Holston Rehab: Care Quality Deficiencies - TN
The resident noticed something was wrong on February 8th when she found a black card lying on her bedside table that she couldn't immediately reach. When she finally retrieved it the next day, she recognized it as her ordination card that allows her to perform marriages.
That card is usually kept in her purse.
She checked her wallet and discovered her debit card and two credit cards were missing.
The resident, identified in inspection records as Resident 43, was cognitively intact according to her admission assessment. She scored a 15 on the Brief Interview for Mental Status, indicating full mental capacity to understand what had happened to her belongings.
She reported the theft to the Director of Nursing on February 10th. The facility immediately suspended Certified Nursing Assistant V pending investigation.
The nursing assistant had been identified as a possible suspect.
During the facility's internal investigation, administrators confirmed that CNA V had taken the cards without the resident's permission and used them to make unauthorized purchases. The total amount stolen was $23.11.
The facility terminated CNA V on February 27th for misappropriation of resident property.
Holston Rehabilitation reimbursed the resident for her stolen funds. A receipt dated February 26th documented the $23.11 repayment, one day before the nursing assistant's termination.
During a September interview with federal inspectors, the resident confirmed the details of the theft. She stated that the facility CNA took her debit card and two credit cards without her permission and stole $23.11.
The facility Administrator confirmed during a separate interview that the allegation of misappropriation had been substantiated. The Administrator stated that CNA V was responsible for taking the resident's property and that the facility had reimbursed the $23.11 to the victim.
The resident had been admitted to Holston Rehabilitation with diagnoses including hereditary and idiopathic neuropathy, respiratory disorders, and muscle wasting and atrophy. Despite her physical conditions, her mental faculties remained sharp enough to notice when her personal belongings had been disturbed.
The ordination card that tipped her off to the theft was an unusual personal item that held special meaning. The fact that it had been moved from its usual place in her purse and left on her bedside table suggested the nursing assistant had been searching through her personal belongings.
Federal regulations require nursing homes to protect residents from the wrongful use of their belongings or money. 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."
CNA V's actions violated both federal regulations and facility policy.
The theft occurred despite the resident's cognitive awareness and ability to monitor her own possessions. Many nursing home thefts involve residents with dementia or other cognitive impairments who may not notice missing items or be able to report them effectively.
In this case, the resident's mental clarity allowed her to quickly identify that her belongings had been tampered with and to report the crime promptly.
The investigation moved swiftly once the theft was reported. The nursing assistant was suspended the same day the resident reported the missing cards. The facility completed its investigation and terminated the employee within 17 days.
However, the relatively small amount stolen raises questions about how long the nursing assistant might have been taking advantage of residents before being caught. The $23.11 theft could represent just the most recent in a series of smaller unauthorized transactions that went unnoticed.
The facility's response included both disciplinary action against the employee and financial restitution to the victim. The resident was made whole financially, receiving her $23.11 back before the nursing assistant was even terminated.
But the violation of trust remains significant regardless of the dollar amount involved.
Nursing home residents are particularly vulnerable to financial exploitation because they often rely on staff for basic care and may have limited ability to monitor their personal belongings. Many residents keep cash, credit cards, and other valuables in their rooms because they have nowhere else to secure them.
The incident at Holston Rehabilitation demonstrates how even cognitively intact residents can become victims of staff theft. The resident's ordination card, which held personal and professional significance as documentation of her authority to perform marriages, was carelessly discarded on her bedside table after the nursing assistant rifled through her purse.
The fact that CNA V left evidence of the search suggests either carelessness or confidence that the theft would go unnoticed.
The resident's quick detection and reporting of the crime prevented what could have been ongoing financial exploitation. Her mental sharpness and attention to her personal belongings served as her primary protection against further theft.
Federal inspectors found that Holston Rehabilitation had failed to protect the resident from misappropriation, despite the facility's eventual response to investigate and terminate the responsible employee.
The violation was classified as causing minimal harm or potential for actual harm, but it affected the resident's fundamental right to security of her personal property while receiving care at the facility.
The resident confirmed to inspectors that she had been reimbursed for her losses, but the breach of trust and violation of her personal space represented damages that could not be easily repaired with a $23.11 check.
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.
The resident noticed something was wrong on February 8th when she found a black card lying on her bedside table that she couldn't immediately reach.
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.