Focused Care At Mount Pleasant

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, interview and record review the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 1 of 16 (Resident #2) residents review for dignity and respect. The facility failed ensure Resident #2 was treated with dignity and respect by LVN A on 11/12/25 when LVN A told Resident #2 to sit his ass down. These failures could place residents at risk of a diminished quality of life, loss of dignity and self-worth.Findings included: 1. Record review of the face sheet dated 11/13/25 indicated Resident #2 was admitted to the facility on [DATE REDACTED] with diagnoses including Alzheimer's, disorganized schizophrenia (a subtype of schizophrenia characterized by disorganized thinking, speech, and behavior), and anxiety disorder. Record review of the MDS dated [DATE REDACTED] indicated Resident #2 sometimes understood others and was sometimes understood by others. The MDS indicated Resident #2 was not able to complete

the BIMS assessment. The MDS indicated Resident #2 had not had any physical behaviors or verbal behaviors directed toward others during the 7-day look back period. Record review of the care plan last revised on 11/11/25 indicated Resident #2 had anxiety related to cognitive deficit and Schizophrenia as evidenced by constant wandering and exit seeking. 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

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/26/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Focused Care at Mount Pleasant

1606 Memorial Ave Mount Pleasant, TX 75455

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641

Ensure each resident receives an accurate assessment.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and record review the facility failed to complete an accurate MDS assessment to reflect residents' status for 1 of 16 residents reviewed for assessments. (Resident #4) The facility failed to ensure Resident #4's MDS dated [DATE REDACTED] documented the presence of a pressure ulcer that she re-admitted to the facility with on 10/16/25. This failure could place residents at risk for inaccurate assessments and not receiving needed services.Findings included:1. Record review of the face sheet dated 11/12/25 indicated Resident #4 was re-admitted to the facility on [DATE REDACTED] with diagnoses including diabetes, schizoaffective disorder (a chronic mental health condition that combines symptoms of schizophrenia with symptoms of mood disorder like bipolar disorder or depression), hypertension (elevated blood pressure), and lack of coordination.

Record review of the MDS dated [DATE REDACTED] indicated Resident #4 usually understood others and was usually understood by others. The MDS indicated Resident #4 was unable to complete the BIMS assessment. The MDS indicated Resident #4 did not have a pressure ulcer. Record review of the nursing progress note dated 10/16/25 indicated, [Resident #4] returned from hospital via wheelchair accompanied by staff.Perineum (the region of the body between the pubic arch (a bony structure in the pelvis) and the tail bone) and scalp assessed, no redness, open areas, or skin breakdown observed on scalp. [Resident #4] does have an existing wound to buttocks dressing changed per wound care orders. 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 REDACTED] did not indicate Resident #4 had a pressure ulcer. The Treatment Nurse said when Resident #4 admitted to the facility on [DATE REDACTED] 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 REDACTED] 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 REDACTED]. 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 REDACTED]. 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.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/26/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Focused Care at Mount Pleasant

1606 Memorial Ave Mount Pleasant, TX 75455

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

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.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/26/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Focused Care at Mount Pleasant

1606 Memorial Ave Mount Pleasant, TX 75455

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and record review, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 of 6 (Resident #1) residents reviewed for quality of care. 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 REDACTED] 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 REDACTED] 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 REDACTED] 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 REDACTED] 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.

Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/26/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Focused Care at Mount Pleasant

1606 Memorial Ave Mount Pleasant, TX 75455

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

bag should not have been kept on the floor. The DCO stated everyone was responsible for monitoring to ensure that Foley catheter drainage bags were kept off the ground. The DCO stated he was new to the position, but he would have provided in-service education for the staff. The DCO stated it was important to keep Foley catheter drainage bags off the floor to prevent urinary tract infections, maintain infection control practices, and prevent injuries. 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.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/26/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Focused Care at Mount Pleasant

1606 Memorial Ave Mount Pleasant, TX 75455

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

signed 11/12/25 indicated the pressure ulcer to Resident #7's left ischium (a thick, irregularly shaped bone

in the pelvis) was worsening. Record review of the audit report dated 11/14/25 indicated the wound assessment dated [DATE REDACTED] had been audited on 11/12/25 by the Treatment Nurse from originally indicating

on 11/7/25 the pressure ulcer to Resident #7's left ischium was worsening to improving. Record review of

the Wound Care NP's progress note dated 11/7/25 indicated the pressure ulcer to Resident #7's left ischium was worsening. 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.

Event ID:

Facility ID:

If continuation sheet