Pembroke Center: Grievance Rights Violations - NC
Resident 86 was admitted to Pembroke Center on March 15, 2025, with wounds severe enough to require specialized vacuum therapy. But the wound vacuum wasn't available when he arrived on a weekend, and nursing staff took no action to begin daily treatments with alternative methods.
The resident went without any wound care until March 18 — three full days after admission.
Federal inspectors found that initial wound assessments with measurements should have been completed within 24 hours of admission. Instead, Unit Manager 1 didn't enter the resident's wound treatment orders into the electronic medical record until March 17 and conducted the initial assessments on March 18.
The weekend admission nurse who should have handled the initial assessment was no longer employed by the facility when inspectors arrived in November.
During a phone interview on November 19, the facility's wound care physician said she couldn't evaluate Resident 86 until March 20 because she wasn't working full-time and floor nurses were responsible for daily wound care. She found the resident had four significant pressure wounds at admission.
"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," inspectors wrote.
The wound physician discontinued the vacuum therapy entirely during her initial evaluation because the equipment remained unavailable. She told inspectors the vacuum supplies "were usually easily accessible and should have been available."
Resident 86's condition deteriorated during his two-month stay. When the wound physician last evaluated him on May 23, 2025, before his discharge, "the sacrum was more necrotic, and the left hip fascia was exposed with muscle."
The physician attributed the worsening wounds to multiple factors, including "not offloading, possible missed wound treatments, osteomyelitis, and other comorbidities."
The facility's Director of Nursing acknowledged the failures during a November 19 phone interview. She confirmed the weekend nurse should have completed initial wound assessments within 24 hours and should have "clarified the treatment orders in order to get daily treatments started due to Resident 86's significant wounds."
Nobody took responsibility for the three-day delay. Medication Aide 1 told inspectors during a November 18 phone interview that she "would not have been responsible for wound care treatments and did not have any information regarding Resident 86's wound care."
The wound treatment nurse said she began working at the facility around the time of Resident 86's admission but wasn't working the weekend he arrived. She described the resident as "compliant with wound care" but provided no explanation for the initial delay.
Unit Manager 1 entered the wound treatment orders two days after admission but couldn't explain why the weekend nurse failed to begin alternative treatments when the vacuum equipment wasn't available.
The Director of Nursing was direct about the facility's failure: "Wound treatments should have been initiated sooner than 3/18/25 and that did not occur."
Resident 86 was discharged to a hospital in May 2025 for reasons unrelated to wound care and never returned to Pembroke Center. By then, his pressure wounds had progressed from four significant injuries to necrotic tissue and exposed muscle.
The wound physician's assessment was stark: the worsening was "multifactorial" but included "possible missed wound treatments" during his stay.
Federal inspectors cited the facility for failing to provide necessary care and services to maintain the highest practicable physical well-being of residents. The violation affected few residents but posed minimal harm or potential for actual harm.
The three-day delay in wound care for a resident with four significant pressure wounds occurred because staff failed to adapt when equipment wasn't available and no one took responsibility for ensuring alternative treatments began immediately.
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: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 5, 2026 · Our methodology
Pembroke Center in Pembroke, NC was cited for violations during a health inspection on November 21, 2025.
Resident 86 was admitted to Pembroke Center on March 15, 2025, with wounds severe enough to require specialized vacuum therapy.
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.