Lillington Health and Rehab: Unsanitized Dishes - NC
Nobody could say how long.
The Certified Dietary Manager at Lillington Health and Rehabilitation Center told inspectors the chemical agents in the machine typically needed to be changed every one and a half to two weeks. He did not know when the agents had last been swapped out before the crossed lines were discovered on July 18, 2025. That meant he could not say how many days of meals had gone out to residents on trays that passed through a machine producing no effective sanitation at all.
The problems had started before that. A local health department inspector visited the facility on July 1 and found the dishwasher was not sanitizing. She directed the facility to stop using the machine, switch to single-use disposable service items for meals, and use a three-compartment sink if sanitation was needed. She left expecting the facility to comply.
She came back on July 17. The dishwasher was still broken, still not sanitizing. There were no disposable meal service items in evidence. Water was on the floor. The CDM told her the facility had been waiting on the health department's written report before moving to fix the machine.
The health department employee told inspectors she did not understand why the facility needed her report to fix a dishwasher.
The administrator, interviewed alongside the CDM on August 8, said it was her understanding that when the health department arrived on July 1, they would provide a written report of the problem and offer some education. She thought the education would be useful. They wanted to cooperate, she said, and were waiting on the actual report. In the meantime, she said, they had been using disposable single-use items for food service, excluding the reusable trays.
The health department employee who visited on July 17 had seen no disposable items in use.
The commercial service provider who arrived on July 18 was not under contract to repair or maintain the machine. His company supplied the chemical agents. When he checked the lines, he found them reversed: detergent feeding into the sanitizer port, sanitizer feeding into the detergent port. He also found water leaking from the back of the machine and a drain motor making a loud chattering noise. The motor appeared to be locking up, which meant the machine was not draining correctly.
Inspectors asked him about the overflow the CDM had noticed during the rinse cycle. He explained it was not necessarily clean water backing up. Once the wash cycle finished, the machine moved into the rinse cycle, but it would first empty the dirty wash water before the clean rinse began. The malfunctioning drain motor could hang up at any point in that process. The water overflowing onto the kitchen floor could be dirty water from the wash cycle.
The health department employee who visited on July 17 told inspectors that dirty water overflowing from the dishwasher was a sanitation issue. Rinse water overflowing onto the floor was also a sanitation issue, because standing water in a kitchen attracts pests. The machine should not have been used if it was leaking water onto the floor or failing to sanitize. Either condition was enough. The facility had both.
A facility invoice reviewed by inspectors showed that holes in the dishwasher, which had been identified as the source of water leaking onto the floor when the CDM was hired in June 2025, were repaired on July 23 by an outside company. The crossed chemical lines had been corrected on July 18. But the facility also submitted to the health department after July 18 that the machine required further repairs.
The CDM had been hired in June. The holes in the machine were already leaking when he arrived.
CMS rated the violation as having caused minimal harm or potential for actual harm and noted it affected many residents. Inspectors completed the survey on August 13, 2025.
What inspectors could not determine, and what the CDM could not answer, was the simplest question: for how many days had residents at Lillington Health and Rehabilitation Center been eating off trays that the machine had cycled through dirty water and called clean.
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.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
Lillington Health and Rehabilitation Center in Lillington, NC was cited for violations during a health inspection on August 13, 2025.
He did not know when the agents had last been swapped out before the crossed lines were discovered on July 18, 2025.
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.