Holston Rehab: Care Planning Failures Cited - TN
Resident 43 discovered the theft on February 8, 2025, when she spotted the black card that authorized her to perform marriages sitting on her table instead of safely tucked in her purse where she always kept it. When she retrieved the card the next day, she realized her financial cards were missing.
The 15-year facility veteran had scored a perfect 15 on her cognitive assessment, indicating she was mentally sharp and fully aware of her surroundings. She knew exactly where she kept her belongings.
Federal inspectors found that Holston Rehabilitation and Care Center failed to protect the resident from theft when they reviewed the case during a November 2025 complaint investigation. The facility's own policy defines misappropriation as "the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent."
That's exactly what happened here.
The Director of Nursing launched an investigation immediately after the resident reported the missing cards on February 10. The facility moved quickly, suspending CNA V the same day after identifying the nursing assistant as a suspect.
The investigation took 17 days. On February 27, the facility fired CNA V for stealing resident property.
During a September interview with federal inspectors, the resident confirmed the details: her debit card and two credit cards were taken without permission, and $23.11 was stolen from her accounts. The facility reimbursed her for the stolen money, providing a receipt dated February 26.
The Administrator confirmed to inspectors that the facility substantiated the theft allegation. CNA V was responsible for stealing from the resident's purse.
But the damage extended beyond the modest dollar amount. The resident's sense of security in her own room was violated. Her personal belongings, including the ordination card that held special meaning for her, were rifled through by someone she trusted to provide care.
The theft occurred in what should have been the safest space for the resident – her own room, where she kept her purse with her important documents and financial cards. The ordination card, apparently discarded carelessly on her bedside table, became the evidence that led to discovering the crime.
Federal regulations require nursing homes to protect residents from having their belongings stolen or misused. The facility admitted it failed in this basic responsibility when one of its own employees violated a resident's trust and property.
The resident had been living at Holston since her admission with diagnoses including hereditary neuropathy, respiratory disorders, and muscle wasting. Despite her physical conditions, her mind remained completely clear – clear enough to notice when something wasn't right with her belongings.
CNA V had access to the resident's room as part of providing daily care. That access became an opportunity for theft.
The facility's investigation process worked as designed in this case. The theft was reported, investigated, and resulted in termination within 17 days. The resident was reimbursed for her losses.
But the case raises questions about how many similar incidents might go undetected when residents are less cognitively aware or when stolen items aren't as obviously displaced as an ordination card left sitting in plain sight.
The inspection report doesn't detail what specific evidence led to CNA V's termination or whether the nursing assistant admitted to the theft. It also doesn't explain how the stolen money was tracked or recovered, or whether any criminal charges were filed.
What's clear is that a resident who trusted the facility to keep her safe had that trust broken by the very person hired to care for her. The $23.11 represents more than pocket change – it represents a fundamental violation of the relationship between caregiver and patient.
The facility policy explicitly prohibits this type of behavior. Every employee should understand that taking resident property without permission is grounds for immediate termination.
Yet it happened anyway.
The resident's sharp observation skills and the distinctive nature of her ordination card led to catching this theft. Other residents might not be so fortunate. Those with cognitive impairments might not notice missing items or might not be believed if they report them.
The February incident occurred during what should have been routine care. The nursing assistant had legitimate reasons to be in the resident's room and near her personal belongings. That legitimate access became criminal when CNA V decided to take what didn't belong to them.
Holston Rehabilitation and Care Center ultimately did the right thing by investigating thoroughly and firing the employee responsible. The facility also made the resident financially whole by reimbursing the stolen money.
But the resident will likely remember this violation long after the $23.11 was repaid. She'll remember finding her ordination card where it didn't belong and realizing someone had been through her purse without permission.
The federal inspection classified this as causing "minimal harm or potential for actual harm." For the resident whose trust was violated and whose personal space was invaded, the harm likely felt much more significant than minimal.
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.
When she retrieved the card the next day, she realized her financial cards were missing.
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.