Below average — CMS composite of the measures below.
The next survey window likely opens around October 2026
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 Rehabilitation And Care Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, impaired mobility, and multiple fall risk factors was found on the floor after an unwitnessed fall, but the LPN did not properly assess or report the incident. The resident was returned to bed, the fall was not promptly communicated to the provider, and the resident later reported left hip pain that led to an x-ray showing a hip fracture.
Dumpster Area Not Maintained in Sanitary Condition: All 3 dumpsters were observed with doors open, and the area contained broken furniture and equipment, including bed frames, nightstands, an end table, an office chair, a toilet, a wheelchair, and a file rack, plus scattered garbage debris. The CDM, Administrator, and Maintenance Director stated the items had been accumulating for weeks to months and were being piled near the dumpsters until a roll dumpster or other removal could be arranged.
Failure to Use PPE for EBP and Source Control During COVID-19 Outbreak: The facility failed to ensure PPE was worn for EBP during high-contact care for two residents and failed to ensure face coverings were used during a COVID-19 outbreak. CNAs repositioned one resident on EBP without donning PPE, and a PTA provided hands-on therapy to another resident on EBP without gloves and a gown. Staff were also observed on a hall with a known COVID outbreak without face coverings, and the RN confirmed the policy required source control.
A resident had a PASARR Level 1 screen showing no known or suspected mental health diagnosis at admission, but later received new diagnoses of PTSD and major depressive disorder. The care plan was updated to reflect depression and PTSD, yet the facility did not submit a new PASARR after the new mental health conditions were identified. The DON confirmed the PASARR was not resubmitted and that the facility did not follow its policy for referral to the state agency after identifying a new mental health condition.
Failure to implement care plan interventions affected three residents. One resident with diabetes and a foot ulcer had an order for daily and PRN accuchecks, but no blood glucose checks were documented and the care plan was not implemented. Two residents with significant fall risk had fall-related interventions that were not followed: one resident’s wheelchair was supposed to have Dycem but observations showed it was not in place, and another resident’s fall was not timely reported or reflected in the care plan after the resident was later found to have a hip fracture.
Care plans were not revised for two residents. One resident had diabetes, a stage 3 pressure injury, and was on enhanced barrier precautions, but the care plan did not reflect those precautions. Another resident had hemiplegia, diabetes, PTSD, and moderate cognitive impairment, but the care plan did not include PTSD-related interventions despite the resident identifying triggers such as loud noises and fireworks.
Failure to Perform Ordered Blood Glucose Monitoring: A resident with diabetes, a diabetic foot ulcer, and moderate cognitive impairment had an order for daily and PRN accuchecks, but the MAR showed no documented blood glucose readings over an extended period. An LPN and the DON confirmed the checks were not obtained or recorded, and the Medical Director stated she was not aware the ordered monitoring had not been done.
A facility failed to follow a physician’s oxygen order for one resident with COPD and supplemental O2 dependence when the concentrator was set above the ordered rate during observations, and staff confirmed the order was not followed. The facility also failed to document required CPAP/BiPAP care for another resident with respiratory failure, COPD, and OSA, with no charting of tolerance, skin, respiratory changes, or other responses despite an active BiPAP order and use noted by the resident and DON.
A cognitively intact resident with neuropathy, respiratory disorders, and muscle wasting had a debit card and two credit cards taken without permission, resulting in $23.11 being stolen. The DON notified the Administrator, the facility investigated, and CNA V was identified as the responsible staff member and later terminated after the allegation of misappropriation was substantiated.
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.
Failure to Report Fall and Assess Hip Pain
Penalty
Summary
The facility failed to provide an environment free of accident hazards and adequate supervision when a resident with severe cognitive impairment and multiple fall risk factors sustained an unwitnessed fall that was not promptly reported to the physician. The resident had diagnoses including chronic respiratory failure, emphysema, weakness, and hospice-related COPD, and was dependent on staff for toileting, bathing, personal hygiene, and required moderate assistance with transfers and bed mobility. The resident’s clinical evaluation identified diminished safety awareness and impaired gait or balance, but no fall interventions were documented on the comprehensive care plan. On 4/4/2025, CNA staff found the resident on the floor beside the bed after hearing the resident call for help. Staff statements indicated the resident complained of left hip pain after the fall, and CNA Y reported that LPN Z was called to assess the resident. According to CNA Y, LPN Z did not assess the resident and stated the resident was all right before the resident was lifted back into bed. The facility investigation later documented that the resident was found on the floor in the room beside the bed and was assisted back to bed by staff. The fall was not reported to the physician at the time it occurred, and the resident’s pain was not evaluated until 9 days later when increased left hip pain was reported. At that time, hospice was notified, an x-ray was ordered, and the resident was diagnosed with a left intertrochanteric femoral/hip fracture. Hospital records later documented continued left hip pain and an angulated hip fracture. Interviews with nursing leadership confirmed the fall had not been discussed in the IDT until the later pain complaint, and the DON stated the supervising nurse did not report the fall and did not complete an incident report.
Dumpster Area Not Kept Clean or Properly Contained
Penalty
Summary
Dispose of garbage and refuse properly was deficient because the facility did not keep the dumpster area clean, sanitary, or properly contained. Review of the facility policy titled, Disposal of Garbage and Refuse, showed that the surrounding area was to be kept clean to minimize debris and insect/rodent attraction and that refuse receptacles were to be maintained in good repair. During an observation with the Certified Dietary Manager, all 3 dumpsters were seen with the doors open, and the area around them contained broken or disused items including 2 bed frames, 4 nightstands, 1 end table, 1 office chair, 1 toilet, 1 wheelchair, and 1 file rack, along with scattered garbage debris on the outer right edge of the dumpster area. The Certified Dietary Manager stated the broken items had been around the dumpster area for more than 2 weeks and confirmed the area was not maintained in an orderly and sanitary condition. Facility records showed extra dumpster service had been used for removal of broken furniture items that could not be collected in the regular dumpster. The Administrator stated the broken items were piled up and a roll dumpster would be ordered when needed, and he was unsure how long the items had accumulated. The Maintenance Director stated the facility had been placing broken items near the dumpsters for about 6 months until they could be removed, that an extra roll dumpster had been obtained previously and again about 1 month earlier, and that there was no current schedule for removal until the day of the later observation.
Failure to Use PPE for EBP and Source Control During COVID-19 Outbreak
Penalty
Summary
The facility failed to ensure appropriate PPE was used for Enhanced Barrier Precautions (EBP) for two residents and failed to ensure face coverings were worn during a COVID-19 outbreak on one shift. The facility policy titled, Nursing Management Manual, effective 3/21/2024, stated that EBP should be implemented for the prevention of transmission of multidrug resistant organisms, that staff receive training on EBP upon hire and annually, and that PPE is required for high-contact care activities such as dressing, changing, wound care, and hygiene care. The facility policy titled, Covid-19 Prevention, Response and Reporting, revised 9/1/2024, stated that source control refers to masks covering the mouth and nose and is recommended for residents or staff on a unit or area experiencing a SARS-CoV-2 or other respiratory outbreak. Resident #25 was admitted with diagnoses including diabetes, muscle wasting, and orthopedic aftercare. The resident’s physician orders included EBP for wound care, the MDS showed a BIMS score of 14 indicating cognitive intactness, and the care plan identified a stage 3 pressure injury of the left heel and a traumatic injury to the right lower shin. On 9/22/2025, EBP signage was posted on the resident’s door, and RN W confirmed the resident was on EBP for MDRO. During observation, CNA O and CNA P entered the room, repositioned the resident in bed, and did not don PPE for EBP. Both CNAs stated they had provided care and had not donned appropriate PPE, and LPN Q confirmed they failed to follow infection control protocols for EBP. Resident #37 was admitted with diagnoses including cellulitis of the right lower limb, sepsis with unspecified organism, COPD, and obstructive reflux uropathy. The admission MDS showed a BIMS score of 15, indicating cognitive intactness, and the care plan noted a wound to the right shin, a sacral wound, an indwelling urinary catheter, and EBP. During observation, a PTA provided hands-on therapy in the resident’s room while the resident was in bed, and EBP signage on the door directed staff to wear gloves and a gown for high-contact resident care activities, including wound care and hygiene. The PTA did not don PPE before entering or while providing therapy, stated she did not see the sign, and the DON confirmed that if PPE was not donned during the contact activity, the PTA had not followed appropriate infection control practices for EBP. In addition, during the COVID-19 outbreak, staff on the 200 hall were observed providing care without face coverings for source control, and RN N confirmed the facility policy required face coverings with known COVID-positive residents.
Failure to Resubmit PASARR After New Mental Health Diagnosis
Penalty
Summary
The facility failed to resubmit a PASARR timely after a new mental health diagnosis was added for one resident reviewed for PASARR. Review of the facility policy showed that applicants are to be screened for serious mental disorders and that the PASARR process continues if a possible serious mental disorder or intellectual disability arises later. The resident had a PASARR Level 1 screen that indicated no mental health diagnosis was known or suspected at admission, and the medical record showed admission diagnoses of encephalopathy, diabetes, and intraspinal abscess and granuloma. The record later showed new diagnoses of Post-Traumatic Stress Disorder and Major Depressive Disorder, and the comprehensive care plan was revised to include a history of depression and PTSD. However, a new PASARR was not submitted after the new mental health diagnoses were added, and the DON confirmed during interview that the facility had not submitted a new PASARR and had not followed its policy for referring to the state agency after identifying a new mental health condition.
Failure to Implement Blood Glucose Monitoring and Fall Care Plan Interventions
Penalty
Summary
The facility failed to implement care plan interventions related to blood glucose monitoring for Resident #109, who was admitted with diagnoses including polyneuropathy, osteomyelitis of the right ankle and foot, diabetes, and cellulitis of the right lower limb. The physician’s order dated 7/23/2025 required accuchecks daily and as needed, and the comprehensive care plan dated 7/24/2025 included monitoring blood sugar levels for the resident’s diabetic ulcer of the right plantar foot related to diabetes. Review of the MAR from 7/23/2025 through 9/24/2025 showed no documentation that the accuchecks were obtained, and both an LPN and the DON confirmed the blood sugars had not been obtained or documented during that period and that the care plan had not been implemented. The facility also failed to implement a fall care plan intervention for Resident #138. The resident had diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the left dominant side, lack of coordination, muscle wasting and atrophy, right femur fracture, fall, and Alzheimer’s disease, and a quarterly MDS showed severe cognitive impairment. After an unwitnessed fall from bed on 7/14/2025 with no injuries, the post-fall investigation identified Dycem to be placed in the resident’s wheelchair, and the care plan dated 8/6/2025 included Dycem in the wheelchair for safety. Multiple observations on 9/22/2025 through 9/24/2025 showed the resident seated in or near the wheelchair with no Dycem present, and an LPN confirmed the Dycem was not in use. The facility further failed to document and update fall interventions for Resident #166. The resident had diagnoses including chronic respiratory failure, emphysema, and weakness, and the clinical health evaluation identified fall risk factors including diminished safety awareness, impaired gait or balance, and impairment to lower extremities. The comprehensive care plan dated 4/2/2025 listed a terminal prognosis/hospice related to COPD but contained no documented fall interventions, while the hospice plan of care included fall precautions and safety assessment. A fall occurred on 4/4/2025, with the resident found on the floor beside the bed, and the facility’s fall investigation was completed 12 days later. The DON stated the incident report was not completed timely, the resident was not notified timely, and the care plan had not been updated timely with interventions for the fall; the DON also stated it was possible failure to implement a fall care plan contributed to the resident incurring a fracture from the fall.
Care Plans Not Revised for Enhanced Barrier Precautions and PTSD
Penalty
Summary
The facility failed to revise the comprehensive care plans for 2 residents out of 25 reviewed. Resident #25 was admitted with diagnoses including diabetes, muscle wasting, and orthopedic aftercare, and the record showed a physician order for enhanced barrier precautions for a wound. The significant change MDS indicated the resident was cognitively intact and also documented a stage 3 pressure injury. However, the comprehensive care plan revised on 8/11/2025 addressed pressure ulcer risk and a stage 3 ulcer of the left heel and traumatic injury to the right lower shin, but did not reflect the enhanced barrier precautions that were in place. During observation on 9/22/2025, enhanced barrier precaution signage was seen on the resident’s door, and an LPN confirmed the resident was on enhanced barrier precautions. Resident #100 was admitted with diagnoses including hemiplegia and hemiparesis, diabetes, and PTSD. The annual MDS showed a BIMS score of 8, indicating moderate cognitive impairment, and further review confirmed the PTSD diagnosis. The comprehensive care plan revised on 9/9/2025 addressed a psychosocial well-being problem related to recent admission, but it did not include a care plan or interventions for PTSD. During interviews, the resident stated he had PTSD from serving in the Vietnam War and identified loud noises and fireworks as triggers, and later stated he had not slept much at night since the war. The LPN confirmed awareness of the PTSD diagnosis and triggers, the SSD confirmed the resident had PTSD and was seen by psychiatric services, and the RN MDS Coordinator confirmed the care plan had not been revised to reflect enhanced barrier precautions for Resident #25 or PTSD for Resident #100.
Failure to Perform Ordered Blood Glucose Monitoring
Penalty
Summary
The facility failed to follow the Physician's Orders for blood glucose monitoring for one resident with diabetes, polyneuropathy, osteomyelitis of the right ankle and foot, and cellulitis of the right lower limb. The resident had an order dated 7/23/2025 for accuchecks daily and as needed, and the care plan identified a diabetic ulcer of the right plantar foot with a goal to monitor blood sugar levels. The resident's quarterly MDS showed a BIMS score of 11, indicating moderate cognitive impairment. Review of the MARs for 7/23/2025 through 9/24/2025 showed no documentation of the ordered daily blood glucose readings. During interview, an LPN confirmed the blood sugars had not been obtained or documented during that period and stated the order had been entered without a time for the checks to be done. The DON also confirmed the readings were not recorded from 7/23/2025 to 9/24/2025, and the Medical Director stated she was not aware the blood sugars were not obtained as ordered.
Failure to Follow Oxygen Orders and Document BiPAP Care
Penalty
Summary
The facility failed to follow a physician’s order for oxygen therapy for Resident #56, who was admitted with diagnoses including COPD with acute exacerbation, dependence on supplemental oxygen, atrial fibrillation, and heart failure. The physician ordered oxygen at 2 liters per minute via nasal cannula continuously and as needed, but during observations on 9/22/2025 and 9/23/2025 the resident’s oxygen concentrator was set at 4 liters per minute. LPNs confirmed the oxygen was greater than the ordered rate, and the DON confirmed the oxygen had been ordered for 2 liters per minute and that the facility failed to ensure it was administered as ordered. The facility also failed to document CPAP/BiPAP care for Resident #72, who was admitted with diagnoses including acute and chronic respiratory failure, COPD, and obstructive sleep apnea. The resident had a physician’s order for CPAP/BiPAP at bedtime and removal in the morning, and the MAR reflected that order. However, the medical record contained no documentation of the resident’s tolerance, skin condition, respiratory changes, or other responses related to BiPAP use. During observation, a CPAP/BiPAP machine was present in the resident’s room, and the resident stated staff helped apply it at night and remove it in the morning. The DON confirmed the resident had a BiPAP order and that staff were not following facility policy by documenting the required information.
Resident Property Misappropriation by CNA
Penalty
Summary
The facility failed to protect a resident from misappropriation of property when money totaling $23.11 was taken from Resident #43 without consent. Review of the facility policy defined misappropriation as the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent. Resident #43 was admitted with diagnoses including Hereditary and Idiopathic Neuropathy, Respiratory Disorders, and Muscle Wasting and Atrophy, and an admission MDS assessment showed a BIMS score of 15, indicating the resident was cognitively intact. Facility investigation records showed Resident #43 reported that a black card was found on the bedside table and later noticed that a debit card and two credit cards were missing. The DON notified the Administrator and the facility initiated an investigation. During the investigation, CNA V was identified as a possible suspect, suspended, and later terminated after the facility substantiated misappropriation of resident property. Resident #43 confirmed that the CNA took the debit card and two credit cards without permission and stole $23.11, and the Administrator confirmed the allegation was substantiated and that CNA V was responsible.
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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Illustrative
What surveyors actually found near you
We read the 53 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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 | ★★★★★ | 2 | 0 |
| Wexford House | 1.5 mi | ★★★★★ | 1 | 0 |
| Orchardview 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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