KINGSPORT, TN - Federal health inspectors cited Holston Rehabilitation and Care Center for nine deficiencies during a complaint investigation completed on November 17, 2025, including a failure to properly coordinate resident assessments with the federally mandated pre-admission screening program.
Resident Assessment Coordination Breakdown
Among the deficiencies identified, inspectors flagged Holston Rehabilitation and Care Center under regulatory tag F0644, which addresses a facility's obligation to coordinate assessments with the Pre-Admission Screening and Resident Review (PASRR) program and to refer residents for appropriate services when needed.
The PASRR program is a federal requirement under the Omnibus Budget Reconciliation Act designed to ensure that individuals with mental illness or intellectual disabilities are not inappropriately placed in nursing facilities when they could be better served elsewhere. When a facility fails to coordinate its own assessments with PASRR findings, residents may miss critical specialized services — including psychiatric care, behavioral health support, or community-based treatment options.
The deficiency was classified at Scope/Severity Level D, meaning the issue was isolated to a limited number of residents and did not result in documented actual harm. However, inspectors determined there was potential for more than minimal harm, indicating the breakdown posed a real risk to resident well-being.
Why Proper Screening Coordination Matters
Nursing facilities are required under federal regulations to integrate PASRR screening data into their comprehensive resident assessments. This coordination serves as a safeguard to ensure every resident receives services tailored to their specific medical, psychological, and social needs.
When this process breaks down, several concerning outcomes become possible. Residents with unidentified mental health conditions may go without appropriate psychiatric treatment. Individuals with intellectual disabilities may not receive specialized programming designed to maintain or improve their functional abilities. In some cases, residents who would benefit from community-based care alternatives may remain in institutional settings unnecessarily.
Proper assessment coordination requires nursing facilities to review PASRR Level I and Level II screening results, incorporate those findings into individualized care plans, and make timely referrals to specialized service providers. The failure to complete any step in this chain can leave vulnerable residents without access to services they are legally entitled to receive.
Nine Total Deficiencies Identified
The assessment coordination failure was one component of a broader pattern identified during the November inspection. Holston Rehabilitation and Care Center received a total of nine deficiencies across the complaint investigation, suggesting inspectors found multiple areas where the facility fell short of federal standards.
The inspection was initiated in response to a complaint, meaning concerns about care at the facility had been raised prior to the survey team's arrival. Complaint-driven investigations are triggered when state or federal agencies receive reports alleging potential violations of nursing home regulations.
Facility Response and Correction Timeline
Holston Rehabilitation and Care Center reported correcting the assessment coordination deficiency as of December 5, 2025, approximately 18 days after the inspection concluded. The facility's correction status is listed as "deficient, provider has date of correction," indicating the facility has acknowledged the issue and implemented changes.
Federal regulations require nursing homes to submit a plan of correction detailing the specific steps taken to address each deficiency, measures to prevent recurrence, and a monitoring system to ensure ongoing compliance. The Centers for Medicare & Medicaid Services (CMS) may conduct follow-up surveys to verify that corrections have been effectively implemented.
Industry Standards for Assessment Compliance
Accredited nursing facilities are expected to maintain systematic processes for integrating PASRR data into resident evaluations. Best practices include designating staff members responsible for reviewing screening results upon admission, establishing protocols for ongoing reassessment, and maintaining documentation that demonstrates coordination between facility assessments and external screening programs.
Holston Rehabilitation and Care Center serves the Kingsport community as a skilled nursing facility subject to regular federal oversight. Families and residents can access the full inspection results, including details on all nine deficiencies, through the CMS Care Compare database or by requesting records directly from the Tennessee Department of Health.
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.