Focused Care at Mount Pleasant: Wound Records Altered - TX
The resident, identified in inspection records only as Resident 7, had a pressure ulcer on the left ischium, a bone in the lower pelvis. On November 7, 2025, the wound care NP examined the wound and documented that it was worsening. A nursing wound assessment completed the same day said the same thing.
Then, on November 12, an audit report showed that the November 7 nursing assessment had been changed. Where it once said the wound was worsening, it now said improving.
The wound care NP, interviewed by inspectors on the morning of November 12, said he expected nursing wound assessments completed on the same day as his own to match his clinical findings on whether a wound was improving, stable, or worsening. He had documented worsening. The nursing assessment, after the change, said the opposite.
The Director of Nursing was interviewed that same afternoon. He said he expected clinical documentation to reflect what the wound care physician documented. He said accurate documentation mattered because it drove the care residents actually received.
That evening, at 5:50 p.m., the facility's administrator sent an email to inspectors. She was unable to locate a policy on accuracy of documentation.
The alteration matters beyond the paperwork. A pressure ulcer documented as improving looks different to a care team than one documented as worsening. It changes what interventions get ordered, how urgently staff respond, and whether family members are notified that a wound is getting worse. When a wound care NP and a nursing assessment say opposite things about the same wound on the same day, someone making a care decision later has no way of knowing which record to trust — or that there was ever a conflict at all, because the original entry is gone.
Inspectors cited the facility under F0842, which covers the accuracy and completeness of medical records. The deficiency was cited at a level of minimal harm or potential for actual harm, affecting a small number of residents.
That citation level reflects the regulatory framework's assessment, not necessarily what was at stake for Resident 7. A pressure ulcer on the ischium is the kind of wound that can deteriorate quickly in a resident who spends significant time sitting or in bed. The wound care NP had already flagged it as worsening on November 7. Whatever happened to that wound in the days that followed, the nursing record, as altered, would have shown it going in the other direction.
The inspection was a complaint investigation, meaning someone — a resident, a family member, or a staff member — contacted regulators before inspectors arrived. The report does not say who filed the complaint or what it alleged.
What inspectors found when they got there was a record that had been quietly rewritten, a wound care NP whose clinical findings had been contradicted after the fact, and an administrator who, when asked about documentation standards, couldn't point to a policy that addressed them.
The Director of Nursing said accurate documentation was important to provide appropriate care. The treatment nurse who changed the record apparently reached a different conclusion about what the record should say.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Focused Care At Mount Pleasant from 2025-11-26 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.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 26, 2026 · Our methodology
Focused Care at Mount Pleasant in Mount Pleasant, TX was cited for violations during a health inspection on November 26, 2025.
The resident, identified in inspection records only as Resident 7, had a pressure ulcer on the left ischium, a bone in the lower pelvis.
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.