Lillington Health and Rehabilitation Center

Inspectors wroteBased on observation and interviews with staff, an employee at the local public health department and a commercial equipment service provider, the facility failed to ensure their kitchen dishwashing machine had the cleaning and sanitation chemical agents connected correctly into the dishwashing machine and also failed to ensure water leaks from the dishwashing machine were repaired to prevent water leaking multiple feet throughout the kitchen floor on multiple days. During the time the dishwasher was not functioning correctly, the facility continued to use the machine to wash reusable meal trays. This was for one of one dishwashing machines utilized by the facility to provide clean dishes for all halls of the facility.

Inspectors wroteBased on record review, and interviews with staff, resident, family, and home health agency staff members, the facility failed to have an effective discharge planning process that ensured a referral with all required documentation was submitted to the home health agency Resident # 5 selected resulting in a delay of planned services when the resident was discharged . This was for one (Resident # 5) of one resident reviewed for discharge services.

Inspectors wroteBased on record review and interviews with resident and staff the facility failed to ensure an accurate accounting and administration of a controlled pain medication. This was for one (Resident # 5) of three residents whose controlled pain medication records were reviewed.

Inspectors wroteBased on observation and interviews with staff, an employee at the local public health department and a commercial equipment service provider, the facility failed to ensure a mechanical dishwashing machine was operating correctly to prevent water leaking multiple feet throughout the kitchen floor on multiple days. This was for one of one dishwashing machines utilized by the facility to service dishes and trays for the entire facility.

Inspectors wroteBased on observation, staff interview, and record review the facility failed to have sufficient dietary staff to serve the breakfast meal on time on 5/22/2025 for 7 of 7 halls.

Inspectors wroteBased on record review, observations, and resident interviews and staff interviews, the facility failed to provide the breakfast meal on 5/22/2025 at times comparable to normal, scheduled mealtimes at the facility. This affected all residents that received food by mouth on 7 of 7 halls (Halls, 100,200, 300, 400, 500, 600 and 700). The facility had a census of 141.

Inspectors wroteBased on observations and staff interviews, the facility failed to close doors on the dumpsters to prevent possible pest and rodents entry for 4 of 4 dumpsters reviewed.

Inspectors wroteBased on observations, record review, and staff interviews the facility failed to maintain a medication error rate of less than 5% as evidenced by 4 errors out of 33 opportunities observed. The medication error rate was 12.12%.

Inspectors wroteBased on observations, record review, and staff and Medical Director interviews, the facility failed to assure the facility was free of significant medication errors when fast acting insulin (insulin lispro and insulin aspart) that starts to work approximately 15 minutes after injection to lower blood sugar levels was administered to 3 residents more than 1 hour before their meal tray was delivered. The significant medication errors could have resulted in adverse side effects for 3 of 8 residents observed for medication administration (Resident #59, Resident #21 and Resident #76).

Inspectors wroteBased on observations and staff interviews, the facility failed to remove leftover food stored past the use by date in 1 of 2 refrigerators observed (reach-in refrigerator). This practice had the potential to affect food served to residents.

Inspectors wroteBased on record review, observations and staff interviews, the facility failed to place a resident's adaptive flat call light device within reach to allow for the resident to request assistance if needed for 1 of 4 residents reviewed for accommodation of needs (Resident #81).

Inspectors wroteBased on record review, and Physician and staff interviews, the facility failed to protect a resident's right to be free from abuse when a cognitively intact resident (Resident #326) hit a moderately cognitively impaired resident (Resident #325) on his arms with an ashtray holder. Resident #325 sustained 3 small skin tears on his left forearm, left elbow, left posterior arm, and right ring finger. This deficient practice affected 1 of 3 residents reviewed for abuse (Resident #325).

Inspectors wroteBased on record review, observations and staff interviews, the facility failed to implement care planned interventions by not placing fall mats at the bedside of a resident with a history of falls with major injuries. This occurred for 1 of 5 residents reviewed with care plan interventions for accidents (Resident #98).

Inspectors wroteBased on record review, observations, and staff interviews and Nurse Practitioner interview, the facility failed to change a chronic wound dressing as ordered by the provider for 1 of 1 resident reviewed for venous wound care (Resident # 40).

Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to ensure a severely impaired resident with a diagnosis of dysphagia (difficulty swallowing) and a physician order for a pureed diet (foods that are smooth and pudding-like texture) did not have access to mechanically chopped food. A nursing assistant realized the resident had received mechanically chopped breakfast sausage on a meal tray and left it with the resident who was able to feed himself independently. This deficient practice occurred for 1 of 3 residents reviewed for accidents.

Inspectors wroteBased on observations and staff interviews, the facility failed to secure medications on an unattended wound care cart that stored topical medications. The facility also failed to secure an unattended blood glucose cart that stored insulin. The blood glucose cart was not only observed to be unsecured and unattended but also had the key inserted into the lock. This deficient practice was found for 2 of 8 medication storage carts (wound cart and blood glucose cart).

Inspectors wroteBased on observations, record review, and resident, family and staff interviews, the facility failed to serve food in a form that met the resident's needs for 1 of 1 resident (Resident #84) reviewed. Resident #84 had been ordered food that was pureed texture and was observed eating a mechanically chopped breakfast meal.

Inspectors wroteBased on record review and staff interviews, the facility failed to notify the resident representative in writing of the reason for the transfer/discharge to the hospital and had not mailed a copy of the bed hold policy for 2 of 2 residents (Resident #73 and #45) reviewed for hospitalization. 1) Resident #73 was admitted into the facility on 9/16/21. A review of Resident #73's quarterly Minimum Data Set, dated [DATE] indicated that she was moderately cognitively impaired. A review of Resident #73's nursing progress notes revealed that she was discharged to the hospital on 3/12/25 and returned on 3/29/25. A review of Resident #73's medical record indicated that on 3/12/25 at both 2:03 PM and 5:20 PM Nurse #1 attempted to contact Resident #73's responsible party by telephone to inform them Resident #73 was transferred to the hospital but were unable to reach them. [...]

Inspectors wroteBased on record reviews and staff interviews, the facility failed to code the Minimum Data Set (MDS) assessment accurately in the area of level 2 Pre-admission Screening and Resident Review (PASRR) (Resident #3) and admission assessment (Resident #98) for 2 out of 30 residents reviewed for accuracy in MDS assessments.

Inspectors wroteBased on record review and staff interviews the facility failed to maintain an accurate Treatment Administration Record (TAR) for wound care treatments for 1 of 1 resident (Resident #2) reviewed for accurate medical records.

Inspectors wroteBased on record review, observations, Responsible Party interview, staff interviews, and a Physician interview, the facility failed to provide wound management to a skin tear that was recorded occurring initially on 3/12/2024 and reoccurring on 3/30/2024 for a resident. The resident's skin tear was reported infected on 4/3/2024 and was treated with antibiotics. There were no treatments for wound care ordered until 4/9/2024, and there were no weekly wound assessments (appearance and measurements of the wound) documented on the skin tear as of 4/26/2024 in the resident's medical record. This deficient practice occurred for 1 of 3 residents reviewed for skin conditions (Resident #118).

Inspectors wroteBased on a lunch meal tray line observation, staff interviews and record review the facility failed to: 1) ensure there was a pre-approved renal diet menu for 8 of 8 residents on a renal diet; 2) follow the approved pureed diet menu and serve pureed bread to 7 of 7 residents on a pureed diet; 3) serve residents on a mechanical soft diet the correct amount of meat. A 3-ounce scoop of ground meat was served instead of 4 ounces as per the menu; and serve residents the correct portion of potatoes. The facility served only 3 ounces of diced potatoes instead of 4 ounces as per the menu to 106 of 121 residents who ate a regular or mechanical soft diet.

Inspectors wroteBased on record review and staff interviews, the facility failed to implement the facility's abuse policy in the areas reporting, investigating, and/or protection in response to allegations of physical abuse. This deficient practice affected 2 of 3 residents reviewed for abuse (Resident #6 and Resident #8).

Inspectors wroteBased on observation and staff interviews, the facility failed to prevent ice build-up on boxes of frozen food stored for use in 1 of 1 walk-in freezer. This practice had the potential to affect frozen foods served to residents.

Inspectors wroteBased on observation, staff interviews, and record review, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor interventions put into place by the Committee following the recertification and complaint investigation surveys of 2/4/22 and 4/11/23. This was for four deficiencies that were recited on the current recertification and complaint investigation survey of 4/26/24 in the areas of Freedom from Abuse and Neglect (F600), Quality of Care (F684), Provision of Medically Related Social Services (F745), and Food and Nutrition Service (F812). The continued failure of the facility during three federal surveys of record showed a pattern of the facility's inability to sustain an effective QAA Program.

Inspectors wroteBased on record review, observation, resident interviews, and staff interviews, the facility failed to protect a resident's right to be free from physical abuse when a resident (Resident #8) was punched in the face multiple times with a closed fist by a resident who resided in the Assisted Living Facility (ALF) on the same campus. On the evening of 4/22/24 while in facility's courtyard, Resident #8 and the ALF resident engaged in a verbal disagreement that escalated into a resident-to-resident physical altercation that resulted in Resident #8 sustaining a small laceration to the left upper eye lid. This deficient practice was for 1 of 3 residents reviewed for physical abuse.

Inspectors wroteBased on record review, staff interviews, and a physician interview, the facility failed to schedule an appointment for a urology consult as ordered by the physician for 1 of 1 resident (Resident #17) reviewed for medically related social services.

Inspectors wroteBased on record reviews, staff and Nurse Practitioners interviews the facility failed to administer an antianxiety medication as ordered resulting in the resident (Resident #1) receiving 3 additional doses of the medication for 1 of 3 residents reviewed for psychotropic medications.

Inspectors wroteBased on record review, staff, Nurse Practitioner, Medical Director, and Radiologist interviews, the facility failed to protect a severely cognitively impaired resident from injury of unknown origin. On 3/18/23 nurse aide #1 observed bruising on Resident #22's left thigh and right fourth toe. On 3/20/23 Resident #22 was assessed by a nurse and found to have a bruise to her left thigh described as the size of a salad plate saucer and swollen knee. X-ray results revealed Resident #22 had a grossly displaced complex fracture of the left distal femur with angulation at the fracture site (the femur was broken in more than one place and the bone fragments were at an angle to each other). This was for one of one resident reviewed for an injury of unknown origin.

Inspectors wroteBased on record review, staff interviews, nurse practitioner, and medical director interview, the facility failed to have a nurse assess a severely cognitively impaired resident (Resident #22) when an injury of unknown origin was discovered. On 3/18/23 nurse aide (NA) #1 did not report new bruising to Resident #22's left thigh and right fourth toe. On 3/20/23 Resident #22 was observed to have a bruise to her left thigh described as the size of a salad plate saucer and swollen knee.

Inspectors wroteBased on record review and staff interviews, the facility failed to accurately code the MDS assessment in the areas of wound care (Resident #62), antipsychotic medication use (Residents #373, #20 and #57), and anticoagulant medication use (Residents #57 and #111), for 5 of 28 residents whose Minimum Data Set (MDS) assessments were reviewed.

Inspectors wroteBased on observations and staff interviews, the facility failed to label, date, and/or remove expired food items stored in 2 of 2 nourishment rooms (100 Hall Nourishment Room and 500 Hall Nourishment Room).

Inspectors wroteBased on record review, observations, staff interviews, nurse practitioner and medical director interview, the facility's Quality Assessment and Assurance Committee failed to maintain implemented procedures and monitor interventions that the committee had previously put in place following the recertification and complaint survey of 2/4/2022. This was for two recited deficiencies on the current recertification and complaint investigation survey of 4/11/2023. The deficiencies included Accuracy of Assessments (F641) in the areas of wound care, use of antipsychotic and anticoagulant medications and Food Procurement: Store, Prepare and Serve, Sanitary (F812). The continued failure during two federal surveys of record showed a pattern of the facility's inability to sustain an effective Quality Assurance Program.

Inspectors wroteBased on record review, observations, resident and staff interviews, the facility failed to attach an indwelling urinary catheter tubing to a secure device to prevent tension and possible injury and failed to provide necessary care and services of the indwelling urinary catheter when Nurse Aide (NA) #3 failed to clean the urinary catheter tubing when providing incontinent care for 1 of 2 residents reviewed for urinary catheters. (Resident #111)

Inspectors wroteBased on record review, physician interview and staff interviews, the facility failed to discontinue an antibiotic medication as ordered by the physician for 1 of 5 residents reviewed for antibiotic medication administration, Resident #62.