KINGSPORT, TN - Federal health inspectors identified nine deficiencies at Holston Rehabilitation and Care Center following a complaint investigation completed on November 17, 2025, including a citation for failing to provide appropriate treatment in accordance with physician orders and resident preferences.
Treatment and Care Order Violations
The inspection, triggered by a formal complaint, found that Holston Rehabilitation and Care Center did not consistently provide appropriate treatment and care according to established orders, resident preferences, and individual care goals. The deficiency was cited under federal regulatory tag F0684, which requires nursing homes to ensure that each resident receives the treatment and care outlined in their individualized plan of care.
The violation was classified at Scope/Severity Level D, meaning inspectors identified an isolated instance where no actual harm occurred but determined there was potential for more than minimal harm to residents. While this classification falls below the most severe categories, it signals a breakdown in processes meant to protect vulnerable individuals receiving skilled nursing care.
When a facility fails to follow established care orders, residents face real clinical risks. Physician orders exist for specific medical reasons — they may dictate medication schedules, wound care protocols, mobility assistance requirements, or dietary restrictions. Deviations from these orders, even in a single instance, can lead to adverse outcomes including medication interactions, delayed healing, increased fall risk, or nutritional deficits.
What Federal Standards Require
Under federal regulations governing Medicare- and Medicaid-certified nursing facilities, providers must ensure that each resident receives treatment and services that are consistent with professional standards of practice. This includes following physician orders accurately, respecting resident preferences as documented in their care plan, and working toward individualized goals established during the care planning process.
The standard under F0684 is fundamental to nursing home operations. Facilities are expected to maintain systems that ensure care orders are communicated clearly to staff, carried out as prescribed, and documented appropriately. When these systems fail, it often points to broader organizational issues such as insufficient staff training, communication gaps during shift changes, or inadequate oversight by nursing supervisors.
According to established clinical protocols, any change in a resident's condition or deviation from a care plan should trigger immediate reassessment by qualified nursing staff and, when appropriate, notification of the attending physician. Facilities must maintain processes to verify that ordered treatments are being delivered correctly and on schedule.
Nine Total Deficiencies Identified
The care order violation was one of nine deficiencies documented during the inspection, suggesting a pattern of regulatory non-compliance at the Kingsport facility. While the full scope of all citations was not detailed in the publicly available narrative for this particular tag, the volume of findings during a single complaint investigation is notable.
For context, the national average number of deficiencies per nursing home inspection is approximately seven to eight, according to data from the Centers for Medicare & Medicaid Services. Holston Rehabilitation and Care Center's nine citations place it slightly above that benchmark, particularly significant given that this was a complaint-driven investigation rather than a routine annual survey.
Complaint investigations are initiated when specific concerns are reported to state survey agencies, meaning inspectors were already focused on potential problem areas when they arrived at the facility.
Facility Response and Correction Timeline
Holston Rehabilitation and Care Center reported correcting the deficiency as of December 5, 2025, approximately 18 days after the inspection date. The facility's status was listed as "deficient, provider has date of correction," indicating that a plan of correction was submitted and accepted by regulators.
A plan of correction typically requires the facility to outline specific steps taken to remedy the cited deficiency, measures implemented to prevent recurrence, and a system for monitoring ongoing compliance. State survey agencies may conduct follow-up visits to verify that corrections have been effectively implemented.
Residents and families seeking complete details about all nine deficiencies cited during this inspection can access the full inspection report through the CMS Care Compare website or by contacting the Tennessee Department of Health's Division of Health Care Facilities.
Holston Rehabilitation and Care Center is a skilled nursing facility located in Kingsport, a city in the Tri-Cities region of northeastern Tennessee. The facility participates in both Medicare and Medicaid programs and is subject to regular federal oversight and periodic inspection surveys.
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.
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