Emerald Health & Rehab Center

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

about what to do when the resident was having pain with transfer and not wanting to use the lift. He should have been called at that point. The physician should also have been called if the resident was having pain

after the transfer and wanting to go to the hospital.Interview with the Administrator in conjunction with the DON on 9/25/25 at 6:00 PM revealed the following information. He had spoken to Resident #1 the following week after 9/5/25. Although she did complain initially to the facility that she felt the injury happened during

the transfer, she had never complained to them about problems during the night following the transfer or problems of continued pain without the physician being notified. NA # 2 had never reported a problem to them that the resident had been requesting to go to the hospital and that the nurse did not call the doctor

before the resident called 911. The resident had returned to the facility on 9/24/25 and they (the DON and Administrator) had both spoken to her again on 9/24/25 and she had not been consistent in reports to them as reports to the surveyor. According to the Administrator and DON the resident reported that she had been experiencing knee pain for several weeks and she had pain all the time. Resident #1 had reported to them that the pain following the transfer was no different than what she had been experiencing for the past few weeks prior to the transfer. Resident #1 reported that she had gotten worked up because the staff did not know what to do on the evening of 9/5/25 to help her. According to the Administrator she had reported on 9/24/25 that she never asked Nurse # 1 to send her to the hospital and that she had wanted to speak to him about NA # 3.Interview on 9/25/25 at 3:27 PM with Resident # 1's Physician, who serves as the facility's medical director, revealed the following information. They had not called and notified him of problems on the evening of 9/5/25. If a resident was having a decrease in function this was something that needed to be conveyed to the physician and if the decrease in function and pain resulted in a resident being stuck in the wheelchair then there would have been a more urgent need to communicate with the physician about that. If he had been notified, then his instructions would have depended on the degree of pain. Potentially they could have done x-rays at the facility, or he may have instructed the staff to send the resident out to the hospital. It was his opinion that the fracture could have occurred prior to the resident being at the facility and not identified on the x-ray films of 8/22/25 when the resident felt a pop while at home.

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/30/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Emerald Health & Rehab Center

54 Red Mulberry Way Lillington, NC 27546

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

transfer status. There were 8 residents with missing transfer status and one that needed clarification.

Minimum Data Set Nurse and the therapy director reviewed the resident medical records and therapy documentation to ensure residents had the most appropriate transfer status. What measures will be put into place or systemic changes made to ensure that the deficient practice will not occur?On 9/9/2025 the Director of Nursing began educating all Nursing staff on Safe Patient Handling and Body Mechanics Policy to promote resident safety by implementing and maintaining safe patient handling process, which include recognition and elimination of hazards, and engineering and administrative controls. Nurse staff were educated on viewing the care profile before transferring a resident to ensure they are transferring the resident according to the plan of care and notifying the on call nursing supervisor if a resident refuses the transfer indicated in the plan of care for further instruction. Director of Nursing/Designee reviewed all signatures and cross referenced the nursing employee roster to ensure all nursing staff were educated. To ensure night shift and weekend employees were included additional nurses were trained to provide the education to other members of the nursing team. Staff that were educated via telephone were able to voice and verbalize understanding. All newly hired nursing staff will be educated by the Director of Nursing or designee on Safe Patient Handling and Body Mechanics Policy to promote enhanced resident safety by implementing and maintaining safe patient handling process, which include recognition and elimination of hazards, and viewing the care profile before transferring a resident to ensure they are transferring the resident according to the plan of care and notifying the on call nursing supervisor if a resident refuses the transfer indicated in the plan of care for further instruction. This education will be completed prior to the employee working independently. The staff development nurse will keep track of new employee information and training to ensure this. How will the facility monitor its corrective actions to ensure the deficient practice will not recur? Director of Nursing or designee will observe 5 resident transfers a week over multiple shifts for 12 weeks to ensure staff are transferring the residents according to their plan of care and using proper techniques. If issues are identified during the transfer, the transfer will be stopped, if safe to do so, and re-education will be completed with the staff. Audits will begin on 9/13/2025. Audits will be reviewed in the Quality Assurance Performance Improvement Committee for 3 months. Quality Assurance Performance Improvement Committee team may extend the audits or modify the plan of correction to ensure ongoing compliance. All corrective actions were completed on 9/9/2025.ADHOC QAPI was conducted on 9/8/2025 and the decision was made to implement this plan. Date of alleged compliance: 9/9/2025The facility's corrective action plan was validated by the following measures.Another sampled resident was observed transferred by staff members on 9/23/25. The staff members were observed to follow the plan of care and

the resident was observed to be transferred safely. The facility presented documentation of their audits and education per their corrective action plan. Nurses and Nurse Aides from different shifts were interviewed on 9/30/25 and validated they attending training. Nursing staff members, who were interviewed, were able to vocalize points that were covered in the training. Nursing staff members reported if a resident refused a safe transfer they would stop and not proceed and then would go to a supervisor for further direction. The facility's corrective action plan compliance date of 9/9/25 was validated.

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