Cycle 1
Health 2025-11-21 · Fire 2024-11-20
20 health deficiencies
Top issue: Pharmacy Service (5 deficiencies)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Pembroke, NC
Pembroke Center
1-star overall rating with 1-star inspections with abuse icon flag with $79,765 in total fines with 20 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
310 E Wardell Drive, Pembroke, NC
(910) 521-1273
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
84
Certified beds
Average residents
74
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Genesis Healthcare
Operator or chain grouping
Approved since
1992-01-07
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.44
Registered nurse staffing
LPN hours / resident day
0.81
Licensed practical nurse staffing
Aide hours / resident day
1.86
Nurse aide staffing
Weekend hours
2.93
Weekend nurse staffing
RN turnover
94%
Annual RN turnover
Total nurse turnover
68%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.2 |
1.8
0.4 pts worse
|
1.9
0.3 pts worse
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 4.0 |
1.8
2.2 pts worse
|
1.8
2.2 pts worse
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 77.9% |
91.5%
13.6 pts worse
|
93.4%
15.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 87.8% |
94.1%
6.3 pts worse
|
95.5%
7.7 pts worse
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.9% |
3.6%
1.7 pts better
|
3.3%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 15.6% |
4.8%
10.8 pts worse
|
11.4%
4.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 14.2% |
7.2%
7 pts worse
|
5.4%
8.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.0% |
21.6%
5.6 pts better
|
19.6%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 8.2% |
15.0%
6.8 pts better
|
16.7%
8.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose ability to walk independently worsened | 31.9% |
21.5%
10.4 pts worse
|
16.3%
15.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 17.4% |
16.8%
0.6 pts worse
|
14.9%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.4% |
0.9%
0.5 pts better
|
1.0%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 3.5% |
2.6%
0.9 pts worse
|
1.7%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 34.1% |
21.2%
12.9 pts worse
|
19.8%
14.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 6.6% |
6.0%
0.6 pts worse
|
5.1%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 21.6% |
79.9%
58.3 pts worse
|
81.7%
60.1 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 21.2% |
13.2%
8 pts worse
|
12.0%
9.2 pts worse
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.7% |
1.5%
0.2 pts worse
|
1.6%
0.1 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 41.8% |
78.1%
36.3 pts worse
|
79.7%
37.9 pts worse
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 16.3% |
22.9%
6.6 pts better
|
23.9%
7.6 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-11-20 · Fire 2023-11-16
10 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
1 fire-safety deficiencies
Top issue: Services (1 deficiency)
Cycle 3
Health 2023-11-16 · Fire 2022-07-25
13 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-11-20
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2025-01-21
D · Potential for more than minimal harm
2024-11-20
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-01-21
D · Potential for more than minimal harm
2024-11-20
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-01-21
D · Potential for more than minimal harm
2024-11-20
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-01-21
D · Potential for more than minimal harm
2023-11-16
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-02-02
D · Potential for more than minimal harm
2022-07-25
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-09-16
D · Potential for more than minimal harm
2022-07-25
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-09-16
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-20
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2026-01-27
E · Potential for more than minimal harm
2025-11-21
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2026-01-20
E · Potential for more than minimal harm
2025-11-21
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2026-01-20
E · Potential for more than minimal harm
2025-11-21
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2026-01-20
E · Potential for more than minimal harm
2025-11-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2026-01-20
D · Potential for more than minimal harm
2025-11-21
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2026-01-20
D · Potential for more than minimal harm
2025-11-21
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2026-01-20
D · Potential for more than minimal harm
2025-11-21
F585 · Resident Rights Deficiencies
Health
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.
Corrected 2026-01-20
D · Potential for more than minimal harm
2025-11-21
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2026-01-20
D · Potential for more than minimal harm
2025-11-21
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2026-01-20
D · Potential for more than minimal harm
2025-11-21
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2026-01-20
D · Potential for more than minimal harm
2025-11-21
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2026-01-20
D · Potential for more than minimal harm
2025-11-21
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2026-01-20
D · Potential for more than minimal harm
2025-11-21
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-09-10
D · Potential for more than minimal harm
2025-11-21
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2026-01-20
D · Potential for more than minimal harm
2025-11-21
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2026-01-20
D · Potential for more than minimal harm
2025-11-21
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2026-01-20
D · Potential for more than minimal harm
2025-11-21
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2026-01-27
G · Actual harm
2025-06-05
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-05-28
D · Potential for more than minimal harm
2025-06-05
F849 · Administration Deficiencies
Health
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.
Corrected 2025-06-07
E · Potential for more than minimal harm
2024-11-20
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-12-18
E · Potential for more than minimal harm
2024-11-20
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-12-18
D · Potential for more than minimal harm
2024-11-20
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-12-18
D · Potential for more than minimal harm
2024-11-20
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-12-18
D · Potential for more than minimal harm
2024-11-20
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2024-12-18
D · Potential for more than minimal harm
2024-11-20
F727 · Nursing and Physician Services Deficiencies
Health
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.
Corrected 2024-12-18
D · Potential for more than minimal harm
2024-11-20
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2024-12-18
D · Potential for more than minimal harm
2024-11-20
F849 · Administration Deficiencies
Health
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.
Corrected 2024-12-18
B · Minimal harm
2024-11-20
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-12-18
J · Immediate jeopardy
2024-05-31
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-05-18
E · Potential for more than minimal harm
2023-11-16
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-12-14
E · Potential for more than minimal harm
2023-11-16
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-12-14
E · Potential for more than minimal harm
2023-11-16
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2023-12-14
E · Potential for more than minimal harm
2023-11-16
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-12-14
D · Potential for more than minimal harm
2023-11-16
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-12-14
D · Potential for more than minimal harm
2023-09-07
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-08-17
G · Actual harm
2023-07-20
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-08-17
G · Actual harm
2023-07-20
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-08-17
D · Potential for more than minimal harm
2023-07-20
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2023-08-17
G · Actual harm
2023-06-29
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-08-17
G · Actual harm
2023-06-29
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-08-17
J · Immediate jeopardy
2023-05-31
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-06-29
J · Immediate jeopardy
2023-05-31
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-06-29
Penalties and ownership
What sits behind the stars
$10,868
2025-06-05
Fine
Fine · fine $10,868
Fine
$16,136
2024-05-31
Fine
Fine · fine $16,136
Fine
$7,634
2023-05-31
Fine
Fine · fine $7,634
Fine
$7,634
2023-05-31
Fine
Fine · fine $7,634
Fine
$37,493
2023-05-31
Fine
Fine · fine $37,493
Fine
$0
2023-05-31
Payment Denial
Payment Denial · denial start 2023-06-20 · 58 days
58 day denial
Ownership
Sunbridge Healthcare LLC
5% Or Greater Direct Ownership Interest · Organization
Berg, Michael
Corporate Officer · Individual
Bridgeford, Laura
Corporate Officer · Individual
Fc Gen Operations Investment LLC
5% Or Greater Indirect Ownership Interest · Organization
Fishman, Steven
5% Or Greater Indirect Ownership Interest · Individual
Gen Operations I LLC
5% Or Greater Indirect Ownership Interest · Organization
Gen Operations Ii LLC
5% Or Greater Indirect Ownership Interest · Organization
Genesis Administrative Services LLC
Operational/Managerial Control · Organization
Genesis Healthcare Inc
5% Or Greater Indirect Ownership Interest · Organization
Genesis Healthcare LLC
5% Or Greater Indirect Ownership Interest · Organization
Genesis Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Hccf Management Group Xi LLC
5% Or Greater Indirect Ownership Interest · Organization
Mendelson, Avi
Corporate Officer · Individual
Parham, Syreeta
Operational/Managerial Control · Individual
Powerback Rehabilitation LLC
Operational/Managerial Control · Organization
Seder, Jeffrey
Operational/Managerial Control · Individual
Sun Healthcare Group, Inc.
5% Or Greater Indirect Ownership Interest · Organization
Welltower Op LLC
5% Or Greater Indirect Ownership Interest · Organization
Whitman, Arnold
5% Or Greater Indirect Ownership Interest · Individual
Zac Properties Xi LLC
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Other facilities in reach
#1
Glenflora
Lumberton, NC
5-star overall rating with 5-star inspections with $14,689 in total fines with 2 fire-safety deficiencies in the latest cycle
#2
Wesley Pines Retirement Community
Lumberton, NC
3-star overall rating with 3-star inspections with 7 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Woodhaven Nursing Center
Lumberton, NC
1-star overall rating with 1-star inspections with $128,210 in total fines with 7 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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