Pembroke Center: Antibiotic Delays in Bone Infection Case - NC
The resident, identified in inspection records as Resident #86, was admitted on March 15, 2025. The orders for two IV antibiotics, Vancomycin and Piperacillin, should have been entered into the system and transmitted to the pharmacy that same day. They were not.
The Piperacillin order didn't reach the pharmacy until 3:31 AM on March 16. The Vancomycin order didn't arrive until 9:32 PM that same night, more than 30 hours after admission. Vancomycin wasn't delivered to the facility until the following Monday, March 17, two days after the resident arrived.
The facility's own Director of Nursing said it plainly. During a phone interview with inspectors on November 21, 2025, the DON acknowledged the orders should have gone to the pharmacy on March 15, the day of admission, and that the IV antibiotics should have been administered sooner.
The physician who treated the resident's wound was more specific about what the delay meant. In a phone interview the same day, the wound physician said missed doses of Vancomycin and Piperacillin in the treatment of osteomyelitis were significant and could delay wound healing. She said she could not say with certainty that the missed doses caused the infection to worsen. But she said missed doses could lead to subtherapeutic antibiotic levels, meaning the drugs would be less effective at fighting the infection even once they were finally given.
Subtherapeutic levels are not a minor concern with osteomyelitis. The infection, which involves bacteria penetrating bone tissue, is notoriously difficult to treat and typically requires sustained, precisely timed antibiotic therapy to drive bacterial levels down before the body can begin to heal. Gaps in that therapy give the bacteria time to rebound.
The inspection, a complaint survey completed November 21, 2025, cited the facility under F0760, the federal tag covering medication errors. Inspectors classified the level of harm as minimal harm or potential for actual harm, affecting a few residents.
What the record shows is a straightforward systems failure. An order was written. Nobody entered it. The pharmacy never got it. The resident didn't get the drugs. The Director of Nursing, when asked, confirmed all of it.
There is no indication in the inspection record that anyone at the facility caught the error before inspectors raised it. There is no documented review of what caused the entry to be missed, no account of who was responsible for transmitting admission orders that day, and no explanation for why a resident admitted with an active bone infection was not flagged for urgent medication follow-through.
The wound physician who treated Resident #86 said she could not say the missed doses made the infection worse. That carefully worded answer is the most the evidence allows. It is also the kind of answer that offers little comfort to a patient who arrived at a care facility with a bone infection and spent the first two days of treatment without the antibiotics that had been ordered for them.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Pembroke Center from 2025-11-21 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 25, 2026 · Our methodology
Pembroke Center in Pembroke, NC was cited for violations during a health inspection on November 21, 2025.
The resident, identified in inspection records as Resident #86, was admitted on March 15, 2025.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.