Pembroke Center

• Star rating

  The CMS quality measures star rating changed from 1 of 5 to 2 of 5.

• Fine

  CMS changed the fine from November 21, 2025 from $15,900 to $10,335.

CMS lists this as a complaint inspection.

• Citation F0695. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide safe and appropriate respiratory care for a resident when needed.

  CMS lists it as corrected on June 11, 2026.

• Citation F0760. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that residents are free from significant medication errors.

  CMS lists it as corrected on June 11, 2026.

  CMS has cited this home for F0760 3 times since 2025.

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• Star rating

  The CMS quality measures star rating changed from 2 of 5 to 1 of 5.

• Star rating

  The CMS quality measures star rating changed from 3 of 5 to 2 of 5.

• Fine

  CMS changed the fine from June 5, 2025 from $16,720 to $10,868.

CMS lists this as a complaint inspection.

• Citation F0760. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that residents are free from significant medication errors.

  CMS lists it as corrected on January 27, 2026.

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CMS lists this as a standard inspection and a complaint inspection.

• Citation F0658. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure services provided by the nursing facility meet professional standards of quality.

  CMS lists it as corrected on January 20, 2026.

• Citation F0755. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

  CMS lists it as corrected on January 20, 2026.

  CMS has cited this home for F0755 2 times since 2023.

• Citation F0761. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

  CMS lists it as corrected on January 20, 2026.

  CMS has cited this home for F0761 2 times since 2023.

• Citation F0880. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide and implement an infection prevention and control program.

  CMS lists it as corrected on January 20, 2026.

• Citation F0558. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Reasonably accommodate the needs and preferences of each resident.

  CMS lists it as corrected on January 20, 2026.

• Citation F0580. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

  CMS lists it as corrected on January 20, 2026.

• Citation F0585. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

  CMS lists it as corrected on January 20, 2026.

• Citation F0600. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

  CMS lists it as corrected on January 20, 2026.

  CMS has cited this home for F0600 4 times since 2024.

• Citation F0638. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Assure that each resident’s assessment is updated at least once every 3 months.

  CMS lists it as corrected on January 20, 2026.

• Citation F0677. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide care and assistance to perform activities of daily living for any resident who is unable.

  CMS lists it as corrected on January 20, 2026.

  CMS has cited this home for F0677 2 times since 2023.

• Citation F0684. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide appropriate treatment and care according to orders, resident’s preferences and goals.

  CMS lists it as corrected on January 20, 2026.

  CMS has cited this home for F0684 2 times since 2024.

• Citation F0686. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide appropriate pressure ulcer care and prevent new ulcers from developing.

  CMS lists it as corrected on January 20, 2026.

• Citation F0689. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS lists it as corrected on September 10, 2025.

  CMS has cited this home for F0689 2 times since 2024.

• Citation F0692. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide enough food/fluids to maintain a resident's health.

  CMS lists it as corrected on January 20, 2026.

• Citation F0730. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Observe each nurse aide's job performance and give regular training.

  CMS lists it as corrected on January 20, 2026.

• Citation F0756. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

  CMS lists it as corrected on January 20, 2026.

  CMS has cited this home for F0756 2 times since 2024.

• Citation F0760. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that residents are free from significant medication errors.

  CMS lists it as corrected on January 27, 2026.

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CMS lists this as a standard inspection.

• Citation K0321. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

  CMS lists it as corrected on February 10, 2026.

• Citation K0353. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Inspect, test, and maintain automatic sprinkler systems.

  CMS lists it as corrected on April 15, 2026.

  CMS has cited this home for K0353 2 times since 2024.

• Citation K0372. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

  CMS lists it as corrected on February 10, 2026.

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CMS fine of $10,335 on November 21, 2025.

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• Star rating

  The CMS health inspection star rating changed from 2 of 5 to 1 of 5. CMS changed how it scores this rating for many homes at once.

• Star rating

  The CMS quality measures star rating changed from 2 of 5 to 3 of 5.

• Fine

  CMS changed the fine from May 31, 2023 from $15,269 to $37,493.

• Fine

  CMS changed the fine from May 31, 2023 from $37,492 to $7,634.

• Staffing

  Total nurse staffing reported to CMS went from 3.1 to 2.8 hours per resident per day.

• Star rating

  The CMS health inspection star rating changed from 1 of 5 to 2 of 5.

CMS lists this as a complaint inspection.

Severity G is the second-highest of CMS's four levels. It means a resident was harmed.

69 of 419 North Carolina homes (16%) got a citation at the actual harm level in 2025.

• Citation F0600. Severity G: actual harm, isolated.

  The rule CMS cited: Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

  CMS lists it as corrected on May 28, 2025.

• Citation F0849. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

  CMS lists it as corrected on June 7, 2025.

  CMS has cited this home for F0849 2 times since 2024.

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CMS fine of $10,868 on June 5, 2025.

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• Star rating

  The CMS quality measures star rating changed from 1 of 5 to 2 of 5. CMS changed how it scores this rating for many homes at once.

CMS lists this as a standard inspection and a complaint inspection.

• Citation F0684. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide appropriate treatment and care according to orders, resident’s preferences and goals.

  CMS lists it as corrected on December 18, 2024.

• Citation F0757. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure each resident’s drug regimen must be free from unnecessary drugs.

  CMS lists it as corrected on December 18, 2024.

• Citation F0600. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

  CMS lists it as corrected on December 18, 2024.

• Citation F0689. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS lists it as corrected on December 18, 2024.

• Citation F0725. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

  CMS lists it as corrected on December 18, 2024.

• Citation F0727. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

  CMS lists it as corrected on December 18, 2024.

• Citation F0756. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

  CMS lists it as corrected on December 18, 2024.

• Citation F0849. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

  CMS lists it as corrected on December 18, 2024.

• Citation F0842. Severity B: potential for minimal harm, pattern.

  The rule CMS cited: Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

  CMS lists it as corrected on December 18, 2024.

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CMS lists this as a standard inspection.

• Citation K0916. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have a battery powered remote alarm panel in a location accessible by operating personnel.

  CMS lists it as corrected on January 21, 2025.

• Citation K0353. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Inspect, test, and maintain automatic sprinkler systems.

  CMS lists it as corrected on January 21, 2025.

• Citation K0363. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Install corridor and hallway doors that block smoke.

  CMS lists it as corrected on January 21, 2025.

• Citation K0923. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Have proper medical gas storage and administration areas.

  CMS lists it as corrected on January 21, 2025.

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• Fine

  CMS changed the fine from May 31, 2024 from $24,825 to $16,136.

• Star rating

  The CMS staffing star rating changed from 3 of 5 to 1 of 5. CMS changed how it scores this rating for many homes at once.

• CMS abuse icon

  CMS added its abuse icon to this home.

• Staffing

  Total nurse staffing reported to CMS went from 3.7 to 3.2 hours per resident per day.

CMS lists this as a complaint inspection.

Severity J is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.

88 of 419 North Carolina homes (21%) got a citation at the immediate jeopardy level in 2024.

• Citation F0600. Severity J: immediate jeopardy, isolated.

  The rule CMS cited: Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

  CMS lists it as corrected on May 18, 2024.

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CMS fine of $16,136 on May 31, 2024.

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• Star rating

  The CMS staffing star rating changed from 1 of 5 to 3 of 5.

• Fine

  CMS changed the fine from May 31, 2023 from $8,652 to $37,492.

CMS lists this as a standard inspection and a complaint inspection.

• Citation F0677. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide care and assistance to perform activities of daily living for any resident who is unable.

  CMS lists it as corrected on December 14, 2023.

• Citation F0697. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide safe, appropriate pain management for a resident who requires such services.

  CMS lists it as corrected on December 14, 2023.

• Citation F0761. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

  CMS lists it as corrected on December 14, 2023.

• Citation F0867. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

  CMS lists it as corrected on December 14, 2023.

• Citation F0755. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

  CMS lists it as corrected on December 14, 2023.

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CMS lists this as a standard inspection.

• Citation K0521. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

  CMS lists it as corrected on February 2, 2024.

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