Holston Rehab: Infection Control Failures - TN
The incident at Holston Rehabilitation and Care Center involved Resident 43, a cognitively intact woman who scored 15 on her mental status assessment, indicating full cognitive function. She had been admitted with diagnoses including hereditary neuropathy, respiratory disorders, and muscle wasting.
The theft came to light in an unusual way. On February 10, 2025, the resident told the Director of Nursing that two nights earlier, around February 8, she had noticed a black card lying on her bedside table. She couldn't retrieve it immediately, but when she finally picked it up the next day, she realized it was her ordination card that allowed her to marry people.
The resident found this strange because the card was normally kept in her purse.
When she checked her purse, she discovered her debit card and two credit cards were missing.
The Director of Nursing immediately notified the facility Administrator about the alleged theft. The facility launched an investigation the same day. During their inquiry, administrators identified CNA V as a possible suspect and suspended the nursing assistant on February 10 pending the investigation.
The facility's investigation took over two weeks to complete. On February 27, 2025, administrators substantiated the theft allegation and terminated CNA V for misappropriation of resident property.
A receipt dated February 26, 2025 showed that Resident 43 was reimbursed for her personal funds that were stolen.
During a September interview with federal inspectors, the resident confirmed that the facility nursing assistant had taken her debit card and two credit cards without permission, stealing $23.11. She also confirmed that the facility had reimbursed her for the stolen money after the theft was identified.
The Administrator told inspectors in a separate interview that the facility had substantiated the misappropriation allegation against Resident 43. The Administrator confirmed that the facility reimbursed the $23.11 to the resident and that CNA V was responsible for stealing the resident's property.
The case illustrates how theft can occur even when residents are cognitively intact and aware of their belongings. Resident 43's mental status score of 15 on the Brief Interview for Mental Status assessment indicated she was fully capable of managing her affairs and recognizing when items went missing.
The facility's policy defines misappropriation of resident property as "the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent."
The theft occurred despite the resident keeping her financial cards secured in her purse. The nursing assistant had access to the resident's room and belongings as part of providing care, creating the opportunity for the crime.
The ordination card left on the bedside table appears to have been an oversight by the nursing assistant, providing the crucial evidence that led to discovery of the theft. Without that telltale sign, the resident might not have immediately checked her purse for missing items.
The investigation process took the facility 17 days from the initial report to the employee's termination. During this period, CNA V remained suspended while administrators gathered evidence to substantiate the allegation.
Federal inspectors found that the facility failed to protect the resident's rights to be free from misappropriation when the nursing assistant took the money. The violation was classified as causing minimal harm or potential for actual harm.
The $23.11 theft, while relatively small in dollar amount, represents a serious breach of trust between caregivers and vulnerable residents. Nursing assistants have intimate access to residents' rooms, belongings, and personal spaces as part of providing daily care.
The resident's cognitive integrity made her a reliable witness to the theft, but also highlights how even mentally capable residents can fall victim to employee misconduct. Her ability to notice the displaced ordination card and connect it to missing financial cards demonstrated her awareness and attention to her personal property.
The facility's reimbursement of the stolen funds came one day before the employee's termination, suggesting administrators wanted to make the resident whole before completing their disciplinary action.
This case was among 22 residents reviewed by federal inspectors for potential misappropriation, with Resident 43 being the only confirmed victim identified during the inspection. The review was conducted as part of a complaint investigation at the facility.
The terminated nursing assistant's access to resident rooms and personal belongings as part of routine care duties created the opportunity for the theft. Certified nursing assistants typically help residents with personal care, medication assistance, and daily activities that require entering private spaces.
The resident's ordination credentials, which authorize her to perform marriage ceremonies, were apparently handled along with her financial cards during the theft. The nursing assistant's decision to leave this card on the bedside table rather than returning it to the purse ultimately exposed the crime.
Resident 43 continues to live at the facility after receiving reimbursement for her stolen funds and seeing the responsible employee terminated.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Holston Rehabilitation and Care Center from 2025-11-17 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 4, 2026 · Our methodology
HOLSTON REHABILITATION AND CARE CENTER in KINGSPORT, TN was cited for violations during a health inspection on November 17, 2025.
She had been admitted with diagnoses including hereditary neuropathy, respiratory disorders, and muscle wasting.
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.