MT Pleasant Healthcare: Staffing Crisis Leaves Residents Soaked - TN
"I know it's going to be a bad night if the trays are still on the hall," CNA B told inspectors during a telephone interview on March 19. By the time she finished feeding residents, it could be 8:30 or 9 o'clock before she started her first rounds of turning and repositioning. "By that time the residents are soaked."
Federal inspectors visited MT Pleasant Healthcare and Rehabilitation on March 20, 2025, and what they documented was a facility running so short on staff that its own nurses were abandoning their clinical duties to work as aides, hospitality workers were answering call lights they weren't certified to answer, and residents with skin breakdown, rashes, and urinary tract infections were sitting for hours in their own waste.
CNA B described nights when she was the only certified nursing assistant in the entire building. When she went to lift residents out of their chairs using a mechanical lift, urine would run onto her. Residents who required two people to move safely were being moved alone because there was no one else on the hall to help. "They are so fragile I am afraid I might hurt them," she said, "and that is hard when you are on the hall by yourself."
She said she connected the staffing conditions directly to what she was seeing in residents' bodies. Skin problems. Rashes. Infections. "It is because they are sitting in s— for hours."
When she raised these concerns with management, she said she was told to take a break. If she pushed further, she was told she was being aggressive. The facility wanted point-of-care charting at 100 percent. She said she sometimes couldn't sit down to do any charting until midnight.
CNA A, interviewed the morning of March 19, said she was caring for 20 residents that day. She noted that hospitality aides were helping answer call lights and pass ice but could not provide any direct care because they were uncertified.
The facility's preferred staffing level was five to six CNAs on the day shift. RN J told inspectors the facility had been dealing with illness for about a month and had been running four most days. "This week has been harder," she said. "Mostly three this week."
Three CNAs, by the facility's own account, for what inspection records indicate is a building with enough residents that individual aides were carrying loads of 20 people each.
LPN L confirmed she tried to help with rounds when she could, but her nursing duties consumed her time. She noted her hall had gone from two CNAs to one.
The Director of Nursing, interviewed on the afternoon of March 20, said a CNA could manage 20 residents if nurses provided support between medication passes. She then listed what nurses are actually doing during those same hours: a morning medication pass that takes two to three hours, additional medication passes throughout the day, meal assistance, wound care, family and physician communication, falls, and occasional lab draws.
The math was not addressed.
Inspectors also found the facility had failed to obtain timely skin treatment orders for one resident, and had failed to maintain registered nurse coverage for eight consecutive hours a day, seven days a week, as required.
CNA B said she had expressed her concerns repeatedly. The response, she said, was consistent. Management told her to take a break. If she pressed, she was told she was being aggressive.
The residents she described, the ones left in chairs all day, the ones soaked through by the time night rounds finally began, did not appear by name in the inspection report. They were there, though. She knew them well enough to be afraid of hurting them.
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.
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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.
"I know it's going to be a bad night if the trays are still on the hall," CNA B told inspectors during a telephone interview on March 19.
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.