Lillington Health and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Lillington Health and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Apr 11, 2023

  Based 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). […]

• Immediate jeopardy, isolatedF684Apr 11, 2023

  Based 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. These findings were reported to Nurse #2 who assessed Resident #22. 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). […]

• Immediate jeopardy, isolatedF578Mar 3, 2022

  Based on record review and interviews with staff, paramedic and family, the facility failed to provide an accurate code status to Emergency Medical Services (EMS) for one of three residents reviewed for advanced directives. Resident #1, who chose a full code status, experienced [CONDITION(S)] on [DATE] and was not provided cardio-pulmonary resuscitation (CPR). Resident #1 expired at the facility on [DATE] and the certificate of death indicated a cause of death included cardiorespiratory arrest. Findings included: Resident #1 was admitted to the facility on [DATE]. Resident #1's active physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A nursing note dated [DATE] and completed by Nurse #1 revealed Resident #1 complained of chest pain to Nurse #1. […]

• Actual harm, isolatedF684Apr 26, 2024

  Based 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). Findings included: Resident #118 was admitted to the facility on [DATE] with diagnoses including a stroke. […]

• Actual harm, isolatedF689Apr 21, 2022

  Based on observation, record review, and staff interview, for one (Resident # 1) of three sampled residents who had experienced accidents, the facility failed to assure a Nurse Aide safely assisted a resident with personal care. While Nurse Aide #1 was turning Resident# 1 for incontinence care, Resident # 1 rolled out of bed and sustained fractures to two toes and a fracture to her left orbital area (the area around the eyeball.) She also sustained a dislocated finger with possible fracture and a laceration to her forehead. The findings included: Resident # 1 was admitted to the facility on [DATE]. Although not all inclusive, the resident had diagnoses of muscle weakness, [CONDITION(S)], and [CONDITION(S)]. […]