Pembroke Center: Safe Handling Failures Cited - NC]
The violation at Pembroke Center, a skilled nursing facility at 310 E. Wardell Drive, was cited under F0689, the federal tag covering accidents and unsafe conditions. Inspectors classified the harm level as minimal or potential, with few residents affected. But the details embedded in the facility's own corrective action plan reveal something more unsettling than the citation level suggests: staff, including agency workers brought in from outside the facility, were not consulting the Kardex, the bedside document that tells a nurse or aide exactly how a resident must be moved, turned, or transferred. Some residents required two-person assistance for bed mobility. Whether they were getting it, before inspectors arrived, is a question the record leaves open.
The Kardex is not a suggestion. For a resident with limited mobility, a fall during an improperly executed transfer can mean a fractured hip, a head injury, a stay in the hospital that becomes a stay in the hospital that never ends. The care plan exists because someone, at some point, assessed that resident and determined what it takes to move them safely. When staff skip that document, they are making a judgment call they are not equipped to make.
Pembroke Center's Director of Nursing launched a facility-wide education push on September 8, 2025, the same day the root cause analysis meeting was held with the Medical Director. Every nurse, every certified nursing assistant, every agency staffer who walked through the door was pulled into training on safe handling, on where to find the Kardex, on when to read it, and on what the abuse and neglect policy requires. Staff who had not completed the training by that date were barred from working until they had. New hires, including agency staff, were folded into the orientation program with the same requirement.
Post-tests were administered to confirm that staff understood not just the mechanics of safe transfers, but the reporting chain. The facility wanted documentation that workers knew to bring any allegation of abuse or neglect directly to the administrator, immediately.
The monitoring plan that followed was specific. Starting September 9, the Director of Nursing or a designee would review all incidents and accidents through the facility's risk management system five mornings a week for twelve weeks, checking each one against the care plan to confirm the Kardex had been followed during bed mobility and transfers. Separately, the Director of Nursing or a Nurse Manager would conduct direct observations of five staff members per week for the same twelve-week period, watching transfers happen in real time to verify technique.
An ad hoc Quality Assurance Performance Improvement meeting convened on September 8 brought together nursing leadership and the Medical Director to work through what had gone wrong and how to prevent it from recurring. The results of the ongoing monitoring were to be reported to the monthly Quality Assurance meeting for three months, with the schedule adjusted based on what the audits turned up.
The facility set September 10, 2025 as its compliance date. State validators returned on October 2, 2025, interviewed staff, reviewed training logs, and watched an incontinence care episode involving a resident who required two-person assistance. No concerns were identified that day. The compliance date was confirmed.
That validation matters, but it answers a narrow question. It tells you that on October 2, the staff member observed followed the care plan. It does not tell you how many times, in the weeks or months before the complaint was filed, a resident who needed two people to move them was moved by one, or moved without anyone checking the document that would have told them otherwise.
The inspection was triggered by a complaint, not a routine survey. Someone, a resident, a family member, a staff member with a conscience, reported a concern to the state. That complaint set the process in motion. Without it, the pattern might have continued.
Agency staff appear throughout the corrective action documents, and their inclusion is deliberate. Facilities that rely on temporary workers from outside agencies face a structural problem that a single training session does not fully solve. An agency nurse who arrives for a night shift may never have seen the Kardex system at this particular facility. They may be experienced in transfers but unfamiliar with this resident's specific limitations. The facility acknowledged this gap by requiring education before the next scheduled shift for all new agency workers, and by folding them into orientation requirements. Whether that holds in practice, across shift changes and staffing shortages, is the kind of thing that only sustained monitoring can reveal.
The twelve-week audit window the facility committed to is a start. What happens in week thirteen is not addressed in the record.
Pembroke Center is a skilled nursing facility serving a rural community in Robeson County, one of the poorest counties in North Carolina. Residents in facilities like this one are often elderly, often have multiple chronic conditions, and often have no one checking on them between visits. A resident who needs two-person assistance to move in bed is, by definition, someone who cannot protect themselves if the care plan is ignored. They cannot get up and walk out. They cannot always articulate what happened or who was responsible. They depend entirely on the staff member in the room to know the rules and follow them.
The federal tag cited here sits at the lower end of the harm scale. Inspectors found minimal harm or potential for harm, not actual documented injury. That is a meaningful distinction in regulatory terms. In human terms, it means the system caught the problem before someone got hurt, or at least before the injury was connected to the practice.
The plan of correction is thorough on paper. The training happened. The audits began. The Medical Director was in the room for the root cause conversation. Those are not nothing.
But the complaint that started this process came from outside the facility's own quality systems. The Kardex was not being followed, and the facility's internal monitoring, whatever form it took before September 8, did not surface that. It took someone deciding to make a call.
That resident, the one whose care prompted the complaint, is still there. Or they have been discharged, or transferred, or they have died, as residents in skilled nursing facilities often do. The record does not say. What the record says is that for some period of time, the instructions for how to move them safely were not being read by the people doing the moving, and that it took a federal inspection to make that stop.
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: June 20, 2026 · Our methodology
Pembroke Center in Pembroke, NC was cited for violations during a health inspection on November 21, 2025.
The violation at Pembroke Center, a skilled nursing facility at 310 E.
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.