Inspection Reports for
Holston Health And Rehabilitation Center
3916 Boyds Bridge Pike, Knoxville, TN 37914, United States, TN, 37914
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Inspection Report — Mar 16, 2026
Enforcement
Date: Mar 16, 2026
Visit Reason
Statement of Deficiencies (CMS-2567) from a survey completed on 2024-12-11 documenting findings of resident-on-resident physical abuse (F-0600) and staff misappropriation of resident funds (F-0602).
Findings
The survey cited deficiencies F-0600 for failure to protect Resident #51 from physical abuse by Resident #84 and F-0602 for a staff member's misappropriation of two of Resident #287's checks (police report value $525). F-602 (misappropriation) was cited as past noncompliance and the facility was not required to submit a plan of correction.
Citations (2)
F-0600: Resident-on-resident physical abuse where Resident #84 entered Resident #51's room and hit Resident #51 on the left arm during an incident on 6/20/2023.
F-0602: Staff misappropriation of Resident #287's property where two of the resident's personal checks were taken and cashed by a Certified Nursing Assistant without the resident's consent.
Report Facts
Deficiencies cited: 2
Residents sampled: 81
Active employees educated: 75
Reported check value: 525
Inspection Report — Mar 16, 2026
Enforcement
Date: Mar 16, 2026
Visit Reason
CMS Statement of Deficiencies form reporting the results of a survey completed on 2019-11-06 for Holston Health & Rehabilitation Center.
Findings
The survey found no health deficiencies for Holston Health & Rehabilitation Center.
Inspection Report — Dec 11, 2024
Enforcement
Date: Dec 11, 2024
Visit Reason
CMS-2567 Statement of Deficiencies following a survey completed on 2024-12-11 at Holston Health & Rehabilitation Center documenting care plan and falls-related deficiencies.
Findings
The survey cited F0656 for failure to develop and implement complete care plans, finding the facility failed to develop an anticoagulant medication care plan for Resident #23 and failed to implement fall interventions for Resident #60; Level of Harm noted as Minimal and Residents Affected noted as Few.
Citations (2)
F0656: The facility failed to develop a comprehensive care plan for anticoagulant medication for Resident #23; the medical record and physician orders indicated the resident received warfarin but no anticoagulant care plan was present.
F0656: The facility failed to implement the care plan for falls for Resident #60; observations showed the bed was not in the lowest position, the tab alarm was not attached to the resident's clothing, and only one fall mat was in use though the care plan required two and a low bed.
Report Facts
Residents reviewed for falls: 5
Residents reviewed for care plans: 18
Residents with falls care plan issue: 1
Residents with anticoagulant care plan issue: 1
Inspection Report — Mar 23, 2022
Enforcement
Date: Mar 23, 2022
Visit Reason
Statement of Deficiencies following a nursing home survey completed on 2022-03-23 that assessed resident dignity and facility QAPI/infection prevention practices.
Findings
F 0550: The facility failed to protect resident dignity and confidentiality by posting medical information visible in resident rooms for 10 residents. F 0868: The facility failed to ensure the Infection Preventionist attended 11 scheduled QAPI meetings held from 02/16/2021–02/15/2022.
Citations (2)
F 0550: The facility failed to protect residents' dignity and confidentiality by posting medical information on signs visible in the rooms of Residents #2, #17, #18, #25, #33, #52, #63, #67, #183, and #185.
F 0868: The facility failed to ensure the Infection Preventionist attended required QAPI meetings, with signature lines blank for 11 scheduled QAPI meetings from 02/16/2021 to 02/15/2022.
Report Facts
Residents with visible medical information: 10
Residents reviewed for dignity: 77
QAPI meetings missed: 11
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