Holston Rehab: Resident Harm, Safety Hazards - TN
The incident at Holston Rehabilitation and Care Center involved Resident 43, who was admitted with diagnoses including hereditary neuropathy, respiratory disorders, and muscle wasting. An assessment showed she scored 15 on a cognitive test, indicating she was mentally intact.
The theft came to light in an unusual way. On February 10, 2025, the resident told the Director of Nursing that two nights earlier she had noticed a black card lying on her bedside table. She couldn't retrieve it until the next day, when she realized it was her ordination card that allowed her to perform marriages.
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, and the facility launched an investigation. During that investigation, Certified Nursing Assistant V was identified as a possible suspect and suspended on February 10, 2025.
The facility's investigation substantiated the theft. CNA V was terminated on February 27, 2025, for misappropriation of resident property.
A receipt dated February 26, 2025, showed the facility reimbursed Resident 43 for the stolen funds.
When federal inspectors interviewed the resident in September, she confirmed that the nursing assistant had taken her debit card and two credit cards without permission and stolen $23.11. She said the facility had reimbursed her for the theft.
The Administrator confirmed to inspectors that the facility had substantiated the misappropriation allegation. The Administrator stated the facility reimbursed the $23.11 to Resident 43 and confirmed that CNA V was responsible for stealing the resident's property.
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."
The case represents a violation of federal requirements that nursing homes protect residents from wrongful use of their belongings or money. Federal inspectors cited the facility for failing to protect the resident's rights when the employee took her cards and used them without permission.
The theft occurred despite the resident being cognitively intact and aware of her belongings. Her discovery of the misplaced ordination card led to uncovering the missing payment cards, suggesting the nursing assistant may have been careless in handling the resident's personal items.
The facility's investigation took more than two weeks from the initial report to the employee's termination. CNA V remained suspended during this period while administrators gathered evidence to substantiate the theft.
Federal inspectors found this was an isolated incident, noting that only one of 22 residents reviewed showed evidence of misappropriation. However, the violation demonstrates how nursing home employees with access to residents' rooms and personal belongings can exploit vulnerable patients.
The resident's ordination card, which qualified her to perform marriage ceremonies, proved to be the key evidence that exposed the theft. Without noticing this card had been moved from her purse to her bedside table, she might not have discovered the missing payment cards.
The facility did reimburse the resident for her financial loss, though the amount was relatively small. The theft represents a breach of trust between the resident and the nursing assistant responsible for her care.
Nursing assistants typically have regular access to residents' rooms for daily care activities, putting them in positions where they can access personal belongings. This case shows how that access can be misused, even when residents are mentally capable of tracking their possessions.
The timing of the discovery also raises questions about how long the cards had been missing before the resident noticed. She only became aware of the theft when she found her ordination card in an unexpected location.
Federal regulations require nursing homes to have policies protecting residents from misappropriation, and Holston Rehabilitation had such a policy in place. However, policies cannot prevent determined employees from stealing from residents when they have unsupervised access to personal belongings.
The case concluded with the nursing assistant's termination and the resident's reimbursement, but it illustrates the ongoing vulnerability of nursing home residents to theft by staff members who are supposed to care for them.
Resident 43's cognitive clarity allowed her to detect and report the theft, but many nursing home residents with dementia or other cognitive impairments might not notice missing items or be able to report them effectively.
The facility's investigation ultimately protected the resident from further theft and removed the offending employee, but the incident had already violated the resident's right to security of her personal property.
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.
An assessment showed she scored 15 on a cognitive test, indicating she was mentally intact.
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.