Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Asbury Health And Rehabilitation Center during CMS and state inspections, most recent first.
A facility failed to ensure a nurse received updated training on glucometer disinfection, leading to improper cleaning between resident use. The nurse, working on a PRN basis, missed recent training sessions, resulting in a lack of knowledge about the disinfection process. This deficiency was identified during observations and interviews, highlighting the risk of spreading bloodborne infections due to inadequate staff training.
A nurse failed to disinfect a shared glucometer between uses on two residents, contrary to the manufacturer's instructions and facility policy. The nurse used an alcohol swab instead of the required EPA-approved disinfectant wipes, which are necessary to prevent the spread of bloodborne infections. The nurse admitted to forgetting the procedure and lacked knowledge of the required disinfection times, indicating a gap in training. This deficiency was identified as an immediate jeopardy situation.
The facility failed to label and date leftover food items in storage areas and resident refrigerators. Observations revealed expired and unlabeled food, including pasta, pork, and various resident food items. The Executive Chef and Dietary Manager acknowledged the oversight, and the Administrator expected proper labeling and disposal of expired items.
A resident, who was cognitively intact, was not invited to participate in their care plan meetings at the facility. Despite having adequate hearing and being readmitted, there was no evidence of their involvement or refusal in the care planning process. Interviews with staff revealed a failure to adhere to protocols for inviting residents to these meetings, with assumptions made about the resident's disinterest due to hearing difficulties, but without proper documentation.
A facility failed to obtain a signed Notice of Medicare Non-Coverage (NOMNC) from a resident before discharge from Medicare Part A services, despite having benefit days remaining. The resident was discharged a day early due to a holiday, and the NOMNC was signed by a social worker with a statement indicating the notice was waived. The social worker attempted to have the form signed, but the resident wanted to discuss the early discharge with her husband. The facility administrator expected a physical or verbal signature from the resident or their representative.
A facility failed to complete a comprehensive MDS assessment within 14 days of the ARD for a resident. The resident's annual MDS assessment was not signed as completed by the required deadline. Interviews with the MDS Coordinator and DON confirmed the assessment was missed and still in progress. Both the DON and Administrator expected timely completion of all MDS assessments.
Expired acetaminophen suppositories were found in the Windsor medication room's refrigerator. A nurse responsible for checking the refrigerator admitted to missing the expiration date, as the medication had not been used recently. The DON and Administrator confirmed that expired medications should have been discarded and expected daily checks by nursing staff.
Deficiency in Glucometer Disinfection Training
Penalty
Summary
The facility failed to ensure that Nurse #1 received the most recent training on blood glucose monitors, leading to a deficiency in her competency. Nurse #1 did not follow the manufacturer's instructions for cleaning and disinfecting a shared blood glucose meter between two residents. During an interview, Nurse #1 admitted to knowing the requirement to use disinfectant wipes but forgot due to nervousness. She also lacked knowledge of the wet and dry times for the disinfectant wipes, which are crucial for proper disinfection. The deficiency was identified during observations, record reviews, and staff interviews, revealing that Nurse #1 had not attended the most recent training session on glucometer disinfection conducted in May 2024. Although she had received training in 2023, her PRN status and infrequent work schedule contributed to her missing the latest training. The Director of Nursing and the Infection Preventionist acknowledged that PRN staff like Nurse #1 might be overlooked in training sessions, which led to her lack of updated knowledge on the disinfection process. The facility's failure to ensure that all nursing staff, including PRN staff, received necessary training on infection control practices, specifically the disinfection of shared medical equipment, posed a potential risk for the spread of bloodborne infections. Although no residents with bloodborne pathogens were present at the time, the improper disinfection of glucometers between resident use could have led to serious health risks. The deficiency was noted for 2 of 4 residents whose blood sugar levels were checked, highlighting the need for consistent and comprehensive training for all staff members.
Removal Plan
- The nurse found to be non-compliant with the glucometer disinfection process was re-educated with return demonstration.
- All nurses in the building at the time of the observation of non-compliance were re-educated with return demonstration.
- All nursing staff that do (or could) perform glucose monitoring will be in-serviced on the glucometer disinfection process before being allowed to work.
- All staff members will have a skills validation performed to ensure they can perform the disinfection appropriately.
- Any staff that do not receive the education and skills validation will not be allowed to work until they are compliant with the educational training.
- Compliance will be monitored by the Assistant Director of Nursing/Staff Development Coordinator and/or the Infection Preventionist nurse.
- All new hires for the nursing team that do (or could) perform glucose monitoring will be educated at hire with a skills competency performed on the glucose monitor disinfection process.
- All staff will be educated with a skills competency performed on the glucose disinfection process on an annual basis.
- Staff members found to be non-compliant with the annual training will not be allowed to return to work until compliance with education is reached.
Failure to Disinfect Shared Glucometer
Penalty
Summary
The facility staff failed to adhere to the manufacturer's instructions for cleaning and disinfecting a shared blood glucose meter between resident uses. This deficiency was observed during a survey when Nurse #1 was seen performing blood glucose checks on two residents without disinfecting the glucometer as per the manufacturer's guidelines. The glucometer was not cleaned with the required EPA-approved disinfectant wipes, which are necessary to prevent the spread of bloodborne infections. Instead, Nurse #1 used an alcohol swab, which is not an acceptable practice according to the facility's policy and the manufacturer's instructions. The facility's policy, revised in May 2024, clearly outlines the procedure for disinfecting glucometers, which includes using two disinfectant wipes to clean and disinfect the device thoroughly, followed by a two-minute air-dry time. However, during the observation, Nurse #1 did not follow these steps and admitted to forgetting the procedure due to nervousness. The nurse also lacked knowledge of the required wet and dry times for the disinfectant wipes, indicating a gap in training and adherence to the facility's infection control protocols. Interviews with the Infection Preventionist and the Director of Nursing revealed that the facility had provided education on glucometer disinfection, but Nurse #1 had not received the recent training. The Infection Preventionist confirmed that the facility did not have dedicated glucometers for each resident, relying instead on staff adherence to disinfection protocols. The Director of Nursing expressed surprise at the non-compliance, as the staff had been trained, and the process had not been an issue previously. The deficiency was identified as an immediate jeopardy situation, highlighting the potential risk of spreading bloodborne pathogens among residents.
Removal Plan
- Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance.
- All residents residing in the building that receive blood glucose monitoring at the time of the observation of non-compliance were identified, especially those that resided in the same household where the non-compliance occurred.
- All residents residing in household two that could have been affected by the deficient practice were seen by the medical provider, with orders received as necessary by the practitioner's assessment.
- All glucometers that are presently in the clinical spaces in the building were disinfected, per policy and manufacturer's recommendations.
- All diagnoses of residents in the building were reviewed to ensure that no one currently has an active diagnosis of a bloodborne pathogen.
- The policy and procedure for glucometer disinfection was reviewed and compared to manufacturer recommendations.
- The nurse found to be non-compliant with the glucometer disinfection process was re-educated with return demonstration, as were all nurses in the building at the time of the observation of non-compliance.
- All nursing staff that do (or could) perform glucose monitoring will be in-serviced on the glucometer disinfection process before being allowed to work.
- All staff members will also have a skills validation performed to ensure that they can perform the disinfection appropriately.
- Any staff that do not receive the education and skills validation will not be allowed to work until they are compliant with the educational training.
- The County Communicable Disease branch was notified of the infection control breach.
- Communication was also provided to the residents affected by the deficient practice and/or their responsible parties.
Improper Labeling and Storage of Food Items
Penalty
Summary
The facility failed to properly label and date leftover food items stored in the dry goods storage area and walk-in cooler, as well as residents' leftover food items in nourishment room refrigerators. During an initial tour of the dry goods storage area and walk-in cooler, it was observed that a bag of bowtie pasta and a metal pan of pork butt were stored past their use-by dates. The Executive Chef acknowledged that staff were responsible for cleaning out expired food items on Mondays, but they had not yet done so on the day of the inspection. Additionally, a tour of the resident common area refrigerators revealed several items that were not labeled with a date or room number, including a bottle of vegetable juice and an ice cream sheet cake. In another refrigerator, items labeled with a room number but lacking a date or name included pre-hardboiled eggs with a foul odor, pears, apples, frozen meals, and a container of coffee ice cream. A carton of heavy whipping cream was also found past its expiration date. The Dietary Manager confirmed that items in the resident refrigerators should be labeled with the resident's name and room number, and that dietary supervisors were expected to check the refrigerators each morning for expired items. The Administrator expressed the expectation that all stored food should be properly labeled and dated, and that expired food should be discarded.
Failure to Involve Resident in Care Plan Meetings
Penalty
Summary
The facility failed to involve a resident in the development and implementation of their person-centered care plan. Resident #9, who was cognitively intact and had adequate hearing, was not invited to participate in care plan meetings. The electronic medical record showed no evidence of the resident's involvement or refusal to participate in these meetings. Despite being readmitted to the facility and having an updated care plan, there was no indication that Resident #9 or their family members were involved in the care planning process. Interviews with facility staff, including the MDS Coordinator, Social Worker, Director of Nursing, and Administrator, revealed a lack of adherence to the protocol of inviting residents to care plan meetings. The Social Worker admitted to scheduling meetings based on family availability and assumed the resident's disinterest due to hearing difficulties. However, there was no documentation to support this assumption or any refusal from the resident. The Director of Nursing and Administrator both emphasized the importance of inviting all residents, regardless of cognitive status, to participate in care plan meetings and documenting any refusal to participate.
Failure to Obtain Signed NOMNC Prior to Discharge
Penalty
Summary
The facility failed to ensure that a Centers for Medicare and Medicaid Services (CMS)-10123 Notice of Medicare Non-Coverage letter (NOMNC) was signed prior to the discharge of a resident from Medicare Part A services, despite having benefit days remaining. This deficiency was identified for one of the three residents reviewed for Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review. The resident in question was admitted under Part A Medicare services and was discharged a day early due to a holiday. The NOMNC letter was not signed by the resident or their responsible party, but instead was signed by a social worker with a statement indicating the notice was waived. The social worker attempted to have the form signed but did not succeed, as the resident wanted to discuss the early discharge with her husband. The facility administrator expected that if a resident could physically sign the NOMNC form, it should be signed, or alternatively, a verbal signature should be obtained from the resident or their representative.
Failure to Complete MDS Assessment Timely
Penalty
Summary
The facility failed to complete a comprehensive Minimum Data Set (MDS) assessment within 14 days of the Assessment Reference Date (ARD) for a resident. The resident was admitted to the facility, and their electronic medical record showed an annual MDS assessment with an ARD that was not signed as completed by the required deadline. Interviews with the MDS Coordinator and the Director of Nursing (DON) confirmed that the assessment had been missed and was still being worked on. The DON and the Administrator both expressed that the expectation was for all MDS assessments to be completed within the appropriate timeframe.
Expired Medications Not Removed from Storage
Penalty
Summary
The facility failed to remove expired medications from the refrigerator in the Windsor medication room, as observed during a survey. Specifically, 81 unopened acetaminophen suppositories with an expiration date of April 2024 were found. Nurse #2, responsible for checking the medication room refrigerator, admitted to missing the expiration date, stating that the medication had not been used for some time, which likely led to the oversight. The Director of Nursing confirmed that the facility follows the expiration dates on packaging and acknowledged that expired medications should have been discarded. The Administrator also stated that the medication should have been discarded and expected nursing staff to check expiration dates daily.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 226 citations issued within 25 miles in the last 12 months — including the 8 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Charlotte
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Shamrock Nursing Center | 0.8 mi | ★★★★★ | 0 | 0 |
| Peak Resources - Charlotte | 1.6 mi | ★★★★★ | 0 | 0 |
| Wilora Lake Healthcare | 2 mi | ★★★★★ | 4 | 0 |
| Redwood Health & Rehab | 2.4 mi | ★★★★★ | 4 | 0 |
| Pelican Health At Charlotte | 3.1 mi | ★★★★★ | 19 | 2 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Asbury Health And Rehabilitation Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.