Mt Pleasant Healthcare And Rehabilitation
MT PLEASANT HEALTHCARE AND REHABILITATION in MOUNT PLEASANT, TN — inspection on March 20, 2025.
Found 8 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Review of Progress Notes dated 4/14/2024, revealed Resident #165 was seen by the Medical Director.
Review of TIBRS (Tennessee Incident Based Reporting System) Narrative dated 4/12/2024 at 10:28 AM, revealed The Director of Nursing (DON ) .stated the staff was made aware of the allegations by a resident of the facility [Named Resident #165] on Wednesday April 10, 2024, and began looking into the allegations .there was an allegation that [Named LPN H] had inappropriate sexual contact with [Named Resident #165] on Tuesday 4/9/2024 during an examination of her pelvic and buttocks region due to complaints of hurting in the area.
The DON stated [Named Resident #165] had a growth on her pelvic region that requires them to have 2 staff with peri care.
Law enforcement reported Resident #165 was confused and was on the phone when she was interviewed. [Named Resident #165] reported to law enforcement she had been raped by [Named LPN H]. [Named Resident #165] allegedly reported she was asleep and knew he had sex with her.After getting information for a report I left the facility. I was contacted a short time later by [Named DON] and advised that after I left Named Resident [Resident #165] requested to speak with her. [Named Resident #165] informed the [named DON] that what she told did not happen.
She stated she lied about it because she was mad.
Named DON stated [Named Resident #165] had called her friend [Named FM I] and told her it was all a lie. [Named FM I] also stated she was on the phone with [Named Resident #165] when I [law enforcement] was speaking with her and she told me something totally different than she told her.
Due to [Named Resident #165] stating she lied about the allegations this report is closed as unfounded .
The Administrator was asked on 3/19/2025 to supply a copy of the URIS report mentioning Resident #165 and was unable to provide.
An email was sent to the Ombudsman on 3/19/2025 at 8:59 AM, asking whether she had been notified of the allegation of sexual abuse by Named Resident #165 and the Ombudsman stated, she had not been notified.
During an interview on 3/20/2025 at 4:45 PM, the Director of Nursing (DON) was asked whether education was done after the allegation of abuse by Resident #165, and she responded No.
The DON was asked when this incident was reported to the state agency and she stated, it was not reported to the state agency.
During an interview in the Conference Room on 3/20/2025 at 5:15 PM, the Administrator was asked if she was the Abuse Coordinator, and she responded that she was, and the DON would fill in when she was absent.
The Administrator was asked when should abuse be reported and the Administrator responded, immediately.
The Administrator was asked whether she reported the incident between Resident #165 and LPN H to the State Agency and she responded, I did not because the investigation was completed with the 2-hour window. A follow up question was asked .
The Administrator stated, [Named LPN H] was suspended pending investigation.
445374 03/20/2025
MT Pleasant Healthcare and Rehabilitation 904 Hidden Acres Dr Mount Pleasant, TN 38474
During an interview on 3/19/2025 at 11:06 AM, CNA E was asked how often the female residents
Review of the medical record revealed Resident #19 was admitted to the facility on [DATE], with diagnoses including Alzheimer's, Bipolar Disorder, Anxiety, and Major Depressive Disorder.
Review of the annual MDS assessment dated [DATE], revealed a BIMS score of 13, which indicated Resident #19 was cognitively intact, uses wheelchair for mobility and required substantial to maximal assist for shower/bath and supervision or touching assist needed for personal hygiene.
Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 12, which indicated Resident #19 was moderately cognitively impaired, required substantial to maximal assist needed for shower/bath and transfers, and supervision or touching assist needed for personal hygiene.
445374 03/20/2025
MT Pleasant Healthcare and Rehabilitation 904 Hidden Acres Dr Mount Pleasant, TN 38474
Review of the care plan revised 2/10/2025, revealed .Resident will not exhibit skin breakdown .Apply moisture barrier to skin .Report any signs of skin breakdown .
Review of the facility's form titled, Skin Integrity Events, dated 3/14/2025, revealed .MASD [Moisture-Associated Skin Damage] to right and left buttock .zinc cream [used to protect skin from being irritated and wet] twice a day .
Review of the Physicians Orders dated 3/14/2025- 3/18/2025, revealed no order for zinc cream.
Review of the Progress Notes dated 3/14/2025 - 3/18/2025, revealed no documentation regarding the resident's skin condition.
Review of the Physicians Orders dated 3/19/2025, revealed .Zinc to bil. bouttucks [bilateral buttocks] BID [twice a day] .
Review of the progress note dated 3/19/2025 at 1:49 PM, the Advanced Practice registered Nurse Practitioner (APRN NP) documented, .Seen today for evaluation of MASD.
The resident has skin irritation, redness to b/l [bilateral] buttocks .consult wound care. cleanse area with wound cleanser, apply zinc oxide to affected area BID until healed .
During an interview in the resident's room on 3/17/2025 at 11:47 AM, the resident confirmed she has an open spot on her bottom and the staff is aware.
During an interview on 3/19/2025 at 10:53 AM, the ADON was asked what the process is when a resident has a new skin condition, she stated, .document in progress note .who we contacted .implement those verbal orders .enter the order in the computer .
The ADON acknowledged there was not a physician's order from 3/14/2025 - 3/19/2025 for treatment of the MASD.
The ADON was asked if any treatments were provided from 3/14/2025-3/19/2025, she stated, .I do know she was getting the zinc applied .
Observation in the resident's room on 3/19/2025 at 3:09 PM with the ADON revealed MASD to buttocks as described in event note.
During an interview on 3/20/2025, at 4:44 PM, the DON was asked what should be done when a skin issue is identified, she stated, .notify the md [Medical Doctor] .look at it .do an event .notify family .get an order for treatment .
The DON acknowledged that an identified skin issue should be documented in the medical record, should receive an order on the day a skin issue is identified, and that nursing staff cannot treat a skin issue without an order.
445374 03/20/2025
MT Pleasant Healthcare and Rehabilitation 904 Hidden Acres Dr Mount Pleasant, TN 38474
During an interview on 3/19/25 at 11:11 AM, CNA A stated, .I am taking care of 20 residents today .the hospitality aides answer call lights, help with activities, pass ice, they cannot give any direct care because they are uncertified .
During a telephone interview on 3/19/2025 at 6:03 PM, CNA B was asked about staffing for the facility. CNA B stated, .it is bad .I work night shift 7 PM to 7 AM, there have been numerous nights I have come in and meals are still not passed out and I have to feed residents on the hall .I know it's going to be a bad night if the trays are still on the hall .the nurses are having to work the floor as CNAs at times because we don't have enough help .baths are not getting done . CNA B was asked if she was able to complete incontinence care, turning and repositioning every 2 hours. CNA B stated, .when we come in and trays are still out it maybe 8:30 [8:30 PM] or 9:00 [9:00 PM] before we can ever start our turns by that time the residents are soaked .residents are left up in their chairs all day and when I go to get them out of the chair with the lift, the urine will get on me .I know of several days that only 1 CNA in the whole building .there are times I don't get to sit down to do any charting until 12:00 [12:00 AM] .I have expressed my concerns to nursing and they tell me just take a break for a little while .If you raise any concerns about the resident care the management staff will say your being aggressive .they want that point of care charting to be 100% .resident with skin issues, rashes, UTI's [Urinary Tract Infections] and it is because they are sitting in s . for hours .residents that really need 2 person assist you have to find help because they are so fragile I am afraid I might hurt them and that is hard when you are on the hall by yourself .there are 3 areas where you can chart showers either on paper or when you go in the computer you click on a link for ADLs and you either chart shower or bath .
During an interview on 3/20/2025 at 9:08 AM, CNA N was asked why most CNA's have 20 residents a piece to care for CNA N stated, We have been short staffed this week.
During an interview on 3/20/2025 at 8:20 AM, Licensed Practical Nurse (LPN) L confirmed she tries to assist staff with rounds when she can but her duties as a nurse often consume all her time. LPN L stated that there were 2 CNAs on her hall but now it is 1 and it is a lot for them to do.
During an interview on 3/20/2025 at 8:27 AM, Registered Nurse (RN) J was asked how many CNAs usually work during the day. RN J stated, .We like to run 5-6, but we've had a lot of sickness over the last month.
Most days we have had 4 people, this week has been harder, mostly 3 this week .
During an interview on 3/20/2025 at 4:46 PM, the Director of Nursing (DON) was asked if a CNA could give adequate care to 20 residents.
The DON stated that they could if they have support from the nurses, and that the nurses could assist with giving showers and doing ADLs between med passes.
The DON confirmed the morning medication pass takes 2 to 3 hours and nurses give medications throughout the day, assist with meals, provide wound care, communicate with family and physicians, deal with events such as falls, and occasionally do lab draws.
Refer to F-F677, F-F684, F-F727
445374 03/20/2025
MT Pleasant Healthcare and Rehabilitation 904 Hidden Acres Dr Mount Pleasant, TN 38474
cannot . referring to accessing a PICC line.
445374 03/20/2025
MT Pleasant Healthcare and Rehabilitation 904 Hidden Acres Dr Mount Pleasant, TN 38474
Review of the facility policy titled Nursing Services and Sufficient Staff, dated 1/23/2025 revealed, .It is the policy of this facility to provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident.
The facility's census, acuity and diagnoses of the resident population will be considered based on the facility assessment .The facility must ensure that licensed nurses have the specific competencies and skill sets necessary to care for resident's needs as identified through resident assessments and described in the plan of care .Except when waived, the facility must use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week .The Director of Nursing [DON] may serve as a charge nurse only when the facility has an average daily occupancy of 60 or fewer residents .
Review of the facility's licensure information revealed the facility has 4 RNs. Review of the staffing clock in and out punches for 2/15/2025, and 2/22/2025 revealed no RN coverage for 8 consecutive hours.
Review of the staffing clock in and out punches for 3/6/2025, revealed no RN coverage for 8 consecutive hours.
Director of Nursing (DON) worked 8.5 hours; facility census was 64.
Review of the facility's Daily Nurse Staffing Form dated 3/6/2025, revealed there were no RNs scheduled that date.
During an interview on 3/20/2025 at 4:46 PM, the DON confirmed there must be RN coverage for 8 consecutive hours every day and that the DON cannot serve as a charge nurse if the facility's average daily occupancy is greater than 60.
445374 03/20/2025
MT Pleasant Healthcare and Rehabilitation 904 Hidden Acres Dr Mount Pleasant, TN 38474
Based on facility policy, observation and interview the facility failed to store all drugs in accordance
The findings include:
Review of the facility policy titled, Medication Storage, with revision date 9/2024 revealed, .It is the policy to this facility to ensure all medications housed on our premises will be stored in accordance to .External Products .drugs for external use are stored separately from internal .medications .Internal Products: Medications to be administered by mouth are stored separately from other formulations ( .eye drops .).
- During an observation and interview on 3/19/2025 at 10:56 AM, Registered Nurse (RN) L was
working on the White medication cart. RN L was asked to open the medication cart so surveyor could review the storage of medications.
Continued observation revealed a bottle of antacid chewable tablets stored with eye drops and an ear wax removal bottle stored with the topical Lidocaine (topical pain medication) and Nicotine (transdermal patch used to quit smoking) patches. RN L was asked if these medications should be stored together and she stated, No.
During an interview on 3/20/2025 at 4:45 PM, the Director of Nursing (DON) was asked if oral medications should be stored with the eye drops; she stated, No.
The DON was asked should an ear wax removal kit be stored with topical patches and she stated, No.
Review of the facility policy titled, Nursing Services and Sufficient Staff, dated 1/23/2025 revealed, .It is the policy of this facility to provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident .The facility must ensure that licensed nurses have the specific competencies and skill sets necessary to care for resident's needs as identified through resident assessments and described in the plan of care .
2.
Review of the facility policy titled, Facility Assessment, revised 1/25/2025 revealed, .The facility assessment will, at a minimum, address or include .care required by the resident population, using evidence-based, data-driven methods .staff competencies and skill sets that are necessary to provide the level and types of care needed .
3.
Review of CHAPTER 1000-02 RULES AND REGULATIONS OF LICENSED PRACTICAL NURSES dated 10/2024, revealed 1000-02-.02 (3), .Licensed Practical Nurses shall not administer the following fluids/medication/agents or drug classifications in the context of intravenous therapy .Titrated medication and dosages calculated and adjusted by the nurse based on patient assessment and/or interpretation of lab values . and 1000-02-.02 (4) (a) 1.The Licensed Practical Nurse administers IV [Intravenous] push medications in peripheral lines [flexible tube inserted into a vein in the arm, hand, leg, or foot] only .
4.
Review of the medical record revealed Resident #50 admitted on [DATE] and readmitted on [DATE] with diagnoses which included Osteomyelitis of Vertebra (bone infection of the spinal column), lumbar region.
Review of the Admission Minimum Data Set (MDS) dated [DATE], revealed Resident #50 was receiving IV medications over the last 7 days.
Review of the Physician Order Report dated 2/20/2025-3/20/2025 revealed an order for PICC line for Antibiotic (ATB) infusion with start date 3/12/2025.
Continued review revealed an order for Vancomycin (Antibiotic given that may require blood levels to monitor dosage) 1,250 mg (milligram) intravenous with start date of 1/28/2025 and Ceftriaxone (antibiotic) 2 gm (gram) intravenous with start date of 2/27/2025.
445374
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 445374 B.
Wing 03/20/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
MT Pleasant Healthcare and Rehabilitation 904 Hidden Acres Dr Mount Pleasant, TN 38474
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.