Lillington Health And Rehabilitation Center

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

email did not show any attachments or further information provided to Home Health Agency #1.Four hours later on 8/4/25 at 2:55 PM the Social Worker emailed Home Health Agency # 1's Healthcare Liaison, I have found another company to accept, thank you.Interview with the Administrator on 8/11/25 at 1:23 PM revealed the Social Worker should have attempted to reach out again to Resident # 1's preferred home health agency when she did not hear back from the initial email on 8/4/25 and prior to making other arrangements.

Event ID:

Facility ID:

If continuation sheet

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

08/13/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Lillington Health and Rehabilitation Center

1995 East Cornelius Harnett Boulevard 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 0755 Level of Harm - Minimal harm or potential for actual harm

Resident # 5 and Nurse # 1 when compared to the documentation on the MAR and the removal of the Tramadol from storage. According to the Nurse Consultant nurses should document the times controlled pain medications are administered and they should match the MAR and the Controlled Drug receipt/ Record/ Disposition Forms.

Residents Affected - Few

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

Event ID:

Facility ID:

If continuation sheet

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

08/13/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Lillington Health and Rehabilitation Center

1995 East Cornelius Harnett Boulevard 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

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

for about 1 1/2 to 2 weeks before they needed to be changed. He did not know when the chemical agents had last been changed prior to the error of the crossed lines being detected on 7/18/25. Therefore, he could not say how many days the trays had been going through the machine and out to residents without being sanitized. He did know that there had been multiple days of problems with the machine leaking water.A local Health Department Employee was interviewed on 8/6/25 at 9:23 AM and reported the following information. An inspection occurred on 7/1/25 by a colleague from the health department. The facility's dishwashing machine was not sanitizing on 7/1/25 at that visit. At that time the facility was directed to not use the dishwasher, use single service items for food service, and the three-compartment sink was to be used if needed for sanitation. She returned on 7/17/25 and the dishwasher was still broken and not sanitizing when checked. There was no evidence that the facility was using disposable meal service items at that time. There was also water on the floor. The CDM had reported to her that they were waiting for the health department's report to fix the dishwashing machine. She did not understand why the facility needed

the report to fix the dishwashing machine. Since 7/17/25 the health department had received information from the facility that a service provider had found that the hoses were not tied into the cleaning agents correctly on 7/18/25 and that issue had been repaired but the facility had also submitted to the health department that the dishwashing machine needed further repairs.On 8/8/25 at 8:52 AM the commercial service provider, who was at the facility on 7/18/25, was interviewed and reported the following information.

Their role was to supply the chemical agents but they were not under contract to repair or maintain the machine. When he arrived on 7/18/25 he checked the chemical agents and the lines from the chemical agents that fed into the machine were crossed. The detergent line was feeding into where the sanitizer should have been fed into the machine, and the detergent was feeding into where the sanitizer should have been feeding into the machine. The machine had water coming out of the backside also and the motor to

the drain was making a loud chatter. The drain line making the chatter seemed to be locking up and therefore it would not drain correctly. This service provider was interviewed regarding whether it would always be rinse water that was not draining since the CDM noticed that the water would overflow the drain when the machine turned to the rinse cycle. The service provider reported that it could be either dirty water or rinse water. This was because once the wash cycle was completed, the machine then would show as being in the rinse cycle, but it would be emptying dirty water before beginning the rinse cycle. The malfunctioning motor could hang up at anytime during the process.The Administrator and the CDM were interviewed together on 8/8/25 at 11:00 AM and reported the following. When the health department employee arrived on 7/1/25 it was her understanding that they would give her a written report of the problem and provide some education. She thought education would be a good idea. They wanted to cooperate and were waiting on the actual report from the health department to have the machine fixed. In

the interim, excluding the reusable trays, they were using disposable single use food service items to serve food to residents.Review of a facility invoice revealed the dishwasher holes, which had been identified as leaking water on the floor when the CDM was hired in June 2025, were repaired on 7/23/25 by a [NAME] company.During an interview on 8/8/25 at 8:19 AM with the Health Department Employee, who visited the facility on 7/17/25, the Health Department employee reported the following. Dirty water overflowing from the dishwasher was a sanitation issue. The health department also considered overflowing rinse water onto the floor as a sanitation issue because the water could attract pests into the kitchen. The dishwasher should not be used if it was leaking water on the floor and/or was not sanitizing.

Event ID:

Facility ID:

If continuation sheet

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

08/13/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Lillington Health and Rehabilitation Center

1995 East Cornelius Harnett Boulevard 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 0908 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

8/8/25 at 11:00 AM and reported the following. The Administrator reported it had not been conveyed to her that the dishwashing machine was not rented and rather was owned by the facility. That week (the week of

the survey) she had learned at one time the machine had been rented and during a corporate buyout the previous year, the dishwashing machine had somehow become the property of the facility. When the health department employee arrived on 7/1/25 it was her understanding that they would give her a written report of the problem and provide some education. She thought education would be a good idea and they wanted to cooperate and were waiting on the actual report from the health department to have the machine fixed.

In the interim, excluding the reusable trays, they were using disposable single use food service items to serve food to residents. The CDM was interviewed again about dates when the dishwashing machine had been leaking and repaired and reported that when he arrived in June it was spurting water and needed to be welded and the feed line was broken and leaking at some point as well. He further reported that the service provider for the chemical agents who discovered the lines were crossed on 7/18/25 was the person who ordered the motor part for the malfunctioning drain. The CDM was interviewed regarding whether he was aware of the date the motor was ordered and who was supposed to actually replace the broken motor when it arrived. The CDM was not sure who the repair person was intended to be when the part was ordered.Review of a facility invoice revealed the dishwasher holes, which had been identified as needing repaired when the CDM was hired in June 2025, were repaired on 7/23/25 by a [NAME] company.

Event ID:

Facility ID:

If continuation sheet