NHC Healthcare Bristol: Fall With Fracture Violation - VA
Federal inspectors classified the violation as causing actual harm. The inspection, conducted August 20, 2025, stemmed from a complaint. The resident identified in the report is referred to only as Resident 7.
The sequence was straightforward and preventable. During a transfer, the shower chair was not locked in place. The chair moved. The resident fell. A fracture followed. Only after several days had passed did staff determine the brakes had never been locked before the transfer began.
The nursing assistant identified as CNA 4 was retrained after the fall was investigated. The Director of Nursing told inspectors the retraining covered falls prevention, specifically the requirement to lock brakes before any resident transfer. As evidence that CNA 4 had already been trained on exactly this, the Director of Nursing handed over a competency checklist dated March 3, 2025, roughly five months before the fall. The checklist indicated CNA 4 had demonstrated understanding of falls prevention. Locking brakes before a transfer was part of that checklist.
The training had happened. The competency had been signed off. The fall happened anyway.
At 4:09 in the afternoon on the day of the inspection, surveyors met with the facility's Administrator and Director of Nursing. The inspectors raised the finding directly: CNA 4 had not locked the shower chair brakes before transferring Resident 7, and Resident 7 had fallen and fractured a bone as a result. The facility offered nothing additional before the exit conference closed out the inspection that same day.
What the report does not explain is why several days passed before anyone connected the fall to the unsecured chair. A resident had fractured a bone during a transfer. The shower chair involved in that transfer had not been locked. Those two facts existed at the same time, and still the gap between the fall and the discovery stretched across multiple days.
Shower chair brakes exist for one reason. A chair that is not locked moves when weight shifts onto it. When a person who needs assistance transferring puts their weight on a chair that can roll or slide, they fall. The facility's own competency documentation acknowledged this. CNA 4 had been assessed on it months earlier and cleared.
The Director of Nursing's response after the fall was retraining, the same intervention the facility had already used before the fall occurred. The March checklist was the proof of that prior training, and the August fracture was the proof of what followed it.
Inspectors tagged the violation under F0689, the federal citation covering the obligation to keep residents free from accidents the facility could reasonably prevent. The harm level was marked actual, not potential. Resident 7 did not narrowly avoid injury. The injury happened.
The facility provided no additional information and offered no explanation for the delay in identifying the cause of the fall before inspectors arrived and asked.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Nhc Healthcare, Bristol from 2025-08-20 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
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Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: October 27, 2026 · Our methodology
NHC HEALTHCARE, BRISTOL in BRISTOL, VA was cited for violations during a health inspection on August 20, 2025.
Federal inspectors classified the violation as causing actual harm.
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.