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Complaint Investigation

Pleasant Springs Healthcare Center

November 20, 2025 · Mount Pleasant, TX · 2003 North Edwards Avenue
Citations 1
CMS Rating 1/5
Beds 90
Provider ID 455532
Healthcare Facility
Pleasant Springs Healthcare Center
Mount Pleasant, TX  ·  View full profile →
Source Document
Official CMS Inspection Report (Medicare.gov)
Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.
Inspection Summary

Pleasant Springs Healthcare Center in Mount Pleasant, TX — inspection on November 20, 2025.

Found 1 citation. 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

FF0727
Nursing and Physician Services Deficiencies
Potential for More Than Minimal Harm

October she only had to work as a charge nurse for two hours until someone came in on 10/28/25 but she could not recall the other times.

The DON stated if she works a shift as an aide or nurse, she did not work the next day as a DON, but she was available by phone if needed.

The DON stated she has an ADON that was RN that would oversee staff that day.

The DON stated if her duties as a DON were not completed, she would report to her RNC that staff have called in, and she had to work on the floor.

The DON stated it was important for her to work as the DON and not work the floor as a charge nurse or CNA to ensure the systems were in place and things were being done.During a telephone interview on 11/05/25 at 9:45 a.m., the RNC stated she was aware the DON was working on the floor as a charge nurse or CNA.

The RNC stated it was ok for the DON to work as a charge nurse or CNA if needed if the census was over 60.

The RNC stated she could still take care of other residents while working as the DON.

During an interview on 11/05/25 at 9:55 a.m., the Administrator stated he was aware that the DON was working on the floor as a charge nurse and CNA if there was a call in.

The Administrator stated he was not aware there was a regulation stating the DON could not work the floor as a charge nurse or CNA if the census was over 60.

The Administrator stated the DON came in later that day if she worked the day before as a charge nurse or CNA.

The Administrator stated he did not know why the DON did not have to work the floor but if the DON knew her patients, she could be bad for the facility.

Record review of document titled Job Description-Director or Nursing revised 05/15/24 reflected, . manage nursing staff through appropriate hiring, training, evaluation, assignment, and delegation of duties, within budget and resident census guidelines.

Augment floor staffing if needed.

Facility ID:

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Mount Pleasant, TX, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Pleasant Springs Healthcare Center or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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About This Inspection Report

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.