Focused Care At Mount Pleasant
Focused Care at Mount Pleasant in Mount Pleasant, TX — inspection on November 26, 2025.
Found 6 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
During an observation and interview attempt on 11/13/25 at 12:50 p.m. Resident #2 was observed wandering around the men's secured unit.
The surveyor attempted to interview Resident #2, but he just smiled and agreed to everything the surveyor said.
During an interview on 11/13/25 at 1:01 p.m. COTA B said she was exiting the shower with CNA C and another resident. COTA B said she observed LVN A walking with Resident #3. COTA B said when LVN A and Resident #3 walked past Resident #2 that Resident #3 accidentally bumped into Resident #2. COTA B said Resident #2 became agitated and started yelling and acting like he was going to hit Resident #3. COTA B said LVN A got in between Resident #2 and Resident #3. COTA B said LVN A began yelling at Resident #2 telling him he was not going to hit her people, and he needed to go sit his ass down.
During an interview on 11/13/25 at 1:11 p.m. the Administrator said she did not have an official disciplinary action for LVN A regarding the incident on 11/12/25 with Resident #2.
The Administrator said LVN A had been suspended and would be terminated if for nothing more than in her statement confirming she told Resident #2 to sit his ass down.
During an interview on 11/15/25 at 1:47 p.m. LVN A said on 11/12/25 during an altercation between Resident #3 and Resident #2 she got in between the residents to intervene. LVN A said she got Resident #2's attention and got him to sit down. LVN A said she told Resident #2 to sit his ass down in his chair before she got into trouble.
Record review of the facility's Resident Rights policy last revised December 2016 indicated, Employees shall treat all residents with kindness, respect, and dignity.
Federal and state laws guarantee certain basic rights to all residents of this facility.
These rights include the residents' right to.b. be treated with respect, kindness, and dignity.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
TITLE
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/26/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Focused Care at Mount Pleasant
1606 Memorial Ave Mount Pleasant, TX 75455
SUMMARY STATEMENT OF DEFICIENCIES
During an interview on 11/12/25 at 11:14 a.m. the Treatment Nurse said the MDS Nurse was responsible for completing the MDS and the Care Plans.
The Treatment Nurse said she did not know why the MDS dated [DATE] did not indicate Resident #4 had a pressure ulcer.
The Treatment Nurse said when Resident #4 admitted to the facility on [DATE] she just had redness to her bottom that they were treating with barrier cream.
The Treatment Nurse said when Resident #4 re-admitted to the facility on [DATE] she had a pressure ulcer to her bottom that was opened.
The Treatment Nurse said she reported the pressure ulcer to the MDS Nurse in the morning meeting after Resident #4 had re-admitted to the facility on [DATE].
During an interview on 11/14/25 at 12:42 p.m. the MDS Nurse was she was responsible for completing all MDSs.
The MDS Nurse said when she was completing an MDS regarding wounds she obtained the information to enter into the MDS from the weekly wound report, skin assessments, and weekly IDT meeting.
The MDS Nurse said she had just missed the wound on Resident #4 when she re-admitted to the facility on [DATE].
The MDS Nurse said the importance of ensuring the MDS was completed accurately was to accurately depict the residents and to trigger all care needed on the care plan.
During an interview on 11/12/25 at 3:00 p.m. the DON said the MDS Nurse was responsible for completing the MDS.
Record review of the facility MDS Completion Accuracy and Timeliness policy last revised 11/15/23 indicated, The purpose of this policy is to ensure accuracy and timeliness of MDS completion.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/26/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Focused Care at Mount Pleasant
1606 Memorial Ave Mount Pleasant, TX 75455
SUMMARY STATEMENT OF DEFICIENCIES
caregivers know the residents' needs and how to care for them.
Record review of the facility's Comprehensive Care Plan policy last revised 4/25/21 indicated, Every resident will have an individualized interdisciplinary plan of care in place. A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of Admission.
The Interdisciplinary Team will continue to develop the plan in conjunction with the RAI (MDS 3.0) ., completing and conducting Comprehensive Care Plan Meeting and Reviews by day 21 after Admission.
The Care Plan is revised every quarter, significant change of condition, Annual, or as the resident condition changes on an individualized basis.
The Care Plan process is an ongoing review process.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/26/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Focused Care at Mount Pleasant
1606 Memorial Ave Mount Pleasant, TX 75455
SUMMARY STATEMENT OF DEFICIENCIES
The facility failed to ensure Resident #1 had a skin assessment performed weekly on the weeks of 10/6/25, 10/13/25, 10/20/25, and 10/27/25 per facility policy.
These failures could result in skin issues on residents being missed, skin issues deteriorating without being monitored, and decreased quality of life.
Findings Included: 1.
Record review of the face sheet dated 11/12/25 indicated Resident #1 admitted to the facility on [DATE] with diagnoses including cerebral infarction (a type of stroke caused by the blood vessels supplying the brain being blocked), Atrial Fibrillation (an irregular heartbeat where the upper chambers of the heart beat chaotically and very fast), COPD, and hypertension (elevated blood pressure).
Record review of the MDS dated [DATE] indicated Resident #1 usually understood others and was usually understood by others.
The MDS indicated Resident #1 had a BIMS of 10 and was moderately cognitively impaired.
The MDS indicated Resident #1 was at risk for developing pressure ulcers.
Record review of the care plan revised 8/21/25 indicated Resident #1 was at risk for skin breakdown related to thin, fragile skin, incontinence and ambulating with decreased sense of safety.
Record review of the weekly skin assessments for October 2025 indicated Resident #1 had a skin assessment on 10/1/25.
The skin assessment dated [DATE] indicated Resident #1 did not have any skin issues.
Record review of the weekly skin assessment for October 2025 indicated Resident #1 did not have weekly skin assessments in the weeks of 10/6/25, 10/13/25, 10/20/25, and 10/27/25.
Record review of the weekly skin assessment dated [DATE] indicated Resident #1 did not have any skin issues.
During an interview on 11/12/25 at 1:38 p.m. the Treatment Nurse said skin assessments were to be performed weekly, and all skin issues should be on the weekly skin assessments.
The Treatment Nurse said the importance of weekly skin assessments was to assess the skin for an issue.
During an interview on 11/12/25 at 2:47 p.m. the DON said skin assessments should be performed weekly, and he would look at his soft file to see if he had skin assessments on Resident #1 for the missing dates in October 2025.
During an interview on 11/12/25 at 3:00 p.m. the DON brought the surveyor shower sheets for Resident #1 for the missing dates that were filled out by the CNAs where they could mark on the image of a body if they saw any skin issues.
The DON showed the surveyor where a nurse signed off on the shower sheets.
The DON said that the nurses were not usually there when a shower was given to assess the skin themselves.
The DON said he understood it was out of the CNAs' scope of practice to assess.
The DON said the weekly skin assessment should be performed by a nurse.
Record review of the facility's Skin Management Policy last revised 10/6/22 indicated, The purpose of this procedure is for prevention and treatment of skin breakdown such as pressure injuries, diabetic ulcers, arterial ulcers, and skin wounds.Skin assessments will be documented at a minimum of every 7 days on a Weekly Skin Assessment.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/26/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Focused Care at Mount Pleasant
1606 Memorial Ave Mount Pleasant, TX 75455
SUMMARY STATEMENT OF DEFICIENCIES
During an interview on 10/22/25 at 2:13 PM, the Administrator stated Foley catheter drainage bags should have been secured to the bed and kept off the ground.
The Administrator stated all staff was responsible for monitoring to ensure Foley catheter drainage bags were kept off the ground.
The Administrator stated the nursing direct care staff should be monitoring the Foley catheter routinely.
The Administrator stated it was important to ensure the Foley catheter drainage bag was kept off the ground to prevent the spread of infection to others or prevent Resident #1 from obtaining a urinary tract infection.
Record review of the Catheters-Insertion and Care: Indwelling, Straight, Supra-Pubic, and External policy, dated 04/2021, reflected It is the policy of this community that the resident with a urinary catheter will be provided services in a safe and appropriate manner to minimize the risks of urinary tract complication.secure urinary drainage bag below the level of the bladder and keep off the floor.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/26/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Focused Care at Mount Pleasant
1606 Memorial Ave Mount Pleasant, TX 75455
SUMMARY STATEMENT OF DEFICIENCIES
During an interview on 11/12/25 at 11:29 a.m. the Wound Care NP said he expected the nursing wound assessments that were completed on the same day as his assessments to accurately reflect what his assessment reflected regarding wound status of improving, stable, or worsening.
During an interview on 11/12/25 at 3:00 p.m. the DON said he expected clinical documentation of wounds to reflect what the wound care physician documented on their notes.
The DON said the importance in accurate documentation was to provide appropriate care.
Record review of an email from the Administrator dated 11/12/25 at 5:50 p.m. indicated the Administrator was unable to locate a policy regarding accuracy of documentation.
Facility ID: