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Complaint Investigation

Asbury Health And Rehabilitation Center

September 30, 2025 · Charlotte, NC · 3211 Bishops Way Lane
Citations 5
CMS Rating 2/5
Beds 120
Provider ID 345544
Healthcare Facility
Asbury Health And Rehabilitation Center
Charlotte, NC  ·  View full profile →
Inspection Summary

Asbury Health and Rehabilitation Center in Charlotte, NC — inspection on September 30, 2025.

Found 5 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF0550
Resident Rights Deficiencies
Potential for More Than Minimal Harm

Federal health inspectors cited Asbury Health and Rehabilitation Center in Charlotte, NC for a deficiency under regulatory tag F-F0550 during a standard health inspection conducted on 2025-09-30.

Category: Resident Rights Deficiencies

The facility was found deficient in the following area: Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 5 deficiencies cited during this inspection of Asbury Health and Rehabilitation Center.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-11.

Federal health inspectors cited Asbury Health and Rehabilitation Center in Charlotte, NC for a deficiency under regulatory tag F-F0607 during a standard health inspection conducted on 2025-09-30.

Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies

The facility was found deficient in the following area: Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 5 deficiencies cited during this inspection of Asbury Health and Rehabilitation Center.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-11.

interventions would be implemented prior to her discharge to the hospital on 8/31/25.

She stated on 9/07/25 after Resident #79 returned to the facility the family was requesting more information as to how the fracture occurred.

She indicated NA #1 reported NA #2 assisted with transferring Resident #79 the morning of 8/30/25 however NA #2 really would not say that she did or did not assist with the transfer.

The DON revealed she did not investigate the inconsistent statements from NA #1 and NA #2 but that it was suspected that NA #1 transferred Resident #79 using the mechanical lift alone.

She stated even if NA #1 transferred Resident #79 alone, she denied an incident occurred resulting in injury and the cause of Resident #79's fracture remained inconclusive.

The DON stated that staff should have a second person assisting when using the mechanical lift to transfer a resident for safety. An interview conducted with the Administrator on 9/25/25 at 11:23 AM revealed she was notified on 8/31/25 at approximately 7:00 AM that Resident #79 was transferred to the hospital due to a femur fracture.

She stated the cause of the injury was unknown and the DON initiated an investigation to determine if an incident or accident had occurred.

The Administrator indicated the inconsistent statements given by NA #1 and NA #2 should have been investigated further and that transferring a resident using the mechanical lift without a second person was not safe.

The Administrator indicated Resident #79 also had several incidents involving the motorized wheelchair and there was question if she had run into something while driving her chair that caused the injury.

The Administrator revealed the cause of Resident #79's leg fracture was still unknown.

Facility ID:

Federal health inspectors cited Asbury Health and Rehabilitation Center in Charlotte, NC for a deficiency under regulatory tag F-F0761 during a standard health inspection conducted on 2025-09-30.

Category: Pharmacy Service Deficiencies

The facility was found deficient in the following area: 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.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 5 deficiencies cited during this inspection of Asbury Health and Rehabilitation Center.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-11.

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Federal health inspectors cited Asbury Health and Rehabilitation Center in Charlotte, NC for a deficiency under regulatory tag F-F0812 during a standard health inspection conducted on 2025-09-30.

Category: Nutrition and Dietary Deficiencies

The facility was found deficient in the following area: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 5 deficiencies cited during this inspection of Asbury Health and Rehabilitation Center.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-02.

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Charlotte, NC, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Asbury Health and Rehabilitation Center or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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