Holston Health & Rehabilitation Center

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF550Mar 23, 2022

  Based on facility policy review, medical record review, observations, and interviews, the facility failed to ensure medical information was not visible for 10 residents (#2, #17, #18, #25, #33, #52, #63, #67, #183, and #185) of 77 residents reviewed for dignity. The findings include: Review of the facility policy titled, PATIENTS RIGHTS, dated 6/2006, showed .The rights of patients are codified in both federal and state statutes with the intent of further protecting each patient's civil, religious, and human rights while they reside in a health care center. […]

• No harm, potential for more than minimal, patternF689Apr 8, 2021

  Based on the facility policy review, medical record review, and interview the facility failed to ensure falls interventions were implemented to prevent falls for 4 residents (#1, #4, #6 and #7) and failed to investigate a fall for 1 resident (#1) of 9 residents reviewed for accidents. The findings include: Review of the facility falls policy, revised 7/16/2017 showed .Based on the preceding assessment, the staff and/or physician will identify pertinent interventions to try to prevent subsequent falls .staff will try various relevant interventions, based on assessment of the nature or category of falling, until falling reduces or stops . […]

• No harm, potential for more than minimal, isolatedF609Apr 25, 2026

  Based on interview, record review, and facility document and policy review, the facility failed to report an allegation of abuse to the state survey agency within the required timeframe for 1 of 3 allegations of abuse, including misappropriation of resident property, reviewed. Specifically, an allegation of staff-to-resident physical and verbal abuse for Resident #89 was not reported to the state survey agency within two hours. Findings included: A facility policy titled, Patient Protection and Response Policy for Allegations/Incidents of Abuse, Neglect, Misappropriation of Property and Exploitation, revised 02/01/2023, indicated, Any partner having either direct or indirect knowledge of any event that might constitute abuse, neglect, misappropriation of patient property or exploitation… […]

• No harm, potential for more than minimal, isolatedF600Dec 11, 2024

  Based on facility policy review, medical record review, facility investigation review, and interviews, the facility failed to ensure 1 resident (Residents #51) was free from physical abuse when 1 resident (Resident #84) hit Resident #51 on the left arm of 81 residents sampled for abuse. The findings include: Review of the facility's policy titled, Patient Protection and Response policy for Allegation/Incidents of Abuse, Neglect, Misappropriation of Property and Exploitation, dated 2/1/2023, revealed .Abuse .will not be tolerated by anyone .including .patients .The patient has the right to be free from abuse .Abuse .includes .physical abuse .Willful .as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict… […]

• No harm, potential for more than minimal, isolatedF602Dec 11, 2024

  Based on facility policy review, medical record review, facility documentation review, and interviews, the facility failed to protect the resident's right to be free from misappropriation and/or exploitation when a staff member deliberately used a resident's personal monetary funds without consent for personal gain for 1 resident (Resident #287) of 81 sampled residents reviewed for misappropriation of personal funds. The findings include: Review of the facility's policy titled, Patient Protection and Response Policy for Allegations/Incidents of Abuse, Neglect, Misappropriation of Property and Exploitation, dated 2/1/2023, revealed .the patient had the right to be free from abuse .misappropriation of property .definitions .misappropriation of property: the deliberate misplacement… […]