MT Pleasant Healthcare: Rape Allegation Unreported - TN
The allegation involved LPN H, a male nurse who had conducted an examination of the resident's pelvic and buttocks region on April 9, 2024, after she reported pain in that area. The resident, identified in inspection records as Resident 165, had a growth on her pelvic region that required two staff members to be present during perineal care. Whether two staff were present during that examination is not addressed anywhere in the inspection report.
Two days later, on April 10, the facility's Social Service Director documented that Resident 165 was making what the director described as "false accusations about staff/care received." Two days after that, on April 12, the Director of Nursing filed a report with the Tennessee Incident Based Reporting System. In it, she described how staff had learned of the allegations on April 10 and had begun looking into them. Law enforcement came to the facility. Officers noted that Resident 165 was confused and was on the phone during the interview. She told them she had been raped. She said she was asleep and knew he had sex with her.
Then the story shifted.
After law enforcement left the building, the Director of Nursing called them back. She said Resident 165 had asked to speak with her and had told her the whole thing was a lie. She said she had made it up because she was angry. She had also called a friend, identified as FM I, and told her the same. FM I told law enforcement she had been on the phone with Resident 165 during the police interview and that Resident 165 told her something entirely different from what she told the officers. Law enforcement closed the case as unfounded.
LPN H was suspended pending investigation.
And then, according to what federal inspectors found nearly a year later, almost nothing else happened.
The facility never reported the allegation to the state agency. The ombudsman, whose role is to advocate for nursing home residents and who is typically notified of abuse allegations, was never contacted. When inspectors sent an email to the ombudsman on March 19, 2025, asking whether she had been notified of the sexual abuse allegation involving Resident 165, she said she had not.
No staff education was conducted after the incident. The Director of Nursing confirmed this directly when inspectors interviewed her on March 20, 2025. She was asked whether any education had followed the allegation. She said no. She was asked when the incident had been reported to the state agency. She said it had not been.
The administrator's explanation, offered during an interview in the conference room on March 20, 2025, at 5:15 in the afternoon, was precise. She confirmed she served as the facility's abuse coordinator, with the Director of Nursing filling in during her absences. She was asked when abuse should be reported. She said immediately. She was then asked whether she had reported the incident involving Resident 165 and LPN H to the state agency. Her answer: "I did not because the investigation was completed with the 2-hour window."
That reasoning, that closing an internal investigation quickly eliminated the obligation to notify state regulators, is what inspectors flagged as a deficiency.
The inspection report also notes that when inspectors asked the administrator on March 19, 2025, to provide a copy of the facility's URIS report mentioning Resident 165, she was unable to produce it.
The Social Service Director's notes from the days surrounding the allegation frame it as a behavioral matter. The April 10 entry describes the resident making false accusations. The April 12 entry, written the same morning the TIBRS report was filed, describes Resident 165 as having "recently exhibited increase in socially inappropriate behaviors related to male staff members and making false allegations." The resident was seen by the facility's medical director on April 14.
What the notes do not reflect, and what the inspection record does not resolve, is how the facility reached its conclusion about the credibility of the allegation before any outside investigation was complete. Law enforcement closed the case after the resident recanted and her friend corroborated the recantation. The facility's own documentation, written two days before law enforcement was even involved, had already characterized her as making false accusations.
Resident 165's cognitive state is referenced only briefly in the record. Law enforcement noted she was confused during the interview. Her friend was on the phone with her during that same interview and reported that what Resident 165 said to police differed from what she said privately. The inspection report does not include any assessment of Resident 165's capacity to consent, her diagnosis, or the nature of her confusion. It does not say whether anyone at the facility requested a forensic examination.
The deficiency was cited at a level of minimal harm or potential for actual harm, affecting a small number of residents. That is the lowest tier of harm in the federal inspection framework. The citation addresses the failure to report and the failure to notify the ombudsman, not a finding that abuse occurred.
What the record shows, without dispute, is this: a resident said a male nurse had sex with her while she was asleep. The facility suspended the nurse. It documented her as someone with a pattern of false accusations and socially inappropriate behavior. It closed its internal inquiry within two hours. It did not call the state. It did not call the ombudsman. It did not train its staff on what had happened or what to watch for. It did none of this for nearly a year, until federal inspectors arrived and started asking questions.
When the ombudsman finally heard about Resident 165 in March 2025, it was because an inspector sent her an email. It had been eleven months.
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.
Whether two staff were present during that examination is not addressed anywhere in the inspection report.
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.