Holston Rehab: Waste Disposal Violations - TN
The resident at Holston Rehabilitation and Care Center noticed something wrong on February 8th when she spotted the ordination card lying on her nightstand. She couldn't reach it immediately, but when she finally retrieved it the next day, she realized it was the card that authorized her to perform marriages — a document that belonged inside her purse.
That's when she discovered her financial cards were missing.
The resident, identified in inspection records as Resident 43, scored a 15 on a cognitive assessment at admission, indicating she was mentally intact. She had been admitted to the facility with diagnoses including hereditary neuropathy, respiratory disorders, and muscle wasting.
On February 10th, she reported the theft to the Director of Nursing, explaining that two nights earlier she had found the black card on her table and thought it odd since the card usually stayed in her purse. When she checked her belongings, her debit card and two credit cards were gone.
The facility immediately suspended Certified Nursing Assistant V pending investigation. The administrator was notified the same day the resident reported the missing cards.
Federal inspectors who reviewed the case in November found that the facility had failed to protect the resident from misappropriation of her belongings, a violation that affects residents' fundamental right to security of their personal property.
The investigation moved quickly. Within 17 days, facility administrators had substantiated the allegation and terminated CNA V for misappropriation of resident property on February 27th.
During the investigation, the facility discovered exactly how much money had been taken. A receipt dated February 26th showed that Resident 43 was reimbursed $23.11 for the personal funds that were stolen.
When federal inspectors interviewed the resident in September, nine months after the incident, she confirmed the details. Her debit card and two credit cards had been taken by the nursing assistant without her permission, along with $23.11 in cash. She acknowledged that the facility had reimbursed her for the stolen money after the theft was identified.
The facility administrator also confirmed the findings during a September interview with inspectors. The administrator stated that the allegation of misappropriation had been substantiated and that CNA V was responsible for stealing Resident 43's property. The $23.11 was reimbursed to the resident by the facility.
The case highlights how quickly a trusted caregiver can violate a resident's most basic rights. Nursing assistants have regular access to residents' rooms and personal belongings as part of their daily care duties. The ordination card left behind on the nightstand became the crucial piece of evidence that alerted the resident to check her purse.
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."
The theft occurred despite the resident being cognitively intact and presumably able to monitor her own belongings. Her score of 15 on the Brief Interview for Mental Status assessment indicated she had full mental capacity to understand and report what had happened to her property.
The violation was classified as causing minimal harm or potential for actual harm to the resident. While the dollar amount was relatively small, the breach of trust between caregiver and resident represents a fundamental violation of the therapeutic relationship that nursing home residents depend on for their daily care and security.
The facility's response included immediate suspension of the suspected employee, a thorough investigation, termination of the responsible party, and full reimbursement to the victim. However, the violation had already occurred, and the resident had experienced the trauma of discovering that someone she trusted with her care had violated that trust by stealing from her.
The case was discovered through a complaint inspection conducted in November, nearly nine months after the original incident and termination. This suggests the violation came to federal attention through a separate complaint process rather than the facility's own reporting of the substantiated abuse case.
For nursing home residents, personal belongings often represent their last connection to independence and their life before entering institutional care. The theft of financial cards is particularly serious because it could potentially compromise a resident's ability to access their own funds for personal needs and preferences.
The resident's ordination card, which gave her the authority to perform marriages, may have held special personal significance beyond its official function. The fact that this meaningful document was carelessly left on her nightstand after being removed from her purse adds another layer to the violation of her personal space and belongings.
CNA V's access to the resident's room and belongings was part of the normal caregiving relationship. Nursing assistants routinely help residents with personal care, medication management, and daily activities that require them to be in close proximity to residents' personal items. This case demonstrates how that necessary access can be exploited by unscrupulous employees.
The facility's investigation and response, while ultimately resulting in appropriate discipline and reimbursement, could not undo the fundamental breach of trust that occurred when the nursing assistant chose to steal from a vulnerable resident under their care.
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.
The resident at Holston Rehabilitation and Care Center noticed something wrong on February 8th when she spotted the ordination card lying on her nightstand.
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.