NHC Healthcare Kingsport: Oxygen Given Without Order - TN
The resident, identified in inspection records only as Resident 11, was admitted to the facility with a constellation of serious cardiac and renal diagnoses, including chronic systolic congestive heart failure, cardiomyopathy, and stage 3A chronic kidney disease. On a standard cognitive assessment, the resident scored a zero out of fifteen, indicating severe cognitive impairment. The resident could not speak up about their own care. That made what inspectors found more striking.
When a state surveyor walked into Resident 11's room on the morning of May 26, 2026, the resident was lying in bed with supplemental oxygen flowing at 3 liters per minute through a nasal cannula. The next afternoon, May 27, the surveyor returned. The oxygen was still running. Still 3 liters per minute. Still no order.
A review of the physician's orders on file for Resident 11, covering the period from April 28 through May 27, 2026, turned up nothing authorizing the oxygen. Not a standing order. Not a conditional order. Nothing.
At 4:32 in the afternoon on May 27, a state surveyor sat down with Licensed Practical Nurse A in Resident 11's room, the oxygen still hissing through the cannula beside them. The nurse confirmed it: there was no physician's order for the oxygen Resident 11 was receiving at that moment.
The order appeared the same day, dated May 27, 2026, after the surveyor's conversation with the nurse.
The Director of Nursing, interviewed the following afternoon, confirmed that an order should have been in place before the oxygen was administered.
Supplemental oxygen is not a minor comfort measure. For a resident with chronic systolic heart failure and cardiomyopathy, the flow rate, the conditions under which oxygen is used, and the parameters for adjusting or discontinuing it are clinical decisions that belong to a physician. A physician's order is how those decisions get documented and communicated to nursing staff. Without one, there is no record of what rate was prescribed, no baseline for comparison if the resident's condition changes, and no clear chain of accountability if something goes wrong.
Resident 11 cannot describe what those weeks felt like, or whether the oxygen helped, or whether anyone ever explained to them what the tube in their nose was for. The cognitive assessment score of zero means the resident had no meaningful ability to participate in that conversation.
The inspection, conducted May 28, 2026, cited the facility for failing to ensure a physician's order was obtained before administering supplemental oxygen. Inspectors reviewed 22 residents for oxygen use and found the lapse in one case. The violation was rated at the level of minimal harm or potential for actual harm, affecting a limited number of residents.
What the report does not say is how long the oxygen had been running without an order. The physician's orders reviewed by inspectors covered the period beginning April 28. Whether the gap stretched back further than that, the inspection record does not resolve.
The Director of Nursing's acknowledgment was brief and factual: an order should have been obtained. The nurse who confirmed the missing order did so only when a state surveyor was standing in the room, looking at the same patient, asking the same question the chart should have answered weeks earlier.
By the time the Director of Nursing sat down with the surveyor on May 28, the order had already been written. The oxygen was authorized. The paperwork was in order.
Resident 11 was still in bed, still breathing through the cannula, still scoring zero on the cognitive scale, still unable to say anything about any of it.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Nhc Healthcare, Kingsport from 2026-05-28 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 8, 2026 · Our methodology
NHC HEALTHCARE, KINGSPORT in KINGSPORT, TN was cited for violations during a health inspection on May 28, 2026.
On a standard cognitive assessment, the resident scored a zero out of fifteen, indicating severe cognitive impairment.
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.