Asbury Health and Rehab: Femur Fracture Investigation Failures - NC
Her family wanted answers. They didn't get them.
The resident, identified in inspection records only as Resident 79, required a mechanical lift for transfers, a piece of equipment that the facility's own director of nursing acknowledged requires two staff members to operate safely. On the morning of August 30, one nursing assistant, identified as NA 1, told investigators that a second nursing assistant, NA 2, had helped with the transfer. NA 2 wouldn't confirm or deny it.
That contradiction sat unresolved for weeks.
The director of nursing, interviewed by inspectors on September 7 after Resident 79 had returned to the facility, acknowledged she had not investigated the conflicting accounts. Her explanation: even if NA 1 had operated the mechanical lift alone, NA 1 denied that any incident had occurred during the transfer. So the director considered the cause of the fracture inconclusive and moved on.
She did not explain how a resident in her care broke a femur bone without a cause being established.
The administrator learned about the hospitalization the morning of August 31, around 7:00 AM. She told inspectors that the director of nursing had opened an investigation to determine whether an accident had taken place. She also acknowledged, plainly, that the conflicting statements from NA 1 and NA 2 should have been investigated further. She agreed that using a mechanical lift without a second person present was unsafe.
Then she offered another possibility. Resident 79 used a motorized wheelchair, and there had been prior incidents involving the chair. Maybe, the administrator suggested, Resident 79 had run into something while driving and that caused the fracture.
By the time inspectors completed their review on September 25, the cause of Resident 79's leg fracture was still listed as unknown.
Federal inspectors cited the facility under F0689, which covers the obligation to protect residents from accidents the facility has the means to prevent. The citation was tagged at actual harm, meaning inspectors determined Resident 79 had already been hurt, not that she might be someday.
What the inspection record shows is a facility that had two employees give contradictory accounts of a transfer that preceded a serious injury, and a director of nursing who acknowledged the inconsistency, acknowledged the safety requirement for two-person lifts, and still chose not to press either employee further. The investigation, such as it was, concluded that the cause was unknown and stopped there.
Resident 79's family was left asking questions the facility hadn't tried to answer. She had come back from the hospital with a healed fracture and no explanation. The staff member who may have transferred her alone denied anything went wrong. The staff member who may have helped couldn't say whether she was there. The director of nursing found that sufficient.
The administrator did not.
In her interview with inspectors, the administrator said the inconsistencies should have been pursued. She did not say they would be.
CITATION: F0689, Actual Harm, Complaint Inspection, September 30, 2025.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Asbury Health and Rehabilitation Center from 2025-09-30 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.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 12, 2026 · Our methodology
Asbury Health and Rehabilitation Center in Charlotte, NC was cited for violations during a health inspection on September 30, 2025.
On the morning of August 30, one nursing assistant, identified as NA 1, told investigators that a second nursing assistant, NA 2, had helped with the transfer.
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.