Holston Health & Rehabilitation

In the surveyor’s words

From the most serious findings on record at Holston Health & Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, patternF684May 7, 2025

  7. The facility staff failed to ensure Resident #90's insulin was ordered and/or administered to address the resident's diabetic needs. Resident #90's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 1/26/25, was signed as completed on 1/29/25. Resident #90 was assessed as usually able to make self understood and as usually able to understand others. Resident #90's Brief Interview for Mental Status (BIMS) summary score was documented as a 15 out of 15; this indicated intact or borderline cognition. Resident #90's clinical documentation indicated the resident arrived at the facility on 1/22/25 at 4:10 p.m. […]

• Actual harm, isolatedF697May 7, 2025

  Based on staff interview, clinical record review and facility document review, the facility staff failed to ensure that pain management is provided to residents consistent with professional standards of practice and the person-centered comprehensive care plan for 1 (one) of 30 residents in the survey sample, resident #448 (R448). The findings included: R448's diagnoses included but were not limited to, right hip fracture post-surgical repair, Alzheimer's Disease, chronic obstructive pulmonary disease, osteoporosis, osteoarthritis, pain unspecified and restless leg syndrome. The minimum data set (MDS) assessment with an assessment reference date of 1/24/24 assigned the resident a brief interview for mental status (BIMS) score of 1 out of 15, indicating severe cognitive impairment. […]

• No harm, potential for more than minimal, widespreadF711Feb 2, 2024

  Based on staff interviews, clinical record review, and facility document review, the facility staff failed to ensure that medical providers co-signed verbal orders, telephone orders, and/or orders documented in the Rounding Binders. The findings include: Review of residents' electronic orders failed to show evidence of orders being co-signed by the medical provider who had given the orders. On 1/30/24 at 11:10 a.m., Nurse Practitioner (NP) #1 reported they do not enter their own orders into the residents' electronic record. NP #1 stated orders are given by telephone, verbal, and/or entered into the communication book. NP #1 reported they do not co-sign orders that are entered into the residents' electronic clinical record. […]

• No harm, potential for more than minimal, patternF578May 7, 2025

  Based on interviews, clinical record reviews, and facility document review facility staff failed to implement a process that ensured all residents were provided written information concerning the right to formulate an advance directive for 11 of 30 sampled residents. (Resident #4, #39, #45, #62, #63, #65, #67, #77, #89, #198, #348). The findings were: The facility staff failed to ensure Residents #4, #39, #45, #62, #63, #65, #67, #77, #89, #198, and #348 were provided with written information on the right to accept or refuse medical or surgical treatment. The aforementioned residents' clinical records contained a document titled, ACKNOWLEDGMENT OF RECEIPT OF admission INFORMATION which residents or responsible parties signed upon admission. […]

• No harm, potential for more than minimal, patternF655May 7, 2025

  Based on staff interviews, clinical record reviews, and facility document review, the facility staff failed to implement a process that ensured a baseline care plan was developed for every resident within 48 hours of admission and failed to provide the resident and their representative with a summary of that baseline care plan for 7 of 30 residents. (Resident #1, #32, #39, #65, #77, #89, and #348). The findings were: The facility staff failed to ensure a process was in place to provide residents and their representatives with a summary of the baseline care plan that was initiated within 48 hours of the resident's admission. The clinical record reviews failed to contain evidence Resident #1, #32, #39, #65, #77, #89, and #348 and their representatives were provided a baseline care plan. […]