KINGSPORT, TN - Federal health inspectors identified nine deficiencies at Holston Rehabilitation and Care Center during a complaint investigation completed on November 17, 2025, including a citation for failing to provide and implement an adequate infection prevention and control program.
Infection Prevention Program Found Deficient
The inspection revealed that Holston Rehabilitation and Care Center did not meet federal requirements under regulatory tag F0880, which mandates that skilled nursing facilities maintain a comprehensive infection prevention and control program. Inspectors determined the deficiency followed a pattern across the facility, meaning the issue was not isolated to a single incident or resident but was observed in multiple instances.
The citation carried a Severity Level E designation, indicating that while no actual harm to residents was documented at the time of the inspection, the conditions presented the potential for more than minimal harm. In infection control, this distinction is critical — lapses in prevention protocols can rapidly escalate from potential risk to active outbreaks, particularly in populations as vulnerable as nursing home residents.
Why Infection Control Is Critical in Skilled Nursing Facilities
Nursing home residents are among the most susceptible populations to infectious disease. Advanced age, chronic medical conditions, weakened immune systems, and close living quarters all create an environment where infections can spread rapidly if proper controls are not maintained.
An effective infection prevention and control program in a skilled nursing facility typically includes several key components: hand hygiene protocols, proper use of personal protective equipment, environmental cleaning and disinfection procedures, surveillance systems to identify and track infections, staff training, and isolation protocols for residents with communicable conditions.
When these programs are not properly implemented, residents face increased risk of exposure to conditions including urinary tract infections, respiratory infections, skin infections, and gastrointestinal illness. For elderly individuals with compromised health, even a common infection can lead to hospitalization, functional decline, or death.
The fact that inspectors identified a pattern of deficiency — rather than an isolated incident — suggests the facility's infection control program had systemic gaps rather than a single oversight. Pattern-level findings typically indicate that multiple staff members, units, or processes were involved in the deficiency.
Nine Total Deficiencies Identified
The infection control citation was one of nine deficiencies found during the complaint investigation at Holston Rehabilitation and Care Center. While the infection control finding was classified under the category of Infection Control Deficiencies, the total number of citations suggests inspectors identified concerns across multiple areas of facility operations.
A facility receiving nine deficiencies during a single inspection falls above the national average. According to federal data, the typical skilled nursing facility receives approximately seven deficiencies per standard inspection cycle. A complaint investigation that yields nine findings indicates that the concerns prompting the investigation may have extended beyond the original complaint.
Correction Timeline and Current Status
Following the inspection, Holston Rehabilitation and Care Center reported correcting the infection control deficiency as of December 5, 2025 — approximately 18 days after the inspection date. The facility's status was listed as "Deficient, Provider has date of correction," meaning the facility acknowledged the findings and submitted a plan of correction to federal regulators.
A plan of correction requires the facility to outline specific steps taken to address the deficiency, measures to prevent recurrence, and a system for monitoring ongoing compliance. However, the submission of a correction plan does not guarantee that follow-up inspectors will confirm the issues have been fully resolved. The Centers for Medicare & Medicaid Services may conduct a revisit inspection to verify that corrections have been effectively implemented and sustained.
What Residents and Families Should Know
Families with loved ones at Holston Rehabilitation and Care Center can review the facility's complete inspection history, including all nine deficiencies cited during this investigation, through the CMS Care Compare website or through NursingHomeNews.org's full inspection report page for this facility.
Infection control deficiencies warrant particular attention from families, as they directly affect the day-to-day health environment in which residents live. Questions about current infection prevention practices, staff training protocols, and any changes implemented since the November inspection are reasonable topics to raise with facility administration.
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.