Pembroke Center: Pressure Ulcer Care Failures - NC
Resident #86 was admitted on March 15, 2025, but didn't receive his first wound treatment until March 18. The facility's own Director of Nursing acknowledged that wound treatments "should have been initiated sooner than 3/18/25 and that did not occur."
The weekend nurse responsible for Resident #86's admission never completed the required initial wound assessments with measurements, which were supposed to be done within 24 hours. Unit Manager #1 didn't enter the resident's wound treatment orders into the electronic medical record until March 17 — two days after admission. She conducted the initial wound assessments on March 18, three days late.
When the wound care physician first evaluated Resident #86 on March 20, she found the resident had been admitted "with four significant pressure wounds." She immediately discontinued the prescribed wound vacuum therapy because the equipment "was not available when she initially evaluated" the resident.
The physician told inspectors the wound vacuum supplies "were usually easily accessible and should have been available." She stated there was "no dedicated wound nurse" at the time of admission and "could not attest to how often the wound care was getting done."
By the time Resident #86 discharged in May 2025, his condition had deteriorated significantly. The wound care physician's final evaluation on May 23 revealed "the sacrum was more necrotic, and the left hip fascia was exposed with muscle."
She attributed the worsening wounds to multiple factors, including "not offloading, possible missed wound treatments, osteomyelitis, and other comorbidities." The resident ultimately discharged to a hospital in May for reasons unrelated to wound care and never returned to the facility.
Multiple staff members interviewed by inspectors revealed gaps in the facility's wound care system. The wound treatment nurse stated she "began working in the facility around the time Resident #86 was admitted but she did not work full-time." Floor nurses were responsible for daily wound care, but she wasn't working the weekend of March 15 when the resident was admitted.
Medication Aide #1 told inspectors during a 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 on 3/15/25 or 3/16/25."
The Director of Nursing acknowledged the facility's failures during her interview on November 19. She stated the weekend nurse "should have completed the initial wound assessments with measurements" within 24 hours of admission. When the wound vacuum wasn't available, she said, "the nurse should have clarified the treatment orders in order to get daily treatments started due to Resident #86's significant wounds."
The wound care physician emphasized that "initial wound assessments should have been completed on admission" and confirmed that proper wound vacuum supplies should have been readily available for a resident with such severe wounds.
Federal inspectors found the facility failed to ensure residents received treatment and care in accordance with professional standards of practice. The violation was classified as causing minimal harm or potential for actual harm, affecting few residents.
The inspection revealed a breakdown in multiple levels of care coordination. No one took responsibility for ensuring the newly admitted resident with serious wounds received immediate attention. The weekend admission nurse failed to complete required assessments. The wound care equipment wasn't available. Management didn't enter treatment orders promptly.
Three days passed while Resident #86's four significant pressure wounds went untreated. By discharge, exposed muscle and necrotic tissue marked the consequences of the facility's delayed response to wounds that the physician described as requiring immediate, specialized care.
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 on March 15, 2025, but didn't receive his first wound treatment until March 18.
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.