Holston Rehab: Resident Property Misuse Cited - TN
The resident discovered the theft on February 8, 2025, when she found an unusual black card on her bedside table. She recognized it as an ordination card that authorized her to perform marriages — something that belonged in her purse, not lying loose on her nightstand.
When she checked her purse the next day, her debit card and two credit cards were missing.
The resident was cognitively intact, scoring 15 out of 15 on a mental status assessment administered during her admission. She had been living at the facility since her arrival with diagnoses including hereditary neuropathy, respiratory disorders, and muscle wasting.
She reported the missing cards to the Director of Nursing on February 10. The nursing director immediately notified the facility administrator, and the facility launched an investigation the same day.
During the investigation, administrators identified Certified Nursing Assistant V as a suspect. The facility suspended the employee on February 10 while the investigation continued.
The facility's inquiry revealed that CNA V had taken the resident's financial cards without her knowledge or consent. Investigators substantiated the misappropriation allegation and terminated the nursing assistant on February 27, seventeen days after the initial suspension.
A receipt dated February 26 showed the facility reimbursed the resident for the stolen funds before the employee's termination was finalized.
During a September interview with federal inspectors, the resident confirmed that the nursing assistant had taken her debit card and two credit cards without permission. She verified that $23.11 had been stolen and that the facility had reimbursed her for the loss.
The administrator told inspectors in September that the facility had substantiated the theft allegation against the resident. The administrator confirmed that CNA V was responsible for taking the resident's property and that the facility had reimbursed the $23.11 to the victim.
The case represents a violation of federal regulations requiring nursing homes to protect residents from 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."
The theft occurred despite the resident's cognitive capacity to manage her own affairs and recognize when her possessions had been disturbed. Her discovery of the misplaced ordination card led her to check her purse, where she noticed the missing financial cards.
The investigation process took more than two weeks from the initial report to the employee's termination. The facility suspended the suspected nursing assistant immediately upon identification but continued gathering evidence before making a final determination.
Federal inspectors found that the facility failed to protect the resident from misappropriation, citing minimal harm or potential for actual harm in their violation notice. The inspection occurred in response to a complaint filed with state regulators.
The resident's case was among 22 resident files reviewed by inspectors for potential misappropriation issues. Inspectors found violations affecting only this single resident during their review of facility practices and protections.
The nursing assistant's access to the resident's personal belongings raised questions about supervision and security protocols within the facility. The theft occurred in the resident's private room, where her purse was apparently accessible to staff members during care activities.
The resident's ordination card, which qualified her to perform marriage ceremonies, served as the inadvertent evidence that led to discovering the financial theft. Had she not noticed the card's unusual placement on her nightstand, the missing credit and debit cards might have gone undetected longer.
The facility's reimbursement to the resident preceded the formal termination of the nursing assistant by one day. This timing suggests administrators had concluded their investigation and determined the employee's guilt before completing the disciplinary process.
The $23.11 theft amount, while relatively small, represented a clear violation of the resident's rights and the facility's duty to protect vulnerable individuals from exploitation by caregivers. Federal regulations make no distinction based on the monetary value of misappropriated property.
The resident's cognitive integrity meant she could clearly articulate what had happened and participate fully in the investigation process. Her 15-out-of-15 score on the mental status assessment demonstrated she had complete awareness of her surroundings and possessions.
The case illustrates how nursing home residents remain vulnerable to theft by staff members who have regular access to their personal spaces and belongings. Even cognitively intact residents depend on facility policies and supervision to prevent exploitation by employees entrusted with their care.
The facility's investigation ultimately protected other residents by removing an employee who had demonstrated willingness to steal from vulnerable individuals. The termination sent a clear message about consequences for misappropriating resident property, regardless of the amount involved.
The resident's quick recognition that something was wrong with her possessions' placement enabled the facility to identify and address the theft promptly. Her attention to detail and memory of where she kept important items proved crucial in detecting the nursing assistant's unauthorized access to her financial cards.
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 5, 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 discovered the theft on February 8, 2025, when she found an unusual black card on her bedside table.
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.