MT Pleasant Healthcare: Skin Treatment Gap - TN
The resident, identified in inspection records only as Resident 8, had been diagnosed with hemiplegia, diabetes, and hypertensive heart disease. A cognitive assessment had flagged her as having moderate impairment and as being at risk for pressure injuries. Her care plan, updated in February 2025, called for applying a moisture barrier to her skin and reporting any signs of breakdown.
On March 14, 2025, nursing staff documented moisture-associated skin damage, a condition known as MASD, to her right and left buttocks on an internal skin integrity form. They noted zinc cream was being applied twice a day. There was no physician's order for that treatment. There was nothing in her progress notes about her skin condition at all.
That gap held for five days.
When an inspector spoke with Resident 8 in her room on March 17, she confirmed she had an open spot on her bottom and that the staff was aware. The inspector reviewed her medical records. No order. No progress note entry. Staff were treating the wound anyway.
On March 19, the facility's assistant director of nursing acknowledged the missing order directly. Asked what the process is when a resident develops a new skin condition, she described a clear sequence: document in a progress note, record who was contacted, implement verbal orders, enter the order in the computer. Then she acknowledged none of that had happened between March 14 and March 19. Asked whether any treatments had been provided during those five days without an order, she said, "I do know she was getting the zinc applied."
That same day, a nurse practitioner saw the resident for the first time and documented what she found: skin irritation and redness to both buttocks. She ordered wound cleanser, zinc oxide twice daily, and a wound care consult. The physician's order, the one that should have existed on March 14, was entered on March 19.
The director of nursing was asked about the facility's protocol the following day. She described it the same way the ADON had: notify the doctor, examine the wound, complete an event report, notify the family, get an order for treatment. She acknowledged that a skin issue should be documented in the medical record on the day it is identified, that an order should be obtained that same day, and that nursing staff cannot treat a skin issue without one.
The inspection report rated the violation at a level of minimal harm or potential for actual harm, affecting a small number of residents. But the facts it contains describe something more specific than a paperwork gap. A woman with diabetes, a condition that impairs wound healing, had open skin damage on both sides of her lower body. Staff knew. They treated it. For five days, none of that appeared in her medical record, and no physician had authorized the treatment being given.
The inspection was completed March 20, 2025. MT Pleasant Healthcare and Rehabilitation is located at 904 Hidden Acres Drive in Mount Pleasant, Tennessee.
Resident 8 sat in her room on March 17 and told the inspector she had an open spot on her bottom. She said the staff knew. She was right. What she may not have known was that for the five days before that conversation, her wound existed in her chart only as silence.
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 resident, identified in inspection records only as Resident 8, had been diagnosed with hemiplegia, diabetes, and hypertensive heart disease.
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.