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Pembroke Center: Missing Hydrocodone Unresolved - NC

Healthcare Facility
Pembroke Center
Pembroke, NC  ·  1/5 stars

That is what the administrator told federal inspectors during a November 2025 complaint inspection at the 310 E. Wardell Drive facility. The missing tablets belonged to Resident 3. The administrator confirmed a full investigation had been completed. It produced nothing.

The decision, according to the administrator, was to begin monitoring controlled medications going forward and to fold the matter into the facility's Quality Assurance program.

Hydrocodone is a Schedule II controlled opioid. Its disappearance from a nursing home raises questions that an inconclusive investigation leaves entirely open: whether a staff member diverted it, whether a resident obtained it who shouldn't have, whether record-keeping failures obscured what happened. The inspection report does not say how many tablets were missing, when they were first noticed gone, or how long the investigation lasted before the facility closed it without answers.

Federal inspectors cited the facility under Tag F0755, which covers pharmacy services and the handling of controlled substances. The deficiency was classified at a level of minimal harm or potential for actual harm, and inspectors noted that some residents were affected.

What the QA program is designed to do with an unresolved theft of a controlled opioid, the inspection report does not explain.

The facility was told to contact the nursing home or the state survey agency for information on its plan to correct the deficiency. Resident 3 is still there.

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

Editorial Standards & Data Disclosure

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

Quick Answer

Pembroke Center in Pembroke, NC was cited for violations during a health inspection on November 21, 2025.

That is what the administrator told federal inspectors during a November 2025 complaint inspection at the 310 E.

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.

Frequently Asked Questions

What happened at Pembroke Center?
That is what the administrator told federal inspectors during a November 2025 complaint inspection at the 310 E.
How serious are these violations?
Violation severity varies from minor documentation issues to serious safety concerns. Review the inspection report for specific deficiency codes and scope. All violations must be corrected within required timeframes and are subject to follow-up verification inspections.
What should families do?
Families should: (1) Ask facility administration about specific corrective actions taken, (2) Request to see the follow-up inspection report verifying corrections, (3) Check if this represents a pattern by reviewing prior inspection reports, (4) Compare this facility's ratings with other nursing homes in Pembroke, NC, (5) Report any new concerns directly to state authorities.
Where can I see the full inspection report?
The complete inspection report is available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request a copy directly from Pembroke Center or from the state Department of Health. The report includes specific deficiency codes, facility responses, and correction timelines. This facility's federal provider number is 345409.
Has this facility had violations before?
To check Pembroke Center's history, visit Medicare.gov's Care Compare and review their inspection history, quality ratings, and staffing levels. Look for patterns of repeated violations, especially in critical areas like abuse prevention, medication management, infection control, and resident safety.