Lillington Health and Rehab: Discharge Planning Failure - NC
That sequence of events, documented by federal inspectors at Lillington Health and Rehabilitation Center following an August 2025 complaint investigation, describes how a resident lost access to their preferred home health agency during discharge planning, not because the agency refused, but because a staff member gave up after a single unanswered message.
The inspection report identifies the resident only as Resident #1. What it makes clear is that this person had a preference, a specific home health agency they wanted to handle their care after leaving the facility. That preference was documented. The social worker knew it.
On the morning of August 4, 2025, the social worker emailed the healthcare liaison at what the report calls Home Health Agency #1. The email, according to inspectors, contained no attachments and no additional information that would have helped the agency evaluate or accept the referral. It went out. No response came back.
Four hours passed.
At 2:55 that afternoon, the social worker emailed the same liaison again. Not to follow up on the referral. Not to ask whether they'd received the first message or needed more documentation. The second email said: "I have found another company to accept, thank you."
That was it. The preferred agency was out. A different provider would now be handling Resident #1's care after discharge, not because of any clinical reason, not because the preferred agency declined, but because one email went unanswered for four hours on a Monday afternoon.
When inspectors interviewed the facility's administrator on August 11, 2025, the administrator acknowledged what should have happened. The social worker, the administrator said, should have attempted to reach out again to Resident #1's preferred agency when she didn't hear back from the initial email, and she should have done so before making other arrangements.
The administrator's own words confirmed the failure. The facility's top official agreed, on the record, that the process was wrong.
The deficiency was cited under F0627, which covers the discharge planning process, specifically the requirement that facilities work to accommodate resident preferences when arranging post-discharge services. Inspectors rated the harm level as minimal or potential for actual harm, affecting a small number of residents.
That rating reflects the lower end of the federal harm scale, and it is worth being precise about what that means and what it does not mean. It means inspectors did not document that Resident #1 suffered a measurable physical injury as a direct result of receiving care from a different home health agency. It does not mean nothing went wrong. It does not mean the resident's preference was honored. It does not mean the process was acceptable.
A person in a nursing home preparing to leave has limited ways to advocate for themselves. They may have chosen a particular home health agency because a family member works there, or because they've used that agency before and trust the staff, or because the agency speaks their language, or because it's the one their doctor recommended. The inspection report doesn't say why Resident #1 wanted that specific provider. It doesn't need to. The preference existed, and the facility's own discharge planning process is supposed to protect it.
Instead, a social worker sent an incomplete email, waited four hours on a business day, and then closed the door.
No one called the agency to check whether the email arrived. No one picked up the phone to explain the resident's needs or ask when they could confirm availability. No one gave the preferred agency a real opportunity to respond before substituting a different provider.
The facility's administrator, when pressed by inspectors, did not defend what happened. The acknowledgment was clear and direct: the social worker should have tried again before going elsewhere.
Whether Resident #1 was told their preferred agency had been replaced, or why, is not reflected in the portion of the inspection report available. Whether they had any opportunity to object is not reflected either. What is reflected is that by 2:55 in the afternoon on August 4th, the decision had already been made, and the preferred agency received a polite goodbye email.
Lillington Health and Rehabilitation Center is located on East Cornelius Harnett Boulevard in Lillington, a small town in Harnett County. The inspection was completed August 13, 2025.
Resident #1 was discharged to care arranged by someone other than the agency they asked for.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Lillington Health and Rehabilitation Center from 2025-08-13 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.
Corrections: We strive for accuracy in everything we publish. If you believe any fact in this article is incorrect, please contact us with details, and we will review and correct it promptly.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: October 25, 2026 · Our methodology
Lillington Health and Rehabilitation Center in Lillington, NC was cited for violations during a health inspection on August 13, 2025.
The inspection report identifies the resident only as Resident #1.
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.