Lillington Health and Rehab: Pain Med Records Don't Match - NC
When federal inspectors visited Lillington Health and Rehabilitation Center in August 2025, they found that documentation for a controlled pain medication, Tramadol, didn't line up. The times a nurse recorded giving the drug to a resident didn't correspond with the times the medication was actually pulled from storage, and neither matched what appeared on the Medication Administration Record.
The discrepancy involved one nurse, identified in inspection records only as Nurse #1, and one resident, identified as Resident #5.
Tramadol is an opioid-class pain reliever. Nursing homes are required to track controlled substances carefully precisely because the gap between what the record says and what actually happened can mean a resident went without pain relief, or that a drug meant for a patient ended up somewhere else entirely.
The facility's own Nurse Consultant told inspectors that the documentation of controlled pain medication administration should match the MAR, and that the times recorded should also correspond with the Controlled Drug Receipt, Record, and Disposition Forms. In this case, they didn't.
Inspectors tagged the deficiency as F0755, covering medication storage and management, and rated the level of harm as minimal harm or potential for actual harm. A small number of residents were affected, according to the report.
That rating, minimal harm or potential for actual harm, sits near the lower end of CMS's severity scale. It does not mean nothing went wrong. It means inspectors could not confirm that a resident was actually hurt, but the conditions existed for harm to occur.
What the report does not say is whether Resident #5 received Tramadol at all during the period in question, whether the nurse offered any explanation for the discrepancy, or whether the facility had identified the mismatch before inspectors arrived. The inspection was triggered by a complaint, not a routine survey.
For residents in a nursing home, pain management is not a secondary concern. Undertreated pain in older adults is linked to declining mobility, worsening depression, disrupted sleep, and reduced participation in rehabilitation. A resident prescribed Tramadol is a resident whose provider determined they needed it. When the record of whether and when that drug was given cannot be reconciled with when it left the locked cabinet, the question of whether the resident actually received it becomes unanswerable.
The facility, located at 1995 East Cornelius Harnett Boulevard in Lillington, had until the date of the printed report to submit a plan of correction to the state survey agency. Whether that plan addressed the specific nurse, the specific resident, or the broader tracking system for controlled substances is not reflected in the inspection documents reviewed for this article.
Lillington Health and Rehabilitation Center is a skilled nursing facility in Harnett County, a rural area roughly 35 miles south of Raleigh. For families whose relatives live there, the question raised by this inspection is a simple one with no simple answer: when the paperwork doesn't match, where did the medication go, and did the person who needed it get it.
That question, as of the inspection date, remained open.
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: November 3, 2026 · Our methodology
Lillington Health and Rehabilitation Center in Lillington, NC was cited for violations during a health inspection on August 13, 2025.
The discrepancy involved one nurse, identified in inspection records only as Nurse #1, and one resident, identified as Resident #5.
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.