident's catheter tubing was not secured with a stabilizing device. A Medication Aide and a Wound Nurse confirmed the absence of the device and applied a sure lock tape to secure the tubing. Interviews with the staff indicated that the stabilizing device was sometimes removed during showers, although the resident had not received a shower that morning. The Director of Nursing confirmed that every catheter should have a stabilizing device to prevent trauma.
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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 Kernersville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Summerstone Health And Rehabilitation Center | 1.8 mi | — | 4 | 0 |
| North Carolina State Veterans Home Kernersville | 1.8 mi | — | 0 | 0 |
| River Landing At Sandy Ridge | 5.9 mi | — | 2 | 0 |
| Trinity Glen | 7.8 mi | — | 2 | 0 |
| Countryside | 9.1 mi | — | 0 | 0 |
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