Inspection Reports for Holston Health And Rehabilitation Center
3916 Boyds Bridge Pike, Knoxville, TN 37914, United States, TN, 37914
Back to Facility ProfileInspection Report Summary
The most recent inspections on December 11, 2024, identified deficiencies related to resident care planning and protection from abuse and misappropriation. Earlier inspections noted issues with resident confidentiality, infection prevention oversight, and care plan implementation, showing a pattern of challenges in care coordination and resident safety. Inspectors cited failures to develop and implement comprehensive care plans, protect residents from physical abuse by others, and prevent staff misappropriation of resident funds. Complaint investigations included substantiated findings of resident abuse and staff theft, with the involved staff member resigning; enforcement actions were not listed in the available reports. The facility’s inspection history shows recurring issues in care planning and resident protection without a clear trend of improvement or worsening.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
55% better than Tennessee average
Tennessee average: 4.4 deficiencies/yearDeficiencies per year
4
3
2
1
0
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Dec 11, 2024
Visit Reason
The inspection was conducted due to complaints involving resident abuse and misappropriation of resident property at Holston Health & Rehabilitation Center.
Complaint Details
The complaint investigation involved a resident-versus-resident altercation where Resident #84 hit Resident #51, and a staff member (CNA A) who misappropriated two personal checks from Resident #287. The abuse was substantiated based on witness statements and medical record reviews. The misappropriation was confirmed by bank and police reports, and the staff member resigned after being placed on administrative leave.
Findings
The facility failed to protect residents from physical abuse and misappropriation of property. One resident was physically hit by another resident, and a staff member was found to have stolen and cashed two personal checks from a resident without consent.
Deficiencies (2)
Failed to ensure a resident was free from physical abuse when another resident hit her on the left arm.
Failed to protect a resident from misappropriation of personal monetary funds by a staff member who cashed two checks without consent.
Report Facts
Residents sampled for abuse: 81
Residents sampled for misappropriation: 81
Checks cashed: 2
Check value: 525
Active employees educated: 75
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA C | Certified Nursing Assistant | Witnessed and reported the resident-versus-resident altercation |
| LPN E | Licensed Practical Nurse | Provided interview details about the resident altercation and supervision |
| CNA A | Certified Nursing Assistant | Staff member who misappropriated resident's personal checks and resigned after investigation |
| Administrator | Provided interviews and confirmed findings related to both abuse and misappropriation investigations |
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Dec 11, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with care planning requirements, specifically focusing on the development and implementation of comprehensive care plans for residents, including fall interventions and anticoagulant medication management.
Findings
The facility failed to develop a comprehensive care plan for anticoagulant medication for one resident and failed to implement fall interventions as care planned for another resident. Observations and interviews confirmed that fall prevention measures such as tab alarms and fall mats were not used as specified in the care plan, and beds were not positioned correctly.
Deficiencies (2)
Failed to develop a comprehensive care plan for anticoagulant medication for Resident #23.
Failed to implement fall interventions as care planned for Resident #60, including improper use of tab alarm, insufficient fall mats, and bed not in lowest position.
Report Facts
Residents reviewed for falls: 5
Residents reviewed for care plans: 18
Fall mats required: 2
Fall mats in use: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MDS Coordinator B | MDS Coordinator | Confirmed Resident #23's care plan did not include anticoagulant medication |
| Certified Nursing Assistant F | Certified Nursing Assistant | Provided information about Resident #60's fall risk and bed/fall mat status |
| Licensed Practical Nurse G | Licensed Practical Nurse | Provided information about Resident #60's fall risk and tab alarm use |
| Certified Nursing Assistant H | Certified Nursing Assistant | Provided information about Resident #60's bed and fall mat requirements |
| Assistant Director of Nursing | Assistant Director of Nursing | Confirmed Resident #60's fall interventions and deficiencies in implementation |
Inspection Report
Routine
Census: 77
Deficiencies: 2
Date: Mar 21, 2022
Visit Reason
The inspection was conducted to assess compliance with residents' rights to dignity and confidentiality, and to evaluate the facility's Quality Assessment and Assurance group membership and meeting attendance.
Findings
The facility failed to ensure medical information signage was not visible in residents' rooms for 10 residents, violating confidentiality and dignity rights. Additionally, the facility failed to ensure the Infection Preventionist attended the 11 scheduled Quality Assurance and Performance Improvement meetings over the past year.
Deficiencies (2)
Medical information signage was visible above beds of 10 residents without documented consent, violating residents' rights to dignity and confidentiality.
Infection Preventionist did not attend any of the 11 scheduled Quality Assurance and Performance Improvement meetings from 2/16/2021 to 2/15/2022.
Report Facts
Residents reviewed for dignity: 77
Residents affected by signage deficiency: 10
Scheduled QAPI meetings missed: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Confirmed presence and visibility of signage above residents' beds during observations and interviews | |
| Infection Preventionist | Stated not attending any QAPI meetings since December 2021 | |
| Administrator | Confirmed lack of Infection Preventionist attendance at QAPI meetings and unawareness of attendance requirement |
Inspection Report
Deficiencies: 0
Date: Nov 6, 2019
Visit Reason
The document is a statement of deficiencies and plan of correction for Holston Health & Rehabilitation Center, summarizing the findings of a regulatory survey completed on November 6, 2019.
Findings
No health deficiencies were found during the survey.
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