Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Holston Health & Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to report an allegation of staff-to-resident physical and verbal abuse to the state survey agency within the required two-hour timeframe. A resident with severe dementia, muscle weakness, and difficulty walking, who required two-person assistance for ADLs, became combative during perineal care, and multiple CNAs later reported that a CNA had roughly grabbed the resident’s arms, slammed the resident’s wrists onto the chest, used profanity, made threats, and stated the resident belonged in a psychiatric ward. These CNAs did not report their concerns immediately, and the allegation was not submitted to the state reporting agency until two days after the incident, contrary to facility policy and the expectations stated by the DON and ADM.
A resident with moderate cognitive impairment and severe agitation hit another resident on the arm over a misunderstanding about shoes. Both residents were in wheelchairs and had dementia. The facility's policy against abuse was not upheld, leading to a confirmed incident of physical abuse.
A resident's funds were misappropriated by a CNA who cashed two personal checks without consent. The resident, who was cognitively intact, reported the incident with their bank after noticing the fraudulent activity. The CNA was placed on administrative leave and later resigned. The facility confirmed the failure to protect the resident from exploitation.
The facility failed to implement a comprehensive care plan for fall interventions for a resident with a history of falls, resulting in inconsistencies such as the use of a regular bed instead of a low bed, only one fall mat, and an unattached tab alarm. Additionally, the facility did not develop a care plan for anticoagulant medication for another resident, despite the resident receiving warfarin. Staff interviews revealed a lack of awareness or understanding of the required interventions.
Failure to Timely Report Staff-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of staff-to-resident physical and verbal abuse to the state survey agency within the required two-hour timeframe. Facility policy required any partner with direct or indirect knowledge of events that might constitute abuse, neglect, misappropriation of patient property, or exploitation to report immediately, but not later than two hours if the events involved abuse or resulted in serious bodily injury, and not later than 24 hours if they did not. Resident #89, admitted with severe dementia with agitation, muscle weakness, and difficulty walking, required assistance of two staff for ADLs. A Facility Reported Incident form documented that on 01/12/2026 at 12:00 PM, the resident became combative during perineal care and witnesses observed CNA #4 strike and pinch the resident several times, hold the resident by the wrists, make threatening comments, and use inappropriate language. However, this allegation was not submitted to the state reporting agency until 01/14/2026 at 2:57 PM. Witness statements from CNAs #3, #5, and #6 described multiple episodes of rough and aggressive behavior by CNA #4 toward Resident #89 during care on 01/12/2026 and 01/13/2026, including roughly taking the resident’s arms, cursing at the resident, slamming the resident’s wrists onto the chest, making threats, and telling the resident they belonged in a psychiatric ward while pushing the resident’s arms into the chest. The DON stated that on 01/14/2026 these CNAs reported the allegations of abuse from the prior dates, and confirmed that her expectation was that allegations of abuse be reported immediately. The Administrator similarly stated that staff were expected to report allegations of abuse immediately and no later than two hours from when the abuse occurred, and that the facility had two hours to report the allegation to the state reporting agency. He acknowledged that CNAs #3, #5, and #6 did not report the allegations in a timely manner, resulting in the late reporting of the abuse allegation to the state survey agency.
Resident-to-Resident Altercation Due to Cognitive Impairment
Penalty
Summary
The facility failed to protect a resident from physical abuse when another resident hit her on the left arm. The incident involved two residents, both with moderate cognitive impairment and utilizing wheelchairs for mobility. Resident #51, who was the victim, was admitted with diagnoses including Dementia and Adult Failure to Thrive. On the night of the incident, Resident #84, who was admitted with diagnoses including Dementia with Severe Agitation and Mood Disturbance, entered Resident #51's room, accused her of taking her shoes, and hit her on the left arm. Resident #51 denied any pain or injury following the incident. The facility's policy on abuse prevention clearly states that abuse, including physical abuse such as hitting, will not be tolerated. Despite this, the altercation occurred, and Resident #84 was found to have a urinary tract infection (UTI) after being transported to the hospital for evaluation of aggressive behaviors. The facility's investigation confirmed the altercation based on a witness statement from a CNA who observed the event. The facility's failure to prevent this incident indicates a deficiency in ensuring residents are free from abuse, as outlined in their policy.
Misappropriation of Resident Funds by CNA
Penalty
Summary
The facility failed to protect a resident's right to be free from misappropriation and exploitation when a staff member, specifically a Certified Nursing Assistant (CNA), deliberately used the resident's personal monetary funds without consent for personal gain. The resident, who was cognitively intact, was admitted to the facility with diagnoses including muscle weakness, chronic kidney disease, and malnutrition. During the resident's stay, the CNA was responsible for their care on several occasions. The incident came to light when the resident, along with a bank representative, reported to the facility that two personal checks had been fraudulently cashed by the CNA. The checks were stolen from the resident's purse during their stay at the facility. The resident recalled an incident where the CNA was seen looking through their purse, claiming to be picking up its contents after it had fallen. The facility's documentation and a police report confirmed the theft and misappropriation of the resident's property by the CNA. The facility's investigation revealed that the CNA had cashed the checks for personal gain without the resident's consent. The CNA was placed on administrative leave and subsequently resigned. The facility reported the incident to the state authority and added the CNA to the abuse registry for exploitation. The administrator confirmed the facility's failure to protect the resident from this deliberate act of misappropriation.
Removal Plan
- Interviews were conducted by the Social Services Director with all residents (and or their responsible parties) to inquire for any items that may have been lost or stolen. Results concluded no other patients were identified as having any checks or money missing.
- The 75 active employees received education to address financial exploitation and misappropriation of resident property.
- Audits for any allegation of misappropriation of property of sampled residents were completed by the Administrator or designee and confirmed there were no issues observed with misappropriation of property.
Deficiencies in Care Planning for Fall Interventions and Anticoagulant Medication
Penalty
Summary
The facility failed to implement a comprehensive care plan for fall interventions for a resident with a history of falls, orthostatic hypotension, anemia, and anxiety. The care plan for this resident included interventions such as a tab alarm, a low bed, and two fall mats. However, observations revealed that the resident was lying in a regular bed that was not in the lowest position, had only one fall mat instead of two, and the tab alarm was not attached to the resident's clothing. Interviews with facility staff, including CNAs and an LPN, indicated a lack of awareness or understanding of the specific interventions required for the resident, leading to inconsistencies in the implementation of the care plan. Additionally, the facility failed to develop a comprehensive care plan for anticoagulant medication for another resident diagnosed with congestive heart failure, anxiety, and dementia. Despite the resident receiving warfarin, a blood-thinning medication, the care plan did not include any specific interventions or monitoring related to the anticoagulant therapy. The MDS Coordinator confirmed that the care plan had not been developed to address the resident's anticoagulant medication needs, indicating a gap in the facility's care planning process for residents on such medications.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 106 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Knoxville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Island Home Park Health And Rehab | 2.5 mi | ★★★★★ | 3 | 0 |
| Nhc Healthcare, Knoxville | 3.8 mi | ★★★★★ | 0 | 0 |
| Creekview Health And Rehabilitation | 3.9 mi | ★★★★★ | 12 | 0 |
| Fort Sanders Tcu | 4.7 mi | ★★★★★ | 0 | 0 |
| Nhc Healthcare, Ft Sanders | 4.8 mi | ★★★★★ | 7 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Holston Health & Rehabilitation Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.