Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Holston Rehabilitation And Care Center during CMS and state inspections, most recent first.
The facility failed to maintain sanitary kitchen equipment, specifically the gas stove griddle, which had dried food debris. The Certified Dietary Manager confirmed the unsanitary condition, acknowledging that the equipment required further cleaning. This deficiency had the potential to affect 120 of the 122 residents.
The facility failed to ensure medical information was not visible for three residents and did not assist a resident to the smoking area as per their care plan. Unauthorized signs with residents' full names and medical needs were posted, and staff inconsistently followed the facility's smoking assistance policy.
The facility failed to accurately complete MDS assessments for two residents. One resident was incorrectly documented as edentulous despite having natural teeth, and another resident was inaccurately coded with an active diagnosis of Septicemia, which was not treated in the 7-day look-back period. Interviews and observations confirmed these inaccuracies.
The facility failed to develop and implement person-centered care plans for two residents. One resident's care plan inaccurately documented dental needs, while another resident's care plan did not reflect her spiritual preferences, leading to inappropriate participation in religious activities.
The facility failed to include a resident or the resident's representative in the care planning process. Despite the resident having severe cognitive impairment and a care plan indicating a knowledge deficit, the resident's daughter confirmed she was never invited to a care plan meeting. The Director of Social Services acknowledged that no care plan conference had been held, contrary to the facility's policy.
A resident had unsecured medications, including Tiotropium Bromide and antacid tablets, left at the bedside without an assessment for self-administration. The LPN was unaware of the unsecured medications, and the DON confirmed that the medications should not have been left in the room.
The facility failed to accurately transcribe an admission order for one resident, leading to an incorrect dosage of Prednisone being administered. Additionally, the facility inaccurately documented another resident's dental condition, recording them as edentulous with dentures when they had natural teeth and a broken tooth.
The facility failed to ensure a coordinated hospice plan of care was available in the medical record for a resident with complex medical needs. Despite the facility's policy and contract requirements, staff were unable to locate the hospice plan of care in either the physical or electronic medical records. The Director of Nursing confirmed the deficiency.
The facility failed to assist four residents with hand hygiene before meals on one of the five hallways observed for meal service. Staff, including the Social Services Assistant, Director of Social Services, and a CNA, did not offer or assist residents with hand hygiene before serving lunch meals. Interviews confirmed that staff were either unaware or did not follow the facility's policy requiring hand hygiene before meals.
Unsanitary Kitchen Equipment
Penalty
Summary
The facility failed to maintain sanitary kitchen equipment, specifically the gas stove griddle, which had a layer of dried brownish-black food debris on the top and the right-side lip of the metal splashguard. This was observed during an initial kitchen inspection with the Certified Dietary Manager (CDM), who confirmed that the kitchen equipment was supposed to be cleaned daily and deep cleaned weekly. The CDM acknowledged that the stove griddle was in an unsanitary condition and required further cleaning. This deficiency had the potential to affect 120 of the 122 residents in the facility.
Failure to Maintain Resident Privacy and Assist with Smoking
Penalty
Summary
The facility failed to ensure medical information was not visible for three residents and failed to assist one resident to the smoking area. For Residents #1, #27, and #31, signs were posted above their beds indicating specific care instructions, including their full names and medical needs, without their or their representatives' consent. These signs were visible to anyone entering the room, which was confirmed by LPN #3 and the Director of Nursing (DON). The DON acknowledged that the signage was a dignity concern and confirmed that the residents' care plans did not reflect any requests for such signage. The signs were removed after the surveyors brought them to the facility's attention, but the staff member responsible for posting them was unknown. Resident #47, who had moderate cognitive impairment and was designated as a supervised smoker, reported that CNA #1 refused to assist him to the smoking area multiple times. CNA #1 stated that she was informed by LPN #1 that if a resident could not propel themselves to the smoking area, staff were not to assist them due to safety concerns. However, the LPN could not articulate what those safety concerns were. During an observation, CNA #1 initially refused to assist Resident #47 to the smoking area but later agreed after the resident requested to speak to management. The Administrator and DON stated that it was their expectation for staff to assist residents to the smoking area if needed. The facility's failure to maintain resident privacy and dignity by posting unauthorized medical information and not assisting a resident to the smoking area as per their care plan led to the deficiencies. The DON confirmed that resident care needs should be communicated through care plans and CNA task sheets, not through visible signage in resident rooms. Additionally, the facility's policy on smoking assistance was not consistently followed, leading to confusion and unmet resident needs.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to accurately complete Minimum Data Set (MDS) assessments for two residents. Resident #364 was admitted with diagnoses including Malignant Neoplasm of Left Breast, Hypertension, and Osteoporosis. The admission MDS assessment inaccurately documented the resident as edentulous, while observations and interviews revealed that the resident had natural teeth, including a broken tooth. The MDS Coordinator confirmed that the admission Oral Cavity Observation and Clinical Admission assessments were inaccurate, and the quarterly MDS assessment did not reflect the resident's actual dental status. Resident #1 was admitted with diagnoses including Hemiplegia, Asthma, Depression, Dementia, Atrial Fibrillation, Hypertension, and Peripheral Vascular Disease. The quarterly MDS assessment inaccurately documented an active diagnosis of Septicemia. Interviews with the LPN, MDS Coordinator, and DON confirmed that the resident had not been treated for Septicemia in the 7-day look-back period, and the MDS assessment was inaccurately coded. The MDS Coordinator acknowledged the expectation that the MDS assessment should be coded accurately based on the RAI manual.
Failure to Develop Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement person-centered care plans for two residents, leading to deficiencies in their care. Resident #364 was admitted with diagnoses including Malignant Neoplasm of the Left Breast, Hypertension, and Osteoporosis. Despite multiple assessments indicating that Resident #364 had natural teeth and a broken tooth, the comprehensive care plan inaccurately documented the resident as edentulous and requiring denture care. Interviews with the resident, her daughter, and facility staff confirmed the presence of natural teeth and the broken tooth, highlighting the care plan's inaccuracy and lack of person-centered care. Resident #100, admitted with Hemiplegia following a Cerebral Infarction, Aphasia, and Nontraumatic Intracerebral Hemorrhage, had a care plan that did not reflect her spiritual preferences. Despite an initial assessment indicating no preference for spiritual activities or clergy visits, the care plan included a generic spiritual distress problem and the resident was taken to church services against her and her family's wishes. Interviews with the resident's family and facility staff confirmed the discrepancy between the resident's documented preferences and the care plan, demonstrating a failure to provide person-centered care.
Failure to Include Resident or Representative in Care Planning
Penalty
Summary
The facility failed to include the resident or the resident's representative in the care planning process for one resident. According to the facility's policy, a comprehensive person-centered care plan should be developed for each resident, including the participation of the resident and their representative when possible. Resident #106, who was admitted with diagnoses including Type 2 Diabetes Mellitus and Obstructive Sleep Apnea, had a care plan dated 1/26/2024, which indicated a knowledge deficit with an intervention to promote participation in the treatment regimen. However, the resident had severe cognitive impairment, as shown in a 5-day Minimum Data Set (MDS) assessment, and the resident's daughter confirmed she had never been invited to a care plan meeting or had a discussion about her mother's plan of care. During an interview, the Director of Social Services (DSS) confirmed that no care plan conference had been held with Resident #106 or the resident's representative. The DSS stated that care conferences are typically set up by the admissions team within 48 hours, or 72 hours if the admission falls on a weekend. Despite this expectation, the care plan meeting for Resident #106 had not been conducted, leading to the deficiency noted in the report.
Unsecured Medications at Bedside
Penalty
Summary
The facility failed to provide a safe environment by leaving medications unsecured at the bedside for one resident. The facility's policy mandates that medications should be stored in a medication cart or other designated area unless a resident has been assessed and approved for self-administration. Resident #419, who was cognitively intact, had a box of Tiotropium Bromide (Spiriva Handihaler) and a bottle of antacid tablets left unsecured in his room. The resident stated he needed the Tiotropium Bromide refilled and had the box in the room to give his daughter the information. He also brought the antacid tablets from home for his indigestion. These medications were observed to be left out on multiple occasions without any assessment for self-administration being conducted for the resident. During an observation and interview, an LPN confirmed that medications are not supposed to be left in a resident's room and should be locked up. The LPN admitted she was unaware of the full capsule left in the Tiotropium Bromide box and had not noticed the antacid tablets. The medications were subsequently removed and locked up. The DON stated that the nurses should have educated the resident about not storing medications in the room and should have removed the medications if the resident refused to comply. The DON confirmed that the medications should not have been left in the resident's room.
Inaccurate Transcription of Admission Orders and Assessments
Penalty
Summary
The facility failed to accurately transcribe an admission order for one resident and ensure admission assessments were accurate for another resident. Resident #48 was admitted with diagnoses including Giant Cell Arteritis, COPD, and Asthma. The hospital discharge orders indicated Prednisone 8 mg daily, but the Medication Administration Record (MAR) showed Prednisone 80 mg was administered instead. This error was confirmed by the Director of Nursing and a Registered Nurse. The Medical Director stated that the resident had no negative side effects from the incorrect dosage, although the order was transcribed incorrectly. Resident #364 was admitted with diagnoses including Malignant Neoplasm of the Left Breast, Hypertension, and Osteoporosis. The Oral Cavity Observation and Clinical Admission assessments inaccurately documented the resident as edentulous with dentures, while the resident actually had natural teeth and a broken tooth. This discrepancy was confirmed through interviews with the resident, her daughter, a CNA, an LPN, and the MDS Coordinator. The assessments did not reflect the resident's actual dental condition, leading to inaccurate medical records.
Failure to Ensure Hospice Plan of Care in Medical Record
Penalty
Summary
The facility failed to ensure a coordinated plan of care with the hospice provider was available in the medical record for Resident #60. The facility's hospice contract and policy required that the hospice plan of care be included in the resident's medical record. However, upon review, it was found that Resident #60, who was admitted to hospice services on 2/2/2024, did not have the hospice plan of care documented in their medical record. This deficiency was confirmed through multiple interviews with facility staff, including Licensed Practical Nurses and a Registered Nurse, who were unable to locate the hospice plan of care in either the physical chart or the electronic medical record. Resident #60 had a complex medical history, including Hemiplegia and Hemiparesis following a cerebral infarction, complete traumatic amputation at the level between the left hip and knee, asthma, diabetes mellitus, atrial fibrillation, hypertension, and post-traumatic stress disorder. Despite the resident's significant medical needs and the requirement for coordinated care, the hospice plan of care was not available for facility staff to reference. The Director of Nursing confirmed that it was her expectation for the hospice plan of care to be accessible in the resident's medical record, but acknowledged that it was not available in this case.
Failure to Assist Residents with Hand Hygiene Before Meals
Penalty
Summary
The facility failed to assist four residents with hand hygiene before meals on one of the five hallways observed for meal service. The facility's policy, dated 6/1/2023, required that hands be clean before serving meals. However, during observations on 3/3/2024, staff did not offer or assist Residents #20, #75, #614, and #39 with hand hygiene before serving their lunch meals. Resident #20 had moderate cognitive impairment, Resident #75 and Resident #614 were cognitively intact, and Resident #39 had moderate cognitive impairment. Despite these varying cognitive statuses, none of the residents were assisted with hand hygiene before their meals. During the meal tray distribution on the 200 hallway, the Social Services Assistant, Director of Social Services, and a CNA were observed distributing meal trays without offering or assisting residents with hand hygiene. Interviews with the Social Services Assistant and the Director of Social Services confirmed that they did not offer or assist residents with hand hygiene prior to the meal. The CNA stated she was unaware that hand hygiene was required before meal service but acknowledged the requirement after being informed. The Director of Nursing stated that it was her expectation for residents to be offered or assisted with hand hygiene prior to meals.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Kingsport
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Nhc Healthcare, Kingsport | 1.4 mi | — | 0 | 0 |
| Wexford House | 1.5 mi | — | 1 | 0 |
| Orchard View Post-acute And Rehabilitation Center | 2.7 mi | — | 0 | 0 |
| Greystone Health Care Center | 6.2 mi | — | 0 | 0 |
| Asbury Place Kingsport | 6.4 mi | — | 6 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.