Pembroke Center: Expired Medication Storage Violation - NC
On the morning of October 2, 2025, an inspector walked the 300-hall medication cart at Pembroke Center alongside the facility's wound and treatment nurse. Sitting in an open foil package were 20 vials of ipratropium bromide inhalation solution, a medication used to open airways in patients with breathing problems. The package had no label. No date written on it. No indication of when it had been opened or how long it had been sitting there.
The manufacturer's instructions were clear: discard the medication two weeks after opening.
Without a date, there was no way to know whether that window had passed. It may have passed weeks ago.
The wound and treatment nurse, who was present during the observation, said she had not known the vials carried a two-week expiration once opened. She acknowledged the package should have had an opened date on it.
Fifteen minutes later, inspectors spoke with the director of nursing. She said the same thing. She had not known ipratropium bromide expired two weeks after opening. She told inspectors that all medications should carry a label and an opened date, and that expired medications should not be available for use in the medication storage rooms.
That standard, by her own account, was not being met.
Ipratropium bromide is not a minor comfort medication. It is prescribed to residents who have difficulty breathing, often those with chronic obstructive pulmonary disease. When it degrades, it does not necessarily look or smell different. A nurse drawing from a compromised vial would have no way to know.
The inspection report does not say whether any resident received medication from the open, undated package. It does not say how long the vials had been sitting in that foil. Twenty vials is not a small number, and an open multi-vial package in active use on a medication cart is not something stored in a back cabinet. It was available. It was being used, or it was about to be.
Inspectors cited the facility under F0761, which covers the safe storage and handling of medications. The deficiency was rated at a level of minimal harm or potential for actual harm, with some residents affected.
What the inspection captured, more than anything, was a gap in basic knowledge at two levels of the nursing chain. The nurse responsible for treatments on that hall did not know the medication had a post-opening expiration. The director of nursing did not know either. Neither had flagged the unlabeled package as a problem before an inspector walked up to the cart and asked about it.
The DON's response, that expired medications should not be available and all medications should be labeled with opened dates, was a description of what should have been happening all along. It was not a description of what inspectors found.
Twenty vials. No label. No date. No one who knew to look.
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 26, 2026 · Our methodology
Pembroke Center in Pembroke, NC was cited for violations during a health inspection on November 21, 2025.
On the morning of October 2, 2025, an inspector walked the 300-hall medication cart at Pembroke Center alongside the facility's wound and treatment nurse.
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.