Pembroke Center

F 0585 Level of Harm - Minimal harm or potential for actual harm

response to the Responsible Party regarding both concerns. She stated the letter dated 07/01/25 was a written response to a grievance that was filed on 07/01/25 and did not relate to the concern of being sent to appointment without being dressed properly.

1. 2. Resident #62 was admitted to the facility on [DATE REDACTED].

Residents Affected - Few

The Minimum Data Set quarterly assessment dated [DATE REDACTED] revealed Resident #62 was severely cognitively impaired.

A review of the facility's grievance log revealed a grievance from Resident #62 for needing help transferring to bathroom. On the bottom page of the grievance dated 05/27/25 read, Date written notification provided, was left blank. Also, on the bottom page of the grievance read, Additional methods that may have been used to discuss resolution with the resident/representative, was checked Face to face. The grievance/concern form reviewed had no back page summary or findings/recommended corrective action(s) filled out.

An interview was conducted on 10/01/25 at 10:30 AM with the Director of Nursing (DON). The DON stated

she did not know the resident/representative needed to receive a written summary of their grievance resolutions. The DON acknowledged Resident #62 should have been provided with a written resolution and summary.

An interview was conducted on 10/01/25 at 10:40 AM with the Administrator. The Administrator confirmed Resident #62 did not receive a written grievance summary of the resolution.

An interview on 10/02/25 at 8:17 AM with the Social Worker (SW) revealed that she did not know until today that she needed to provide a written grievance summary to the resident or representative who filed the concern. The SW stated she thought the verbal summary was okay. The SW stated before today, she had only called or verbally spoken to the complainant in person and verbally summarized the grievance, with nothing given to them in writing. The SW added, now she knows to provide a written grievance summary to complainants.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/21/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Pembroke Center

310 E Wardell Drive Pembroke, NC 28372

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

transferring Resident #21 to bed or providing incontinence care. Nurse #7 indicated she was unaware that Resident #21 had a bowel movement and needed incontinence care. An interview was completed with NA #7 on 10/2/25 at 8:10 AM. NA #7 stated that she was working the 11:00 PM to 7:00 AM shift on 9/29/25.

She further stated that there was only 2 NA assigned to the 300 and 400 halls at night, and that NA #6 was approximately an hour late for work on 9/29/25. NA #7 indicated Resident #21 was still up in her electric wheelchair when she came on shift at 11:00 PM. She stated that Resident #21 was very upset and was crying that she was left up in her wheelchair and she needed incontinent care. NA #7 further stated that

she and NA #6 did transfer Resident #21 to bed and provide incontinence care at approximately 12:30 AM.

She explained that she had not asked Nurse #7 to assist her with transferring Resident #21 to bed because

she was busy with new admissions and other work. An interview was completed with the Director of Nursing (DON) on 11/18/25 at 3:15 PM. The DON stated that NA #4 and NA #5 were suspended pending

an investigation on 9/30/25 after becoming aware of the allegation of neglect for Resident #21. She further stated the NAs should have provided the care that Resident #21 requested, regardless of her use of a curse word. The DON stated the facility did not tolerate the type of unprofessional behavior that was displayed by the NAs. An interview was conducted with the Administrator on 11/18/25 at 3:55 PM. The Administrator reported that NA #4 and NA #5 were suspended on 9/30/25 after she was made aware of the allegation of neglect involving Resident #21. She stated that she expected the staff to provide care for the residents, regardless of the residents' behavior. The Administrator stated that the police were notified and a report was filed with the state. She indicated that the facility took allegations of abuse and neglect very seriously and an investigation was conducted.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/21/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Pembroke Center

310 E Wardell Drive Pembroke, NC 28372

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 Level of Harm - Minimal harm or potential for actual harm

receiving the medication, but that the expired medications could have been contaminated due to the short shelf life. An interview with the Physician on 11/17/25 at 1:10 PM revealed there would be no adverse effects from receiving the expired medication, but that nursing staff needed to follow the regulations and ensure there were no expired medications on the medication carts to avoid the administration of expired medications.

Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/21/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Pembroke Center

310 E Wardell Drive Pembroke, NC 28372

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

on 11:00 PM to 7:00 AM shift. She further stated that Resident #21 informed her that the NA from 3:00 PM to 11:00 PM shift had refused to provide care for her. An interview with Nurse #7 who was working the 7:00 PM to 7:00 AM shift on 9/29/25 occurred on 10/2/25 at 1:29 PM. Nurse #7 stated she recalled the incident with Resident #21 and NA #4 and NA #5 occurred on 9/29/25 at approximately 10:30 PM. She stated the NAs reported to her that Resident #21 had cursed them when they went into her room to transfer her to bed. Nurse #7 further stated that she had told the NA's she would speak to Resident #21 about the incident. She indicated she was unaware that NA #4 and NA #5 were not going to provide Resident #21 care prior to them leaving their shift. Nurse #7 explained that one of the NAs on the 11:00 PM to 7:00 AM shift was late for work on 9/29/25 and Resident #21 was not assisted to bed until around 12:30 AM. She stated that the NA's had not asked her to assist them with transferring Resident #21 to bed or providing incontinence care. Nurse #7 indicated she was unaware that Resident #21 had a bowel movement and needed incontinence care. An interview was completed with NA #7 on 10/2/25 at 8:10 AM. NA #7 stated that she was working the 11:00 PM to 7:00 AM shift on 9/29/25. She further stated that there was only 2 NA assigned to the 300 and 400 halls at night, and that NA #6 was approximately an hour late for work on 9/29/25. NA #7 indicated Resident #21 was still up in her electric wheelchair when she came on shift at 11:00 PM. She stated that Resident #21 was very upset and was crying that she was left up in her wheelchair and she needed incontinent care. NA #7 further stated that she and NA #6 did transfer Resident #21 to bed and provide incontinence care at approximately 12:30 AM. She explained that she had not asked Nurse #7 to assist her with transferring Resident #21 to bed because she was busy with new admissions and other work. An interview was conducted with the Director of Nursing on 11/18/25 at 3:15 PM. The DON stated that it was unacceptable that NA #4 and NA #5 had refused to transfer Resident ##21 to bed and provide incontinent care for her when she requested. She further stated that she expected the nursing staff to provide care for residents, regardless of the residents' use of a curse word. The DON explained that it was their job to provide ADL care for residents.An interview was completed with the Administrator on 11/18/25 at 3:55 PM. The Administrator stated that NA #4 and NA #5 were wrong for not providing ADL care for Resident #21. She indicated that she expected the staff to provide care for the residents, regardless of the residents' behavior. The Administrator stated that NA #4 and NA #5 should have provided ADL care for Resident #21 when she requested their assistance.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/21/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Pembroke Center

310 E Wardell Drive Pembroke, NC 28372

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

and then gave the weights to her and she entered the weights into the residents electronic medical record.

Unit Manager #1 stated she did not always check the previous weight to identify any significant weight gain or loss which was an error on her part. She stated the facility policy was that with any weight increase or decrease a reweigh should be done at that time for accuracy and she had not been directing staff to do the reweighs. Unit Manager #1 stated she should have asked for Resident #6 to be reweighed for accuracy to determine if Resident #6 had a 10 to 20 pound weight loss to verify accuracy. A phone interview was conducted on 10/01/25 at 9:20 AM with Nurse Practitioner #1 who stated it was her expectation that residents with significant weight changes get reweighed. She stated that a reweigh was to be done on all weight loss or gain greater than 5% within a month, or greater than 10% in six months, so in order to make

the necessary treatment recommendations. During an interview on 10/2/25 at 10:00 AM Nurse Aide #10 stated she received a list each morning of which residents needed weights. She completes the weights and gives the results to Unit Manger #1. Nurse Aide #10 indicated she would not know to reweigh a resident unless a nurse or the Unit Manger instructed her to do so, then she would reweigh the resident. During an

interview on 11/19/25 at 1:00 PM the Physician stated some of the weights documented in Resident #6's medical record could not be accurate because it was impossible for her to have a 20 pound loss in 4 days.

The Physician stated that staff had not reported any change in condition and there were no concerns with Resident #6. He stated accurate weights should be documented in the medical record in order to make the appropriate treatment decisions. During a phone interview on 11/19/25 at 2:00 PM the Director of Nursing (DON) stated weights were to be reviewed and compared to the previous weight and if any significant increase or decrease then another weight should be obtained at that time. The DON stated the staff were to verify the accuracy of weights and report any changes to the physician if significant changes.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/21/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Pembroke Center

310 E Wardell Drive Pembroke, NC 28372

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

were no longer employed by the facility. Unit Manger #1 stated she entered Resident #86's wound treatment orders into the residents electronic medical record on 3/17/25, and she conducted the initial wound assessments with measurements on 3/18/25 and that should have been done by the admission nurse on 3/15/25. During a phone interview on 11/18/25 at 7:00 PM Medication Aide #1 stated she would not have been responsible for wound care treatments and did not have any information regarding Resident #86's wound care on 3/15/25 or 3/16/25. During an interview on 11/19/25 at 8:15 AM the wound treatment nurse stated Resident #86 was compliant with wound care. She stated that she began working in the facility around the time Resident #86 was admitted but she did not work full-time, and the floor nurses were responsible for daily wound care. She stated she was not working on the weekend of 3/15/25 when Resident #86 was admitted . During a phone interview on 11/19/25 at 10:00 AM the Wound Care Physician stated her initial evaluation of Resident #86 was done on 3/20/25, then weekly until he discharged from the facility. She stated Resident #86 admitted with four significant pressure wounds. At the time of his admission there was no dedicated wound nurse, and she could not attest to how often the wound care was getting done. The Wound Physician stated she last evaluated Resident #86 on 5/23/25 before he discharged and at the time of discharge the sacrum was more necrotic, and the left hip fascia was exposed with muscle. She stated the worsening of Resident #86's wounds during his stay in the facility was multifactorial, and also due to not offloading, possible missed wound treatments, osteomyelitis, and other comorbidities. The Wound Physician indicated initial wound assessments should have been completed on admission, and the wound vac supplies were usually easily accessible and should have been available. The Wound Physician stated she discontinued the wound vac due to it not being available when she initially evaluated Resident #86. The Wound Physician indicated Resident #86 discharged to the hospital May 2025 unrelated to wound care and did not return to the facility. During a phone interview on 11/19/25 at 1:00 PM

the Director of Nursing (DON) stated the weekend nurse on 3/15/25 should have completed the initial wound assessments with measurements which was to be done within the first 24 hours of admission. The DON stated when Resident #86 admitted on [DATE REDACTED] and the wound vac was not available the nurse should have clarified the treatment orders in order to get daily treatments started due to Resident #86's significant wounds. The DON indicated wound treatments should have been initiated sooner than 3/18/25 and that did not occur.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/21/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Pembroke Center

310 E Wardell Drive Pembroke, NC 28372

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

concerns noted during the audit. On 9/8/25 the Director of Nursing and designee-initiated education to all nursing staff on safe handling of the residents, the location of the Kardex, when to review the Kardex, and

the importance of following the Kardex when providing resident care, and the abuse and neglect policy.

Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. Beginning 9/8/25, licensed nurses and certified nursing assistants to include agency licensed nurses and agency certified nursing assistants were provided education by the DON and Nurse Educator on resident safe handling, location of the Kardex, when to review the Kardex, and the importance of following the Kardex when providing resident care. All new staff and new agency staff will be educated in

the new hire orientation program and before the next scheduled shift. Beginning 9/8/25, education was provided to all facility staff, to include agency staff, by the Nurse Educator on the abuse policy with an emphasis on neglect. Any staff identified as not receiving abuse and neglect education by 9/8/25 will not be allowed to work before receiving education on the facility's abuse policy. All newly hired staff, to include new agency staff, will be educated on the facility's abuse prohibition policy in the new hire orientation program.

Post tests were completed beginning on 9/8/25 for validation of understanding of abuse reporting timeframe, the requirements and reporting any allegations or witnessed abuse to the facility Administrator immediately. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. Effective 9/9/25, the Director of Nursing and designee will review all incidents and accidents through the Risk Management System in the morning clinical meeting 5 times weekly for 12 weeks to ensure the Kardex and care plans were followed with bed mobility and transfers to ensure resident safety.

Effective 9/9/25, the Director of Nursing or Nurse Manager will conduct random audits through observations of 5 staff per week for 12 weeks to ensure safe bed mobility and transfers were maintained. An ADHOC Quality Assurance Performance Improvement (QAPI) meeting was conducted on 9/8/25 in collaboration with the Medical Director to discuss the root cause analysis of the deficient practice, to formulate a plan to include monitoring beginning on 9/8/25, and to ensure resident safe handling and residents bed mobility were followed during care as outlined in the patient's care plan. The results of the quality monitoring will be brought to the monthly Quality Assurance meeting to ensure compliance of resident safety for 3 months.

The improvement-monitoring schedule will be modified based on the findings of monitoring. The facility's alleged compliance date of the corrective action plan was 9/10/25. The corrective action plan was validated

on 10/2/25. The following documentation was reviewed along with staff interviews and observations: Validation included staff interviews regarding the incident and in-service training that was received to ensure understanding and knowledge of the training provided. Staff members interviewed stated they had received training. In-service training included safe handling during resident care, the importance of reviewing the residents Kardex, and the abuse and neglect policy. Inservice logs were verified, and the initial and ongoing audits were verified. An observation of incontinence care was conducted of a resident who required two-person assistance with bed mobility and activities of daily living. There were no concerns identified. The compliance date of 9/10/25 was validated.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/21/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Pembroke Center

310 E Wardell Drive Pembroke, NC 28372

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm

regarding Resident #3. During an interview on [DATE REDACTED] the Administrator indicated a full investigation was conducted regarding the missing Hydrocodone tablets. They were unable to determine who took the missing medications. The decision was made on [DATE REDACTED] to monitor controlled medications and put it in their Quality Assurance (QA) program.

Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/21/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Pembroke Center

310 E Wardell Drive Pembroke, NC 28372

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

record review, staff interviews, and the Consultant Pharmacist's interview the facility failed to act on the Pharmacist's recommendation to remove a residents (Resident #3) discontinued narcotic pain medication (Hydrocodone- Acetaminophen 5-325 milligrams) from the medication cart. This resulted in 20 missing tablets. This occurred for 1 of 6 residents (Resident #3) reviewed for medication administration.Findings included:Resident #3 was re-admitted to the facility on [DATE REDACTED] with diagnoses including a stage IV pressure wound and osteomyelitis (infection of the bone). A hospital physician's order dated 7/14/25 for Resident #3 revealed Hydrocodone-Acetaminophen oral tablets 5-325 milligrams (mg). Give 1 tablet by mouth every 6 hours as needed for up to 5 days beginning 7/14/25. This order was administered to Resident #3 from 7/15/25 through 7/19/25 and completed. A second hard copy physician's order dated 7/14/25 for Resident #3 revealed Hydrocodone-Acetaminophen oral tablets 5-325 milligrams (mg). Give 1 tablet by mouth every 6 hours as needed for pain for 14 days (56 tablets). A packing slip and proof of delivery from the dispensing pharmacy dated 7/15/25 revealed the facility physician's order was filled with a delivery of Hydrocodone-Acetaminophen oral tablets 5-325 mg and a total of 54 tablets for Resident #3 was received

in the facility on 7/15/25. The delivery was signed as received by Nurse #7 and Nurse #5. The declining count sheet for the 54 tablets of Hydrocodone-Acetaminophen 5-325 mgs for Resident #3 was signed out by nursing staff as needed during the month of July 2025 and signed as administered one time in August

1. 2025. Review of the Consultant Pharmacist's Controlled Substance Random Audit form dated 8/14/25

conducted by Consultant Pharmacist #2 revealed Resident #3 was selected for a random medication audit.

The Pharmacist noted that Resident #3's Hydrocodone-Acetaminophen 5-325 mg order had been discontinued in July 2025 and to pull the medication card from the cart and return to pharmacy. An investigation report completed by the Administrator dated 11/5/25 revealed in part; On 11/5/25 Nurse #10 discovered the count on the narcotic sheet noting 20 missing tablets of Hydrocodone-Acetaminophen and reported this to the Director of Nursing (DON). During a phone interview on 11/18/25 at 2:30 PM the Consultant Pharmacist (#2) who was the consultant during July through September 2025 stated she did random audits on the controlled medications and randomly selected 4 or 5 cards for auditing at each visit.

She stated she looked at documentation, final counts, and verified that the card and the order matched. The Consultant Pharmacist stated a note was sent to the Director of Nursing (DON) regarding Resident #3's Hydrocodone - Acetaminophen 5-325 mgs that remained on the medication cart on the August 2025 pharmacy report. The Consultant Pharmacist stated the note read to pull the Hydrocodone Acetaminophen 5-325 mg for Resident #3 from the medication cart and return to the Pharmacy for disposal because the order was discontinued on 7/29/25 after 14 days. She stated she typically did not go back and

review the previous months recommendations that were sent to the Director of Nursing (DON) and just expected the recommendations would be followed. During an interview on 11/18/25 at 10:45 AM the Director of Nursing (DON) indicated she was responsible for acting on the monthly pharmacy reports. She stated she received the Consultant Pharmacist's medication audit reports each month and would complete

the necessary recommendations when she received the report. The DON indicated that the Pharmacist's note to pull Resident #3's discontinued medication from the medication cart on the 8/14/25 review was missed in error. The DON stated had the Hydrocodone- Acetaminophen been removed after the order was discontinued or at least removed after the Consultant Pharmacists recommendations the missing medications would not have occurred.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/21/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Pembroke Center

310 E Wardell Drive Pembroke, NC 28372

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

stated Resident #86's Vancomycin order was not received in the pharmacy until 3/16/25 at 9:32 PM and it was delivered to the facility Monday 3/17/25. The Piperacillin order was received in the pharmacy on 3/16/25 at 3:31 AM and delivered to the facility on 3/16/25. During a phone interview on 11/21/25 at 12:30 PM the Wound Physician stated missing doses of Vancomycin and Piperacillin in the treatment of osteomyelitis was significant and could delay wound healing. The Wound Physician stated she could not say the missed doses caused any worsening of the infection regarding Resident #86 but missed doses could lead to subtherapeutic levels causing the antibiotic to be less effective. During a phone interview on 11/21/25 at 1:00 PM the Director of Nursing (DON) stated the orders for Resident #86's IV antibiotics should have been entered into the electronic medical and sent to Pharmacy on 3/15/25 the day of admission. The DON indicated that the IV antibiotics should have been administered to Resident #86 sooner.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/21/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Pembroke Center

310 E Wardell Drive Pembroke, NC 28372

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

An interview was completed with the DON on 10/2/25 at 10:30 AM. The DON stated there should not be any expired medications available for use in the medication storage rooms.

1. 4. An observation of the 300-hall med cart was conducted on 10/2/25 at 10:13 AM with the

Wound/Treatment Nurse. The observation revealed 20 vials of ipratropium bromide inhalation solution in an open foil package with no label or date opened. The manufacturer's instructions included discarding the medication 2 weeks after opening.

An interview was completed with the Wound/Treatment Nurse on 10/2/25 at 10:25 AM. The Wound/Treatment Nurse stated she was unaware the vials expired 2 weeks after opening and it should have had an opened date.

An interview was completed with the DON on 10/2/25 at 10:30 AM. The DON stated she was not aware that

the vials expired 2 weeks after opening. She indicated all medications should have a label and an opened date.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet