Holston Rehabilitation and Care Center

In the surveyor’s words

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

• Actual harm, isolatedF689Nov 17, 2025

  Based on facility policy review, medical record review, facility investigation review, hospital record review, and interview, the facility failed to provide an environment that was as free of accident hazards as possible and provide adequate supervision to prevent accidents for 1 of 5 (Resident #166) residents reviewed for falls. Resident #166 had an unwitnessed fall, nursing staff failed to report the fall to the physician resulting in a 9-day delay in evaluation and Resident #166 was later diagnosed with a left hip fracture. […]

• No harm, potential for more than minimal, widespreadF812Mar 5, 2024

  Based on facility policy review, observation, and interview the facility failed to maintain sanitary kitchen equipment which had the potential to effect 120 of the 122 residents in the facility. The findings include: Review of the facility's undated policy titled, Cleaning and Sanitizing Dietary Areas and Equipment, showed .All kitchen areas and equipment shall be maintained in a sanitary manner and be free of build-up of food, grease, or other soil . During the initial kitchen observation on 3/3/2024 at 10:55 AM, with the Certified Dietary Manager (CDM), showed the facility's gas stove griddle had a layer of dried brownish-black food debris observed on the top and the right-side lip of the metal splashguard of the griddle. […]

• No harm, potential for more than minimal, patternF814Nov 17, 2025

  Based on facility policy review, observations, and interviews, the facility failed to ensure the dumpster area was maintained in a clean and sanitary condition and garbage and refuse were properly contained in 3 of 3 dumpsters.The findings include:Review of the facility's policy titled, Disposal of Garbage and Refuse, dated 9/1/2024, revealed .Garbage and refuse .Surrounding area shall be kept clean so that accumulation of debris and insect/ rodent attractions are minimized .receptacles for refuse shall be maintained in good repair .During an observation with the Certified Dietary Manager (CDM) on 9/22/2025 at 11:50 AM, revealed the following: The 3 of 3 dumpsters were observed with the doors open. […]

• No harm, potential for more than minimal, patternF880Nov 17, 2025

  Based on facility policy review, medical record review, observation, and interview, the facility failed to ensure appropriate Personal Protective Equipment (PPE) was donned for 2 residents (Resident # 25 and #37) of 25 residents observed for Enhanced Barrier Precautions (EBP) and the facility failed to wear face coverings during a COVID-19 outbreak on 5 of 5 hallways of 1 of 2 shifts.The findings include: Review of the facility's policy titled, Nursing Management Manual, effective 3/21/2024, revealed .implement Enhance Barrier Precautions (EBP) for the prevention of transmission of multidrug resistant organisms .all staff receive training on enhanced barrier precautions upon hire and annually .training in high risk activities .are expected to comply with all precautions .an order for… […]

• No harm, potential for more than minimal, isolatedF602Nov 17, 2025

  Based on facility policy review, medical record review, facility investigation review, personal file review, and interview, the facility failed to protect a resident's rights to be free from misappropriation and/or exploitation when money totaling $23.11 was taken from 1 resident (Resident #43) of 22 residents reviewed for misappropriation. The findings include:Review of the facility policy titled, Abuse, Neglect, Misappropriation of Resident Property, Suspicious Injuries of Unknown Source, Exploitation, undated, revealed .Misappropriation of Resident Property means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent .Review of the medical record revealed Resident #43 was admitted to the… […]