The incident at Pembroke Center occurred on September 29, 2025, when Resident #21 spent the entire day in her wheelchair without being transferred to bed or receiving needed care. Federal inspectors found that nursing assistants #4 and #5 abandoned their duties after the resident became upset and used curse words while requesting help.
Resident #21 remained in her wheelchair from the day shift through the evening, crying and asking for assistance. When the night shift arrived at 11:00 PM, they found her still sitting in the chair, distressed and needing incontinence care.
Nursing assistant #7, who worked the overnight shift, discovered the situation when she arrived for her 11:00 PM to 7:00 AM shift. She found Resident #21 "very upset and was crying that she was left up in her wheelchair and she needed incontinent care."
The night shift was already short-staffed. Only two nursing assistants were assigned to cover the 300 and 400 halls, and nursing assistant #6 arrived approximately an hour late for work. Despite the staffing challenges, nursing assistant #7 and the late-arriving colleague transferred Resident #21 to bed and provided the needed incontinence care at approximately 12:30 AM.
Nursing assistant #7 explained that she hadn't asked the night nurse for assistance with the transfer because the nurse was busy with new admissions and other duties.
The day shift nursing assistants had refused to provide care after Resident #21 became frustrated and used profanity while requesting help. According to the inspection report, the assistants told the resident they wouldn't help her because of her language.
This left Resident #21 in her electric wheelchair for the entire day and evening shift, approximately 16 hours, without receiving basic care or being transferred to bed.
The facility's Director of Nursing addressed the incident during an interview on November 18, 2025. She stated that nursing assistants #4 and #5 were suspended pending investigation on September 30, the day after facility administrators became aware of the neglect allegation.
"The NAs should have provided the care that Resident #21 requested, regardless of her use of a curse word," the Director of Nursing told inspectors. She emphasized that the facility did not tolerate the unprofessional behavior displayed by the nursing assistants.
The facility's Administrator confirmed the suspensions during a separate interview the same day. She reported that both nursing assistants were suspended on September 30, 2025, after she learned of the neglect allegations involving Resident #21.
"She expected the staff to provide care for the residents, regardless of the residents' behavior," the Administrator told federal inspectors. The Administrator emphasized that providing care should not be conditional on a resident's demeanor or language.
The incident prompted a broader institutional response beyond the staff suspensions. The Administrator notified police about the incident and filed a report with the state, following protocols for potential abuse and neglect cases in nursing facilities.
"The facility took allegations of abuse and neglect very seriously and an investigation was conducted," the Administrator stated during her interview with inspectors.
The case illustrates how personal conflicts between staff and residents can escalate into neglect when caregivers abandon their professional responsibilities. Resident #21's use of profanity, while inappropriate, did not justify withholding basic care services that she required.
Federal regulations require nursing home staff to provide necessary care regardless of residents' behavior or communication style. The regulations recognize that residents may become frustrated, especially when experiencing discomfort or when their needs aren't being met promptly.
The incident also highlights staffing vulnerabilities that can compound care failures. The night shift's reduced staffing levels meant that correcting the day shift's neglect fell to just two nursing assistants covering multiple halls, with one arriving late to work.
Nursing assistant #7's response demonstrates how professional caregivers should handle challenging situations. Despite discovering a distressed resident who had been neglected for hours, she focused on providing the needed care rather than making judgments about the resident's earlier behavior or language.
The timing of the incident created additional complications. Resident #21 spent the entire day shift and evening shift in her wheelchair, becoming increasingly distressed as hours passed without receiving help. By the time the night shift arrived, her physical discomfort had been compounded by emotional distress from being ignored.
The wheelchair confinement also prevented Resident #21 from resting properly. Remaining in a seated position for 16 hours can cause circulation problems, skin breakdown, and general discomfort, particularly for residents who rely on staff assistance for position changes and transfers.
The facility's investigation and disciplinary response occurred quickly once administrators learned of the incident. The one-day gap between the September 29 incident and the September 30 suspensions suggests the facility had protocols in place for addressing neglect allegations promptly.
However, the incident raises questions about supervision and oversight during the day and evening shifts when the neglect occurred. The nursing assistants' decision to refuse care based on a resident's language suggests a fundamental misunderstanding of professional caregiving responsibilities.
The Administrator's decision to involve law enforcement reflects the serious nature of the neglect. Filing police reports for nursing home incidents helps ensure external oversight and can lead to criminal charges if warranted.
Federal inspectors classified the violation as causing minimal harm or potential for actual harm, affecting few residents. However, for Resident #21, the 16-hour ordeal of being trapped in her wheelchair while needing incontinence care represented a significant breach of basic human dignity.
The case demonstrates how quickly professional caregiving can deteriorate when staff allow personal reactions to override their duty to provide care. Resident #21's profanity, while unprofessional, reflected her frustration at not receiving needed assistance.
The incident left Resident #21 crying in her wheelchair until well past midnight, when nursing assistant #7 finally provided the care that should have been available throughout the day.
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.