Holston Rehab: Care Plan Failures Found - TN
The theft at Holston Rehabilitation and Care Center unfolded over several days in February 2025, with the resident discovering the crime only after finding her ordination card mysteriously moved from her purse to her bedside table.
Resident 43, who scored a 15 on cognitive testing indicating she was mentally intact, had been admitted to the facility with diagnoses including hereditary neuropathy, respiratory disorders, and muscle wasting. She lived at the facility with her personal belongings secured in her room, including the purse that contained her financial cards.
On February 8, 2025, the resident noticed something odd on her bedside table. A black card lay there that she couldn't immediately retrieve. When she finally got hold of it the next day, she realized it was her ordination card that allowed her to perform marriages.
The discovery troubled her. The card belonged in her purse, where she always kept it.
She checked her purse. Her debit card was gone. So were two credit cards.
The resident reported the theft to the Director of Nursing on February 10, 2025. The DON immediately notified the facility administrator, and the facility launched an investigation that same day.
Within hours, investigators had identified a suspect: Certified Nursing Assistant V, who had access to the resident's room. The facility suspended the CNA pending the investigation.
The investigation continued for more than two weeks. On February 27, 2025, the facility concluded that CNA V was responsible for the theft and terminated the employee for misappropriation of resident property.
The facility reimbursed the resident $23.11 on February 26, 2025, one day before the CNA's termination. A receipt documented the repayment of the stolen funds.
When federal inspectors interviewed the resident in September 2025, seven months after the theft, she confirmed that the nursing assistant had taken her cards without permission and stolen the money. She also confirmed that the facility had reimbursed her for the loss.
The facility administrator, interviewed the same day, confirmed that the investigation had substantiated the allegation of misappropriation. The administrator stated that CNA V was responsible for stealing from Resident 43 and that the facility had reimbursed the $23.11.
The case highlighted vulnerabilities that exist even when residents maintain their mental faculties. Resident 43's cognitive testing showed she was fully capable of managing her affairs and recognizing when something was amiss. Her sharp observation that her ordination card had been moved led to the discovery of the larger theft.
The theft occurred despite facility policies designed to prevent such incidents. The facility's policy on abuse, neglect, and misappropriation defined such crimes as "the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent."
The nursing assistant's method suggested familiarity with the resident's routines and belongings. Moving the ordination card from the purse to the bedside table may have been an attempt to make the theft less obvious, but it backfired by alerting the resident that someone had been in her personal items.
The investigation moved quickly once the theft was reported. The facility identified and suspended the suspect within hours and completed its investigation in 17 days. The termination followed one day after the facility reimbursed the resident.
Federal inspectors found the facility had failed to protect the resident from misappropriation, citing the violation under regulations requiring nursing homes to safeguard residents' belongings and money. The citation noted minimal harm or potential for actual harm.
The case was one of 22 residents reviewed by inspectors for potential misappropriation, with Resident 43 being the only confirmed victim found during the inspection.
The resident's quick detection of the crime may have prevented larger losses. Her attention to detail in noticing the displaced ordination card and checking her purse immediately led to the discovery and reporting of the theft.
The facility's response included immediate suspension of the suspected employee and full reimbursement of the stolen amount. However, the fact that a nursing assistant with direct access to residents could take financial cards and use them raised questions about oversight and security measures for residents' personal property.
The theft amount of $23.11 was relatively small, but the violation of trust was significant. Nursing home residents depend on staff for daily care and must trust employees with access to their most personal spaces and belongings.
For Resident 43, the ordination card that led to discovering the theft held special meaning as a credential allowing her to perform marriage ceremonies. Its misplacement served as the crucial clue that exposed the larger crime against her financial security.
The terminated nursing assistant's actions violated both facility policy and federal regulations designed to protect some of society's most vulnerable individuals from exploitation by those entrusted with their care.
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: June 20, 2026 · Our methodology
HOLSTON REHABILITATION AND CARE CENTER in KINGSPORT, TN was cited for violations during a health inspection on November 17, 2025.
She lived at the facility with her personal belongings secured in her room, including the purse that contained her financial cards.
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.