Below average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Emerald Health & Rehab Center during CMS and state inspections, most recent first.
A resident with a recent knee replacement and multiple comorbidities experienced pain and difficulty during a transfer after refusing the recommended mechanical lift. Despite the resident's complaints of pain, requests to speak to a supervisor, and desire to go to the hospital, nursing staff did not notify the physician or respond appropriately. The resident ultimately called 911 herself and was found to have a patellar fracture. The deficiency involved the facility's failure to communicate with the physician and obtain further instructions in response to the resident's change in condition.
A resident with a recent knee replacement and multiple comorbidities was not assisted in accordance with physical therapy's recommended transfer method. Staff did not consult the care plan or confirm the appropriate transfer technique, proceeded with a stand and pivot transfer despite the resident's refusal of the mechanical lift, and failed to seek further direction from the DON or physician. The resident experienced significant pain during the transfer and was later found to have a displaced patellar fracture requiring surgery.
The facility did not provide correct menu portion sizes as ordered by physicians, resulting in several residents receiving single portions instead of large or double portions, pureed diet residents receiving less than the specified amount, and those on low concentrated sweets diets receiving full slices of cake instead of half. Staff and dietary management were unaware of these discrepancies, which affected multiple residents during meal service.
The facility did not obtain food from approved sources and failed to store, prepare, distribute, or serve food according to professional standards, as identified by surveyors.
A resident with a DNR order had conflicting code status information in their care plan, and their code status was missing from the code status binder used by staff. Staff interviews revealed that code status was supposed to be clarified and documented at multiple points, but inconsistencies in the medical record and reference materials led to inaccurate information being available.
A resident with severe malnutrition and dysphagia was incorrectly coded on the MDS as being on a physician-prescribed weight-loss regimen, despite documentation and staff interviews confirming the resident was not on such a program. The error was attributed to a mistake by the RD, which was not identified by the MDS Coordinator.
A deficiency was cited when a resident was not provided with sufficient food and fluids to maintain their health, as required. The report does not include further details about the circumstances or the resident's condition.
The facility did not have RN coverage for a full 24-hour period due to a scheduled RN calling out and no replacement being found. The DON was unable to cover the shift due to the facility's census exceeding 60 residents.
The facility failed to maintain a clean and sanitary condition under the shelf of a steam table, as dark dried food particles were observed on two occasions. This deficiency was identified during a kitchen inspection and confirmed through interviews with the Dietary Manager and Administrator, highlighting a lapse in adherence to professional standards for food service.
The facility failed to accurately document medical records for residents, including blood glucose levels, insulin administration, enteral feedings, and medication administration. A resident with diabetes experienced missing documentation due to a new EMR system, while another resident's enteral feeding was not recorded due to shift changes. Additionally, a third resident's medication administration was inaccurately documented, leading to discrepancies in the records.
A resident with multiple diagnoses, including chronic respiratory failure and atrial fibrillation, experienced a medication administration error when an LPN crushed and mixed all prescribed medications together with a laxative solution, contrary to facility policy. The error resulted in a medication error rate of 20.69%. Interviews with the DON, pharmacist, and physician confirmed that medications should have been administered individually, and there was no order to administer them together.
A facility failed to verify that a staff member had an active nursing license before allowing her to perform LPN duties. The staff member, hired as a Nurse Aide while attending nursing school, was promoted to LPN without proper licensure verification. Despite her Nurse Aide I Registry listing being expired and not being listed as a Medication Aide, she was assigned to work as a nurse and documented medication administration for residents. Interviews revealed she worked the medication cart due to staff shortages, and the facility's Administrator admitted the oversight.
A resident was not involved in their care plan development after readmission to the facility, despite being cognitively intact. The care plan was updated for various health issues, but no meeting was held with the resident. Staff interviews revealed that the oversight was due to the resident's frequent hospitalizations, disrupting the scheduling of care plan meetings.
A resident with a subdural hematoma continued to receive the anticoagulant Eliquis after it was discontinued during a hospital stay. The error occurred due to a failure in the reconciliation process when the facility's electronic medical records system was changed, leading to outdated orders being used. The Director of Nurses and Medical Director acknowledged the oversight and the risk posed to the resident.
The facility was observed to have an open dumpster door with debris, including a disposable glove and a trash bag, on two occasions. The Dietary Manager confirmed the condition, and interviews revealed shared responsibility between kitchen and housekeeping staff for maintaining the area. The Administrator planned to remind staff to close the dumpster door.
A resident with diabetes and hypertension, who was dependent on staff for ADL care, experienced a delay in receiving incontinence care, resulting in missed therapy. Despite using the call bell, the resident waited two hours for a change of her adult brief. Staff interviews revealed inconsistencies, with some unable to recall the incident and others claiming to have provided care. The resident expressed irritation over the delay.
A resident with severe cognitive impairment and physical limitations experienced two falls in one day due to inadequate fall prevention interventions. Despite being at high risk, the resident's care plan was not effectively updated, and staff communication was lacking. The resident was found on the floor twice, once with a head injury requiring hospitalization. The facility failed to implement timely interventions such as moving the resident closer to the nurses' station and using fall mats.
The facility did not display survey results in an accessible location for residents. During a tour, the survey results were not found in the building. Residents believed the results were near the nurse's station, but further tours confirmed their absence. Staff interviews revealed a lack of awareness about the location of the survey results. The Administrator indicated the results were at the reception desk, but they were obscured by an easel and a plant, with no signage.
Failure to Notify Physician and Respond to Resident's Change in Condition During Painful Transfer
Penalty
Summary
The facility failed to communicate with the physician and obtain further instructions when a resident, who had recently undergone a total left knee replacement and had a history of rheumatoid arthritis, gout, osteoporosis, and muscle weakness, was experiencing pain and difficulty during transfers. The resident was admitted for rehabilitation and had specific transfer recommendations from physical therapy, including the use of a mechanical lift when fatigued or unable to safely perform a scoot transfer. On the evening in question, the resident refused the mechanical lift and attempted to transfer with staff assistance, resulting in significant pain and a loud scream during the process. Despite these events, the nursing staff did not contact the physician for further guidance or assessment. Following the painful transfer, the resident repeatedly requested to speak to a supervisor and later asked to be sent to the hospital due to ongoing pain. The nurse on duty did not respond promptly to these requests, nor did he notify the physician of the resident's complaints or her desire to go to the hospital. The resident ultimately called 911 herself after her requests were not addressed, and was transported to the hospital where imaging revealed a periprosthetic patellar fracture. Documentation and interviews confirmed that the physician was not notified of the resident's change in condition or her requests for medical evaluation prior to her self-initiated transfer to the hospital. Interviews with staff, the resident, and the facility's medical director confirmed that there was a lack of communication with the physician regarding the resident's pain, difficulty with transfer, and her request for hospital evaluation. The medical director stated that he should have been notified of the decrease in function and pain, and that appropriate interventions could have been initiated if he had been informed. The deficiency centers on the facility's failure to notify the physician and obtain further instructions in response to the resident's change in condition and expressed needs.
Failure to Follow Prescribed Transfer Technique and Communication Protocols
Penalty
Summary
A deficiency occurred when staff failed to assist a resident, who had recently undergone a total left knee replacement and had multiple comorbidities including rheumatoid arthritis, gout, osteoporosis, and muscle weakness, in a manner consistent with the transfer recommendations provided by physical therapy. The resident had a history of post-operative complications and was assessed by physical therapy to require a mechanical lift for transfers, with the possibility of performing an incremental scoot transfer if able. On the evening in question, the resident requested assistance to transfer from her wheelchair to her bed. The nurse aide and nurse involved did not consult the resident's care plan or confirm the appropriate transfer method, instead relying on the resident's statements and their own recollections. The resident refused the use of a mechanical lift and gait belt, and staff proceeded with a stand and pivot transfer, which was not the recommended method for her condition at that time. During the transfer, the resident experienced significant pain and reported a 'pop' in her left knee. Staff did not stop the transfer or seek further direction from the DON or physician when the resident refused the safe transfer technique. The nurse and nurse aide did not ensure the wheelchair was properly positioned, nor did they use the recommended incremental scoot transfer or mechanical lift. After the transfer, the resident continued to experience pain, which she later reported to staff. The nurse did not immediately notify the physician or escalate the situation when the resident's pain persisted and her functional ability had acutely declined. Subsequently, the resident called 911 herself and was transported to the hospital, where imaging revealed a displaced periprosthetic patellar fracture requiring further surgery. Interviews with staff and the resident confirmed that the plan of care was not followed, and there was a lack of communication and verification of the appropriate transfer method. The failure to follow the prescribed transfer technique and to seek further guidance when the resident refused the safe method directly led to the resident's injury.
Failure to Follow Physician-Ordered Menu Portion Sizes
Penalty
Summary
The facility failed to follow the approved menu and physician-ordered dietary requirements for multiple residents during meal service. Specifically, seven residents with physician orders for large or double portions were served only a single portion of chili, despite the menu specifying a double portion. Observations of the lunch service revealed that cooks used a single 6-ounce ladle for all residents, and no double portions were prepared or served. Staff interviews confirmed that all residents received the same portion size, and the dietary manager was unaware that double portions had not been provided as ordered. Additionally, seven residents on a pureed diet received only 4 ounces of chili instead of the 6 ounces specified on the menu. Twelve residents with orders for a regular or mechanical soft, low concentrated sweets (LCS) diet received a full slice of cake rather than the half slice indicated on the menu. Dietary staff confirmed that all residents received the same size dessert portion, and the dietary manager was not aware of the need to provide a half slice for those on an LCS diet. These failures were identified through direct observation, record review, and staff interviews, affecting a total of 26 residents.
Failure to Follow Professional Standards in Food Procurement and Handling
Penalty
Summary
The facility failed to procure food from approved or satisfactory sources and did not store, prepare, distribute, or serve food in accordance with professional standards. This deficiency was identified through surveyor observation and review of facility practices related to food procurement and handling. No additional details regarding specific residents, staff, or observed outcomes were provided in the report.
Failure to Maintain Accurate Code Status Documentation
Penalty
Summary
The facility failed to maintain accurate and consistent code status information for a resident with a history of malignant neoplasm of the uterus, anxiety, depression, and non-Alzheimer's dementia. Upon readmission, the resident had a physician's order for Do Not Resuscitate (DNR) status, and the resident's representative confirmed that this status had been in place since a hospital stay in January and had not changed. However, the resident's care plan was updated to indicate full code status, which conflicted with the physician's order and the representative's statements. Interviews with staff revealed that code status information was obtained from admission orders and hospital records, and was supposed to be reviewed with the resident or responsible party. The MDS nurse was responsible for updating the care plan, and the DON stated that code status was clarified on admission and during care plan meetings. Despite these procedures, the code status for the resident was missing from the red code status binder at the nurses' station, and staff relied on this binder to verify code status in emergencies. This inconsistency in documentation and communication led to the deficiency.
Inaccurate MDS Coding for Nutritional Status
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessment in the area of Swallowing/Nutritional Status for one resident. The resident, who had diagnoses of severe protein-calorie malnutrition and dysphagia, was not on a physician-prescribed weight-loss regimen, as documented in the Registered Dietitian's (RD) progress note and confirmed by the care plan, which instead indicated interventions to address unintentional weight loss and underweight status. However, the MDS assessment incorrectly indicated that the resident was on a physician-prescribed weight-loss regimen. The MDS Coordinator stated that the RD completed the relevant MDS section and acknowledged the error, noting she had not noticed the incorrect selection. The Medical Director also confirmed that the resident required additional calories and was not on a weight-loss program.
Failure to Provide Adequate Nutrition and Hydration
Penalty
Summary
A deficiency was identified regarding the facility's failure to provide adequate food and fluids necessary to maintain a resident's health. The report notes that the required provision of nutrition and hydration was not met, which is essential for the resident's well-being. Specific details about the actions or inactions leading to this deficiency, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Failure to Provide RN Coverage for 24 Hours
Penalty
Summary
The facility failed to schedule a Registered Nurse (RN) for at least 8 consecutive hours per day, 7 days a week, as required. On April 13, 2024, there was no RN coverage for the entire 24-hour period. The daily nursing staffing sheets and census posting sheets indicated that an RN was scheduled for the day shift, but there was no RN recorded for the evening and night shifts. Nurse #1, who was supposed to work on that day, called out, and the Director of Nursing (DON) was unable to find a replacement RN. The DON also believed she could not serve as the RN coverage due to the facility's census being greater than 60 residents.
Unsanitary Kitchen Equipment
Penalty
Summary
The facility failed to maintain kitchen equipment in a clean and sanitary condition, specifically under the shelf of a steam table. During observations on two separate occasions, dark dried food particles were found under the shelf of a five-well steam table. This unsanitary condition was noted during a kitchen inspection, indicating a lapse in the facility's adherence to professional standards for food storage, preparation, and service. The deficiency was identified through observations and confirmed during interviews with the Dietary Manager and the Administrator, who acknowledged the expectation for kitchen staff to maintain cleanliness in this area.
Deficiencies in Medical Record Documentation
Penalty
Summary
The facility failed to maintain accurate medical records for several residents, leading to deficiencies in documenting blood glucose levels, insulin administration, enteral feedings, and medication administration. For one resident with diabetes, the facility's transition to a new electronic medical record (EMR) system resulted in missing documentation of blood glucose levels and sliding scale insulin administration over several days. Despite nurses performing the necessary checks and administering insulin, the new EMR system lacked a designated space for recording these actions, leading to incomplete records. Another resident, who required enteral feeding due to dysphagia, did not receive the prescribed feeding on two occasions. The feeding was scheduled to start during the day shift, but due to staff being occupied with other tasks, it was delayed until the night shift. However, the night shift nurse was unable to document the feeding in the EMR as it was not scheduled during her shift, resulting in a lack of recorded administration. Additionally, a third resident's medication administration was inaccurately documented. Medications scheduled for 8:00 p.m. were recorded as given at 10:50 p.m., as the nurse documented the administration after completing rounds for all residents. This practice led to discrepancies in the medication administration record, failing to reflect the actual time of administration.
Medication Administration Error Due to Misinterpretation of Orders
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by 6 medication errors out of 29 opportunities, resulting in a 20.69% error rate during medication administration observations. This deficiency was observed in the case of a resident with chronic respiratory failure, Myasthenia Gravis, anxiety disorder, and atrial fibrillation, who was receiving medications via a gastrostomy tube. The resident's medications included Amiodarone, Apixaban, Glycopyrrolate, Vitamin D, Lorazepam, and polyethylene glycol powder. During the medication administration, Nurse #5 crushed and mixed all the medications together with the laxative solution, contrary to the facility's policy, which required each medication to be administered separately with water flushes before and after each dose. Nurse #5 misunderstood the physician's orders, believing that all medications could be administered together, despite the facility's policy and the absence of any specific physician order to do so. Interviews with the Director of Nursing, the pharmacist, and the physician confirmed that the medications should have been administered individually. The pharmacist noted that while no drug reaction would occur from mixing the medications, the proper procedure was not followed. The physician clarified that his review of the orders did not imply that medications should be given together, and there was no order in the resident's electronic medical record to crush and administer the medications together.
Failure to Verify Nursing Licensure Leads to Unqualified Staff Performing LPN Duties
Penalty
Summary
The facility failed to verify that a staff member, Nurse Aide #7, had an active professional nursing license with the North Carolina Board of Nursing (NCBON) before allowing her to perform the duties of a nurse. Nurse Aide #7 was hired as a Nurse Aide while attending nursing school and was later promoted to a Licensed Practical Nurse (LPN) without proper licensure verification. The North Carolina Health Care Professional Registry indicated that her Nurse Aide I Registry listing had expired, and she was not listed as a North Carolina Medication Aide. Despite this, she was assigned to work as a nurse on multiple occasions, as recorded in the daily nurse staffing sheets and timecard reports. Nurse Aide #7 documented medication administration and created nurse's notes for several residents, signing them with the title of LPN, even though she was not licensed as such. In interviews, Nurse Aide #7 admitted to working the medication cart due to staff shortages, despite not being licensed as a medication aide or LPN. Nurse #2, who was unaware of Nurse Aide #7's lack of licensure, confirmed that she performed LPN duties, including implementing physician orders and providing various types of resident care. The facility's Administrator acknowledged that the previous administration team did not ensure Nurse Aide #7 was licensed before assigning her LPN duties.
Resident Not Involved in Care Plan Development
Penalty
Summary
The facility failed to involve a resident in the development of their care plan, as required by regulations. Resident #66, who was cognitively intact, was admitted to the facility, discharged due to hospitalization, and then readmitted. Despite updates to the resident's care plan to address issues such as bladder incontinence, long-term placement for wound care, and edema, there was no documentation of a care plan meeting that included the resident's participation since their readmission. The resident expressed a need for a care plan meeting to discuss diabetes management, indicating a lack of involvement in their care planning process. Interviews with facility staff, including the MDS nurse and the Director of Nursing, revealed that care plan meetings were not scheduled or conducted for the resident since their readmission. The MDS nurse acknowledged the oversight, attributing it to the resident's frequent hospitalizations, which disrupted the scheduling of care plan meetings. The Director of Nursing confirmed that the resident should have had a care plan meeting or a 'Your Path' meeting since readmission, but it was missed. The facility administrator also noted the need for care plan meetings to be conducted around the time of quarterly MDS assessments, which did not occur in this case.
Failure to Discontinue Anticoagulant for Resident with Subdural Hematoma
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications, specifically an anticoagulant that had been discontinued. Resident #82, who was admitted with conditions including epilepsy, hemiplegia, and a cerebral infarction, was diagnosed with a subdural hematoma while hospitalized. During the hospital stay, the anticoagulant Eliquis was discontinued to prevent further bleeding. However, upon returning to the facility, the resident continued to receive Eliquis from 5/6/24 to 5/10/24, despite the absence of orders to restart the medication. The error occurred due to a failure in the reconciliation process when the facility's electronic medical records system was changed. The Director of Nurses acknowledged that the medication should have been removed from the medication cart when the resident was hospitalized, and staff should have identified the discrepancy. The Medical Director confirmed that the medication should not have been administered due to the resident's high risk of falls and noted that the pharmacy had used outdated orders during the transition to the new eMAR system.
Improper Disposal and Maintenance of Dumpster Area
Penalty
Summary
The facility failed to maintain the cleanliness and proper closure of the dumpster area, as observed on two separate occasions. On 5/08/24 at 8:10 AM, the dumpster door was found open, with a disposable glove and a clear plastic trash bag lying beside it. A similar observation was made on 5/10/24 at 10:02 AM, where the dumpster door remained open, and the same items were noted beside the dumpster. During a follow-up observation with the Dietary Manager on 5/10/24 at 10:17 AM, the area was still in the same condition. Interviews revealed that both kitchen and housekeeping staff shared the responsibility for maintaining the cleanliness of the dumpster area and ensuring the door was closed. The Administrator acknowledged the issue and indicated a plan to remind staff to keep the dumpster door closed.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care to a resident who was dependent on staff for activities of daily living. The resident, who was admitted with diagnoses including Diabetes Mellitus and hypertension, was cognitively intact and frequently incontinent of stool. On the morning in question, the resident used the call bell to request a change of her adult brief, which was wet with urine. Despite notifying a staff member, the resident waited two hours without receiving the necessary care, resulting in her missing scheduled therapy. The resident expressed irritation over the delay and the impact on her therapy session. Interviews with staff revealed inconsistencies in the account of events. The nurse aide assigned to the resident could not recall responding to the call bell or providing care, while a nurse and the Director of Nursing claimed to have assisted the resident, stating the brief was not saturated. The Director of Nursing also mentioned reminding staff about the importance of regular rounding for personal care needs. However, the resident's account and the therapy aide's observation of the resident being tearful suggest a lapse in care, leading to the deficiency noted in the report.
Failure to Implement Fall Prevention Interventions for High-Risk Resident
Penalty
Summary
The facility failed to implement effective interventions to reduce the risk of falls for a resident identified as high risk. The resident, who had a history of severe cognitive impairment, fluctuating disorganized thinking, and physical impairments, experienced two falls on the same day. Despite being assessed as high risk for falls, the resident's care plan interventions were not adequately updated or implemented to prevent these incidents. The resident was found on the floor twice, once with a head injury that required hospitalization. Interviews with staff revealed a lack of consistent communication and understanding of the resident's fall risk and necessary interventions. Nurse #8, an agency nurse on her first shift, was not informed of the resident's high fall risk and did not implement additional safety measures beyond placing the call bell in the resident's hand, despite the resident's inability to use it effectively. The resident's room location, away from the nurses' station, and the absence of fall mats on both sides of the bed contributed to the risk of falls. The Interdisciplinary Team (IDT) did not adequately review and update the resident's care plan following the falls. Although the IDT discussed potential interventions, such as moving the resident closer to the nurses' station and using fall mats, these were not implemented in a timely manner. The Director of Nurses acknowledged the lack of effective interventions and communication among staff, which contributed to the resident's repeated falls and subsequent injury.
Survey Results Not Accessible to Residents
Penalty
Summary
The facility failed to display survey results in a location accessible to residents, affecting all residents in the facility. During a tour of the facility, it was observed that the survey results were not located in the building. Residents during a council meeting indicated that the survey results were supposed to be near the nurse's station. However, subsequent tours revealed that the survey inspection results binder was not present in the facility. Interviews with staff, including a nurse and a social worker, showed they were unaware of the location of the survey results. The Administrator later stated that the survey inspection results book was available at the reception desk, but it was obscured by a 5 ft. easel and a large leaf plant, with no signage to indicate its location.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 64 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Lillington
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lillington Health And Rehabilitation Center | 2.5 mi | ★★★★★ | 0 | 0 |
| Harnett Woods Nursing And Rehabilitation Center | 10.9 mi | ★★★★★ | 0 | 0 |
| The Carrolton Of Dunn | 12.3 mi | ★★★★★ | 5 | 0 |
| Fuquay-varina Health And Rehabilitation Center | 13.4 mi | ★★★★★ | 10 | 0 |
| Windsor Point Continuing Care | 14 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Emerald Health & Rehab Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.