Holston Manor
3641 Memorial Blvd, Kingsport, TN 37664


Holston Manor is nursing home registered in the Centers for Medicare & Medicaid Services (CMS). The Provider Number is 445295. The address is 3641 Memorial Blvd, Kingsport, TN 37664. The zip code is 37664. The phone number is 4232462411.


Holston Manor · 3641 Memorial Blvd, Kingsport, TN 37664

Federal Provider Number 445295
Provider Name HOLSTON MANOR
Address 3641 MEMORIAL BLVD
KINGSPORT, TN 37664
Phone Number 4232462411
SSA County Code 810
County Name Sullivan
Ownership Type For profit - Corporation
Certified Beds 204
Certified Beds Residents 150
Provider Type Medicare and Medicaid
Resides in Hospital false
Legal Business Name HOLSTON NH OPERATIONS LLC
Date First Approved to Provide Medicare Medicaid Services 08/01/1992
Continuing Care Retirement Community false
Special Focus Facility false
Most Recent Health Inspection More Than 2 Years Ago false
Changed Ownership Last 12 Months false
With Resident Family Council Resident
Automatic Sprinkler Systems in All Required Areas Yes
Overall Rating 1
Health Inspection Rating 2
Quality Measure Rating 4
Staffing Rating 1
RN Staffing Rating 2
Reported CNA Staffing Hours per Resident per Day 1.74867
Reported LPN Staffing Hours per Resident per Day 0.76667
Reported RN Staffing Hours per Resident per Day 0.44833
Reported Licensed Staffing Hours per Resident per Day 1.215
Reported Total Nurse Staffing Hours per Resident per Day 2.96367
Reported Physical Therapist Staffing Hours per Resident Per Day 0.04733
Expected CNA Staffing Hours per Resident per Day 2.28541
Expected LPN Staffing Hours per Resident per Day 0.63755
Expected RN Staffing Hours per Resident per Day 1.05644
Expected Total Nurse Staffing Hours per Resident per Day 3.9794
Adjusted CNA Staffing Hours per Resident per Day 1.87744
Adjusted LPN Staffing Hours per Resident per Day 0.9981
Adjusted RN Staffing Hours per Resident per Day 0.31709
Adjusted Total Nurse Staffing Hours per Resident per Day 3.00203
Cycle 1 Total Number of Health Deficiencies 8
Cycle 1 Number of Standard Health Deficiencies 7
Cycle 1 Number of Complaint Health Deficiencies 1
Cycle 1 Health Deficiency Score 28
Cycle 1 Standard Survey Health Date 12/14/2016
Cycle 1 Number of Health Revisits 1
Cycle 1 Total Health Score 28
Cycle 2 Total Number of Health Deficiencies 11
Cycle 2 Number of Standard Health Deficiencies 8
Cycle 2 Number of Complaint Health Deficiencies 4
Cycle 2 Health Deficiency Score 48
Cycle 2 Standard Health Survey Date 12/16/2015
Cycle 2 Number of Health Revisits 1
Cycle 2 Total Health Score 48
Cycle 3 Total Number of Health Deficiencies 10
Cycle 3 Number of Standard Health Deficiencies 10
Cycle 3 Number of Complaint Health Deficiencies 2
Cycle 3 Health Deficiency Score 44
Cycle 3 Standard Health Survey Date 10/22/2014
Cycle 3 Number of Health Revisits 1
Cycle 3 Total Health Score 44
Total Weighted Health Survey Score 37.333
Number of Substantiated Complaints 6
Total Amount of Fines in Dollars $0.00
Processing Date 08/01/2017

Owner or Manager · Holston Manor

Owner Name Role Association Date
CASH, TERRENCE (Individual) 5% OR GREATER INDIRECT OWNERSHIP INTEREST
NO PERCENTAGE PROVIDED
since 01/01/2013
EPIC GROUP LP (Organization) 5% OR GREATER DIRECT OWNERSHIP INTEREST
100%
since 01/01/2013
HERZOG, LAVERNE (Individual) 5% OR GREATER INDIRECT OWNERSHIP INTEREST
NO PERCENTAGE PROVIDED
since 01/01/2013
HERZOG, LAVERNE (Individual) DIRECTOR since 01/01/2013
SMITH, LEONARD (Individual) MANAGING EMPLOYEE since 08/05/2014
SWAIN, WILLIAM (Individual) 5% OR GREATER INDIRECT OWNERSHIP INTEREST
NO PERCENTAGE PROVIDED
since 01/01/2013
SWAIN, WILLIAM (Individual) DIRECTOR since 01/01/2013

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