MT Pleasant Healthcare: Drug Storage Failures - TN
The nurse already knew it was wrong.
The March 2025 inspection of MT Pleasant Healthcare and Rehabilitation flagged one of the facility's four medication storage areas for failing to keep drugs separated according to the facility's own written policy. The violation was cited at a level of minimal harm or potential for actual harm, affecting a small number of residents.
The mixing of medication types is not a minor bookkeeping problem. Antacid tablets are swallowed. Eye drops are instilled directly into the eye. Ear wax removal solution is applied to the ear canal. Topical Lidocaine is a pain medication absorbed through the skin. Nicotine patches deliver a drug transdermally. Each formulation is designed for a specific route of administration, and errors in how medications are selected and prepared, especially in a fast-moving care environment, carry real risk.
The facility's own Medication Storage policy, revised as recently as September 2024, is explicit. External products, meaning drugs for external use, are to be stored separately from internal medications. Oral medications, those taken by mouth, are to be stored separately from other formulations, with eye drops listed as a specific example.
On the morning of March 19, 2025, at 10:56 a.m., an inspector observed Registered Nurse L working at the White medication cart and asked her to open it. The antacid tablets were there with the eye drops. The ear wax removal bottle was there with the Lidocaine and nicotine patches. The inspector asked RN L directly whether those medications should be stored together. She said no.
The next afternoon, at 4:45 p.m. on March 20, the Director of Nursing was interviewed. She was asked whether oral medications should be stored with eye drops. She said no. She was asked whether an ear wax removal kit should be stored with topical patches. She said no.
Both the nurse working the cart and the facility's top nursing administrator confirmed the same thing: what inspectors found was not how medications were supposed to be stored. The policy said so. They said so. The cart said otherwise.
What the inspection report does not explain is how long the medications had been stored that way, or how many times nurses had opened that cart and worked around the mixing without correcting it. The report covers one observation, one cart, one morning. It notes the violation affected one of four medication storage areas reviewed.
MT Pleasant Healthcare and Rehabilitation is a nursing and rehabilitation facility in Maury County, in middle Tennessee. The March 20 inspection was a standard health survey.
The citation carries the lowest level of harm designation available under the federal inspection framework. That classification reflects the absence of documented injury to a resident, not the absence of risk. Medications pulled from a disorganized cart under time pressure, by a nurse working through a full medication pass, are medications that can end up in the wrong hands, administered by the wrong route, to the wrong person.
The nurse who opened the cart knew the storage was wrong. The director of nursing knew it was wrong. The policy, updated six months before inspectors arrived, knew it was wrong.
The cart stayed the way it was until someone came to look.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Mt Pleasant Healthcare and Rehabilitation from 2025-03-20 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Corrections: We strive for accuracy in everything we publish. If you believe any fact in this article is incorrect, please contact us with details, and we will review and correct it promptly.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: November 2, 2026 · Our methodology
MT PLEASANT HEALTHCARE AND REHABILITATION in MOUNT PLEASANT, TN was cited for violations during a health inspection on March 20, 2025.
The nurse already knew it was wrong.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.