KINGSPORT, TN - Federal health inspectors identified respiratory care deficiencies at Holston Rehabilitation and Care Center following a complaint investigation completed on November 17, 2025, one of nine total violations documented during the inspection.
Respiratory Care Deficiency Raises Safety Concerns
The Centers for Medicare & Medicaid Services (CMS) cited the facility under regulatory tag F0695, which requires nursing homes to provide safe and appropriate respiratory care for residents who need it. The citation falls under the broader category of Quality of Life and Care Deficiencies, a classification that encompasses some of the most fundamental obligations nursing facilities owe to the people in their care.
Inspectors assigned the violation a Scope/Severity Level D, indicating an isolated incident where no actual harm was documented but where the potential existed for more than minimal harm to residents. While Level D represents one of the lower severity classifications on the CMS enforcement scale, respiratory care failures carry inherent medical risks that warrant close attention.
Respiratory care in long-term care settings encompasses a range of critical services, including oxygen therapy administration, nebulizer treatments, ventilator management, suctioning, and monitoring of residents with chronic pulmonary conditions. When these services are not delivered safely and appropriately, residents face elevated risks of oxygen deprivation, respiratory distress, aspiration pneumonia, and in the most serious cases, respiratory failure.
Medical Context for Respiratory Standards
Nursing home residents are disproportionately vulnerable to respiratory complications. Many residents in skilled nursing facilities have conditions such as chronic obstructive pulmonary disease (COPD), congestive heart failure, or neuromuscular disorders that compromise their ability to breathe independently. These residents depend on facility staff to manage their respiratory equipment correctly, monitor oxygen saturation levels, and respond promptly to changes in respiratory status.
Proper respiratory care protocols require that staff members receive specialized training in the operation and maintenance of respiratory equipment. Oxygen delivery systems must be set to physician-prescribed flow rates, tubing must be changed at regular intervals to prevent bacterial colonization, and equipment must be cleaned according to manufacturer specifications. Nebulizer treatments must be administered at prescribed intervals with correct medication dosages.
When facilities fail to follow these protocols, the consequences can escalate rapidly. A resident receiving insufficient oxygen may experience confusion, elevated heart rate, and tissue damage. Conversely, excessive oxygen delivery can suppress the respiratory drive in residents with COPD, potentially leading to carbon dioxide retention and respiratory arrest.
Nine Deficiencies Signal Broader Compliance Issues
The respiratory care citation was one of nine deficiencies identified during the complaint investigation at Holston Rehabilitation and Care Center. While the specific details of each additional citation were not included in this particular report, the volume of findings during a single inspection suggests the facility faced compliance challenges across multiple areas of resident care and facility operations.
A complaint investigation, as opposed to a routine annual survey, is triggered when state or federal agencies receive reports of potential problems at a facility. The fact that inspectors found nine separate deficiencies during such an investigation indicates that the concerns prompting the complaint may have reflected broader operational issues.
Correction Timeline and Oversight
The facility has been classified as "Deficient, Provider has date of correction" and reported that corrections were implemented as of December 5, 2025, approximately 18 days after the inspection date. This timeline suggests the facility acknowledged the findings and took steps to address the identified deficiencies.
Under federal regulations, facilities that fail to correct cited deficiencies within established timeframes face escalating enforcement actions, which can include civil monetary penalties, denial of payment for new admissions, and in the most serious cases, termination from the Medicare and Medicaid programs.
Holston Rehabilitation and Care Center serves the Kingsport community in northeastern Tennessee. Families with loved ones in the facility or those considering placement can review the complete inspection findings, including all nine citations, through the CMS Care Compare database at medicare.gov/care-compare.
The full inspection report provides detailed accounts of each deficiency, including specific observations made by inspectors during their on-site investigation.
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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