PEMBROKE, NC — Federal health inspectors identified 11 deficiencies at Pembroke Center during a complaint investigation completed on November 21, 2025, including a citation for failing to provide appropriate pressure ulcer care and prevent new pressure ulcers from developing. The facility has not submitted a plan of correction.
Pressure Ulcer Prevention Breakdown
The inspection found Pembroke Center deficient under federal regulatory tag F0686, which requires nursing facilities to provide proper pressure ulcer prevention and treatment. The citation falls under the category of Quality of Life and Care Deficiencies, indicating failures in fundamental resident care standards.
Inspectors assigned the violation a Scope/Severity Level D, meaning the deficiency was isolated in nature but carried the potential for more than minimal harm to residents. While no actual harm was documented at the time of the survey, the finding signals that facility practices were insufficient to protect residents from a well-known and largely preventable medical condition.
Pressure ulcers — also referred to as bedsores or decubitus ulcers — develop when sustained pressure restricts blood flow to soft tissue, typically over bony prominences such as the sacrum, heels, and hips. Residents with limited mobility, poor nutrition, or chronic medical conditions face the highest risk. Without consistent repositioning schedules, proper skin assessments, adequate nutrition support, and appropriate wound care, these ulcers can progress rapidly through four stages, from superficial skin reddening to deep tissue destruction involving muscle and bone.
Why Pressure Ulcer Standards Exist
Federal regulations under 42 CFR §483.25(b) establish clear expectations: a facility must ensure that residents who enter without pressure ulcers do not develop them unless clinically unavoidable, and residents who arrive with existing pressure ulcers must receive treatment and services to promote healing and prevent infection.
Standard clinical protocols call for comprehensive skin assessments upon admission and at regular intervals, individualized care plans addressing each resident's specific risk factors, repositioning schedules typically every two hours for immobile residents, proper support surfaces such as pressure-relieving mattresses, nutritional optimization including adequate protein and hydration, and detailed wound documentation tracking size, depth, and healing progress.
When these protocols are not consistently followed, residents face increased risk of serious medical complications. Advanced pressure ulcers can lead to cellulitis, osteomyelitis (bone infection), and sepsis — a life-threatening systemic infection. According to published clinical data, mortality rates among nursing home residents with Stage IV pressure ulcers are significantly elevated compared to those without such wounds.
Eleven Deficiencies and No Correction Plan
The pressure ulcer citation was one of 11 total deficiencies identified during this complaint investigation, suggesting broader systemic concerns at the facility beyond a single care area. When inspectors find multiple deficiencies during a single survey — particularly one triggered by a complaint — it often points to organizational challenges in staffing, training, or quality oversight.
Perhaps most concerning is that Pembroke Center has not submitted a plan of correction for the cited deficiencies. Federal regulations require facilities to submit a credible plan of correction detailing how each deficiency will be addressed, the steps taken to prevent recurrence, and the timeline for achieving compliance. The absence of such a plan raises questions about the facility's responsiveness to regulatory findings.
What Residents and Families Should Know
Pressure ulcer prevention is considered a core quality indicator in long-term care settings. The Centers for Medicare & Medicaid Services (CMS) tracks facility-level pressure ulcer rates as part of its quality reporting program, and persistent deficiencies in this area can affect a facility's overall star rating.
Families with loved ones at Pembroke Center should be aware of their right to review inspection reports, request care plan meetings, and report concerns directly to the North Carolina Division of Health Service Regulation. Warning signs of pressure ulcer development include persistent redness on the skin that does not fade when pressed, skin that feels warmer or cooler than surrounding areas, and any open wounds or areas of skin breakdown.
The full inspection report, including details on all 11 cited deficiencies, is available through the CMS Care Compare database and on NursingHomeNews.org's [facility page for Pembroke Center](/facility/pembroke-center-pembroke-nc).
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.
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