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Deficiency Records for Holston Health and Rehabilitation

View the most recent health deficiencies and inspection results for Holston Health and Rehabilitation. Stay informed about quality of care issues.

View the most recent health deficiencies and inspection results for Holston Health and Rehabilitation. Stay informed about quality of care issues.

Deficiency Type of Deficiency Deficiency Date Date Corrected Resulted from a Complaint?
To conduct inspection, testing and maintenance of fire doors by qualified individuals. Fire Safety 2025-05-07 2025-09-25 N
Meet other general requirements. Fire Safety 2025-05-07 2025-09-25 N
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Health 2025-05-07 2025-09-04 N
Provide care or services that was trauma informed and/or culturally competent. Health 2025-05-07 2025-09-04 N
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Health 2025-05-07 2025-09-04 N
Provide safe and appropriate respiratory care for a resident when needed. Health 2025-05-07 2025-09-04 N
Ensure that residents are free from significant medication errors. Health 2025-05-07 2025-09-04 N
Allow residents to self-administer drugs if determined clinically appropriate. Health 2025-05-07 2025-09-04 N
Provide and implement an infection prevention and control program. Health 2025-05-07 2025-09-04 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2025-05-07 2025-09-04 N
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2025-05-07 2025-09-04 Y
Ensure each resident receives an accurate assessment. Health 2025-05-07 2025-09-04 N
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Health 2025-05-07 2025-06-06 N
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Health 2025-05-07 2025-06-06 N
Ensure services provided by the nursing facility meet professional standards of quality. Health 2025-05-07 2025-06-06 N
Provide enough food/fluids to maintain a resident's health. Health 2025-05-07 2025-06-06 N
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Health 2025-05-07 2025-06-06 N
Provide safe, appropriate pain management for a resident who requires such services. Health 2025-05-07 2025-06-06 N
Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. Health 2025-05-07 2025-06-06 N
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. Health 2025-05-07 2025-06-06 N
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Health 2025-05-07 2025-06-06 N
Address subsistence needs for staff and patients. Fire Safety 2025-05-07 2025-06-06 N
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Health 2025-05-07 2025-06-06 N
Provide timely, quality laboratory services/tests to meet the needs of residents. Health 2025-05-07 2025-06-06 N
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. Health 2025-05-07 2025-06-06 N
Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them. Health 2025-05-07 2025-06-06 N
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members. Health 2025-05-07 2025-06-06 N
Provide behavior health training consistent with the requirements and as determined by a facility assessment. Health 2025-05-07 2025-06-06 N
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Health 2025-05-07 2025-06-06 Y
Employ staff that are licensed, certified, or registered in accordance with state laws. Health 2025-05-07 2025-06-06 Y
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Health 2025-05-07 2025-06-06 N
Establish staff and initial training requirements. Fire Safety 2025-05-07 2025-06-06 N
Conduct testing and exercise requirements. Fire Safety 2025-05-07 2025-06-06 N
Establish policies and procedures for volunteers. Fire Safety 2025-05-07 2025-06-06 N
Address patient/client population and determine types of services needed. Fire Safety 2025-05-07 2025-06-06 N
Prepare residents for a safe transfer or discharge from the nursing home. Health 2025-05-07 2025-06-06 N
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Health 2025-05-07 2025-06-06 N
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Health 2025-05-07 2025-06-06 N
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. Health 2025-05-07 2025-06-06 N
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2024-02-02 2024-03-13 Y
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Health 2024-02-02 2024-03-13 Y
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Health 2024-02-02 2024-03-13 Y
Assess the resident when there is a significant change in condition Health 2024-02-02 2024-03-13 Y
Keep all essential equipment working safely. Health 2024-02-02 2024-03-13 Y
Ensure services provided by the nursing facility meet professional standards of quality. Health 2024-02-02 2024-03-13 Y
Provide and implement an infection prevention and control program. Health 2024-02-02 2024-03-13 Y
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2024-02-02 2024-03-13 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2024-02-02 2024-03-13 Y
Provide enough food/fluids to maintain a resident's health. Health 2024-02-02 2024-03-13 Y
Provide safe and appropriate respiratory care for a resident when needed. Health 2024-02-02 2024-03-13 Y
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. Health 2024-02-02 2024-03-13 Y
Provide medically-related social services to help each resident achieve the highest possible quality of life. Health 2024-02-02 2024-03-13 Y
Ensure each resident?s drug regimen must be free from unnecessary drugs. Health 2024-02-02 2024-03-13 Y
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Health 2024-02-02 2024-03-13 Y
Use approved construction type or materials. Fire Safety 2022-05-12 2023-01-19 N
Ensure proper usage of power strips and extension cords. Fire Safety 2022-05-12 2022-12-30 N
To conduct inspection, testing and maintenance of fire doors by qualified individuals. Fire Safety 2022-05-12 2022-12-30 N
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. Fire Safety 2022-05-12 2022-12-30 N
Have approved installation, maintenance and testing program for fire alarm systems. Fire Safety 2022-05-12 2022-12-30 N
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. Fire Safety 2022-05-12 2022-12-30 N
Have properly installed electrical wiring and gas equipment. Fire Safety 2022-05-12 2022-12-30 N
Provide rooms that can be unlocked from inside without a key. Fire Safety 2022-05-12 2022-10-03 N
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. Fire Safety 2022-05-12 2022-10-03 N
Provide a written emergency evacuation plan. Fire Safety 2022-05-12 2022-10-03 N
Install corridor and hallway doors that block smoke. Fire Safety 2022-05-12 2022-10-03 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2022-05-12 2022-10-03 N
Have properly located and lighted "Exit" signs. Fire Safety 2022-05-12 2022-10-03 N
Perform COVID19 testing on residents and staff. Health 2022-05-12 2022-05-13 N
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Health 2022-05-12 2022-05-13 N
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Health 2022-05-12 2022-05-13 N
Have properly installed electrical wiring and gas equipment. Fire Safety 2019-06-07 2019-07-29 N
Install an approved automatic sprinkler system. Fire Safety 2019-06-07 2019-07-29 N
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. Fire Safety 2019-06-07 2019-07-29 N
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Fire Safety 2019-06-07 2019-07-29 N
Provide and implement an infection prevention and control program. Health 2019-06-07 2019-07-19 N
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Health 2019-06-07 2019-07-19 N
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Health 2019-06-07 2019-07-19 N
Ensure that residents are free from significant medication errors. Health 2019-06-07 2019-07-19 N
Ensure medication error rates are not 5 percent or greater. Health 2019-06-07 2019-07-19 N
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Health 2019-06-07 2019-07-19 N
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Health 2019-06-07 2019-07-19 N
Provide safe, appropriate pain management for a resident who requires such services. Health 2019-06-07 2019-07-19 N
Provide safe and appropriate respiratory care for a resident when needed. Health 2019-06-07 2019-07-19 N
Provide for the safe, appropriate administration of IV fluids for a resident when needed. Health 2019-06-07 2019-07-19 N
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Health 2019-06-07 2019-07-19 N
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2019-06-07 2019-07-19 N
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2019-06-07 2019-07-19 N
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Health 2019-06-07 2019-07-19 N
Ensure each resident receives an accurate assessment. Health 2019-06-07 2019-07-19 N
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Health 2019-06-07 2019-07-19 N
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Health 2019-06-07 2019-07-19 N
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2019-06-07 2019-07-19 N

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