Pembroke Center

In the surveyor’s words

From the most serious findings on record at Pembroke Center, in the surveyor’s own words.

• Immediate jeopardy, patternF684Jul 6, 2021

  Based on record review and Physician and staff interviews the facility failed to provide care for a diabetic by failing to obtain and monitor blood sugar (BS) levels for 1 of 1 residents (Resident #171) which resulted in the resident being admitted to the hospital for Diabetic Ketoacidosis (DKA). DKA is the formation of a toxic chemical in the blood caused by prolonged high blood sugar which can be life threatening. Resident #171 was also admitted to the hospital with hyperosmolar [CONDITION(S)] (a complication from high blood sugar for a long period of time that causes severe dehydration and confusion). […]

• Immediate jeopardy, isolatedF600May 31, 2024

  Based on observations, record review, and interviews with residents, staff, medical doctor, nurse practitioners, and law enforcement, the facility failed to protect a female (who was deemed an incompetent person by the North Carolina Clerk of Court) resident's (Resident #1), right to be free from sexual abuse by a cognitively impaired male resident (Resident #2). On 05/15/24 Resident #1 was naked from the waist down in her bed when Nursing Assistant (NA) #1 observed Resident #2 in Resident #1's bed with his face between Resident #1's legs. Resident #1 was incapable of giving consent for Resident #2 to touch her. A reasonable person expects to be protected from abuse in their home environment and sexual abuse would cause trauma. […]

• Immediate jeopardy, isolatedF580May 31, 2023

  Based on record review and staff and physician interviews, the facility failed to notify the physician when Resident #1 developed an opened area the size of a nickel on his scrotum with significant amounts of pus or drainage. Resident #1 had a history of Fournier's gangrene (a rare, life-threatening bacterial infection of the scrotum, penis or perineum), abscess of corpus cavernosum (tissue forming the bulk of the penis), and sepsis. Resident #1 was assessed for abscesses at the emergency department of Hospital #1 and transferred to Hospital #2 for urology care. Hospital #2 operated on the scrotal abscess and debrided the Fournier's gangrene. […]

• Immediate jeopardy, isolatedF684May 31, 2023

  Based on record review and staff and physician interviews, the facility failed to identify the seriousness of an open area on the scrotum that nurse aides reported had significant amounts of pus or drainage and failed to seek urgent medical attention once the resident refused an assessment. Resident #1 had paraplegia, had no feeling in his groin/scrotum area, and had a history of prior debridement for Fournier's gangrene. Fournier's gangrene is a type of flesh-eating disease (necrotizing fasciitis) that destroys the soft tissue of the scrotum, penis and perineum and is associated with a high mortality rate and requires immediate medical attention. Resident #1 was sent to Hospital #1's emergency department (ED) for evaluation. […]

• Actual harm, isolatedF600Jun 5, 2025

  Based on record review, and staff , Psychiatrist, Nurse Practitioner, and the Medical Director's interviews the facility failed to protect a residents right to be free from resident-to-resident abuse when Resident #1 hit and scratched Resident #2 on her left arm resulting in multiple areas of bruising and abrasions. This occurred for 1 of 4 residents reviewed for abuse (Resident #1). Findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses of bipolar disorder, and bilateral below the knee amputation. Review of the care plan dated 12/28/24 revealed Resident #1 required assistance with activities of daily living. There was no care plan in place regarding Resident #1 having behavioral disturbances. […]