Holston Rehab: Respiratory Care Failures - TN
The resident noticed something wrong on February 8th when she found a black ordination card lying on her bedside table — a card that allowed her to perform marriage ceremonies and was normally kept safely in her purse.
She couldn't retrieve the card until the next day. When she finally examined it, alarm set in.
The ordination card should have been tucked away with her other important documents. Instead, someone had removed it and left it exposed on her nightstand. Checking her purse, she discovered her debit card and two credit cards were missing.
The resident, identified in inspection records as Resident #43, was cognitively intact according to facility assessments. She scored 15 on the Brief Interview for Mental Status assessment, indicating full mental capacity to understand what had happened to her belongings.
On February 10th, she reported the theft to the facility's Director of Nursing.
The nursing director immediately notified the administrator, and the facility launched an investigation that same day. Within hours, they had identified a suspect: CNA V, one of their certified nursing assistants.
The facility suspended CNA V on February 10th pending the investigation.
For seventeen days, the investigation continued as administrators gathered evidence and interviewed staff. The facility's policy defined misappropriation clearly: "the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent."
On February 27th, the facility reached its conclusion. They had substantiated the allegation against CNA V and terminated the nursing assistant for misappropriating resident property.
The resident had been living at Holston Rehabilitation and Care Center since her admission with diagnoses including hereditary and idiopathic neuropathy, respiratory disorders, and muscle wasting and atrophy. Despite her physical conditions, her mental faculties remained sharp — sharp enough to notice when someone violated her personal space and stole from her.
A receipt dated February 26th showed the facility reimbursed the resident $23.11 for the money stolen from her accounts.
During a September interview with federal inspectors, the resident confirmed the details of the theft. CNA V had taken her debit card and two credit cards without permission and used them to steal $23.11. The facility had reimbursed her after identifying the theft, she said.
The administrator also confirmed the details to inspectors during a September 24th interview. The facility had substantiated the misappropriation allegation against the resident. The $23.11 was reimbursed by the facility. CNA V was responsible for stealing the resident's property.
Federal inspectors found the facility had failed to protect the resident from wrongful use of her belongings and money. The violation affected few residents, but represented a fundamental breach of trust between caregiver and patient.
The theft occurred despite facility policies designed to prevent exactly this type of exploitation. The policy explicitly prohibited the deliberate misuse of resident belongings or money without consent, yet CNA V had accessed the resident's purse and removed her financial cards anyway.
For the resident, the violation went beyond the $23.11 taken from her accounts. Someone entrusted with her care had invaded her personal space, gone through her belongings, and stolen from her while she was vulnerable and dependent on facility staff for assistance.
The ordination card left on her nightstand served as evidence of the intrusion — a calling card, intentional or not, that revealed someone had been through her most personal possessions. The card that normally stayed hidden in her purse with her other important documents had been carelessly discarded where she would find it.
The facility's investigation moved quickly once the resident reported the theft, but the damage was already done. CNA V had access to the resident's room, her belongings, and her trust. That access was exploited for personal gain, however small the amount.
The resident's mental clarity made the violation particularly stark. This was not a case of someone taking advantage of cognitive impairment or confusion. The resident knew exactly what belonged to her, where she kept it, and when it went missing. Her score of 15 on the mental status assessment confirmed her capacity to understand and report what had happened.
The facility ultimately made the resident financially whole, reimbursing the $23.11 taken from her accounts. But the broader violation — the breach of trust, the invasion of privacy, the exploitation of vulnerability — could not be undone with a receipt.
CNA V's termination came more than two weeks after the initial theft, during which time the nursing assistant remained employed by the facility, though suspended from duties. The investigation period allowed the facility to gather evidence and substantiate the allegation, but also meant the perpetrator remained connected to the facility for over half a month after stealing from a resident.
Federal inspectors classified the harm as minimal, but for the resident whose purse was rifled through and whose cards were stolen, the impact was immediate and personal. Her belongings were no longer secure in her own room, and someone she depended on for care had betrayed that dependence for $23.11.
The theft at Holston Rehabilitation and Care Center illustrates how even small amounts of money can represent significant violations when taken from nursing home residents who rely on staff for their daily care and safety.
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.
She couldn't retrieve the card until the next day.
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.