Pleasant Springs Healthcare Center
Pleasant Springs Healthcare Center in Mount Pleasant, TX — inspection on February 23, 2026.
Found 10 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 on 02/17/26 at 11:29 AM, surveyor entered Resident #5's room. Resident #5 was laying in her bed. Resident #5's gown was lifted up to her chest.
Resident was exposed completely from the chest down and the blinds were open. CNA Q went to close the blinds upon surveyor's' entrance into the room. CNA Q said the blinds should have been closed prior to starting Resident #5's care. CNA Q said if someone had seen Resident #5 through the window undressed and half naked that would have been embarrassing for Resident #5.
During an interview on 02/17/26 at 12:15 PM, Resident #5 said she wanted the staff to close the window blinds but sometimes she forgets to ask the staff to close the window blind before they provide her care.
During an interview on 02/19/26 at 3:24 PM, the ADON said she expected the staff to treat all the residents with dignity and respect.
The ADON said the blinds should be closed prior to any type of personal care such as dressing or incontinent care to prevent embarrassment.
The ADON said it was a dignity issue for the residents if window blinds were left open when personal care was provided.
During an interview on 02/23/26 at 6:04 PM, the DON said she expected all the staff to treat the residents with dignity and respect their rights.
The DON said it could be embarrassing for the residents to be exposed when the window blinds were left open during incontinent care.
The DON said she expected nursing staff to be aware of those situations during personal care to ensure those situations do not occur.
The DON said she and the ADON worked on the floor all the time to observe, monitor and instruct the staff.
During an interview on 02/23/26 at 07:11 PM, the Administrator said all staff were responsible for ensuring the residents were treated with dignity and respect.
The Administrator said it was her expectation that the nursing staff provided privacy during personal care to increase all residents' quality of life.
Record review of the undated facility policy Resident Rights indicated, the resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this policy. A facility must 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, recognizing each resident's individuality.
The facility must protect and promote the rights of the resident.Respect and dignity - The resident has a right to be treated with respect and dignity.
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Pleasant Springs Healthcare Center 2003 N Edwards St Mount Pleasant, TX 75455
During an observation and interview on 02/17/2026 at 01:32 PM, there was an odor of musty urine on Hall C.
The Housekeeper Supervisor stated she thought it was because one of the residents had incontinent episode in the hallway or maybe it was somebody that had walked by.
During an observation on 02/17/2026 at 04:32 PM, there was an odor of musty urine on Hall C.
During an observation and interview on 02/18/2026 at 10:32 PM, there was an odor of musty urine on Hall C.
While walking down Hall C, CNA T said she could smell a strong odor but was unable to identify the odor.
During an interview on 02/19/2026 at 3:24 PM, the ADON said she had not noticed a urine odor or any foul odors on C Hall.
The ADON said the residents had not complained to her about any odors.
The ADON said all the staff were responsible for making sure the facility did not have offensive odors.
The ADON said the offensive odors could make the residents not want to leave their room, and it could affect their mental health.
During an observation on 02/19/2026 at 10:23 AM, there was an odor of musty urine on Hall C.
During an observation 02/20/2026 at 08:15 AM, there was an odor of musty urine on Hall C.
During observation and interview on 02/20/2026 at 10:30 AM, there was an odor of musty urine on Hall C.
The Social Worker stated she smelled an offensive odor but was unable to identify the smell or location.
During an observation and interview on 02/20/2026 at 10:45 AM, there was an odor of musty urine on Hall C. NA Z said she smelled an offensive odor and thought it was from the end room on Hall C because a resident's soiled brief was changed recently.
During an observation and interview on 02/20/2026 at 11:20 AM, there was an odor of musty urine on Hall C.
The Corporate Compliance Nurse said a resident that resided on Hall C had told the staff that the family was going to be washing their laundry.
The Corporate Compliance Nurse said the family was contacted and stated they were not washing the residents' laundry therefore housekeeping had started to clean up the resident's room where the dirty laundry had been stored.
Staff were observed transferring soiled laundry with a pungent musty urine odor into a bag.
During an observation on 02/23/2026 at 08:00 AM, there was an odor of musty urine on Hall C.
During an interview on 02/23/2026 at 6:04 PM, the DON said she had not noticed any offensive odors in the facility.
The DON said she expected the CNAs to change the residents' sheets on shower days and clean the mattress when necessary and keep the residents clean and dry frequently to prevent odors.
The DON said all the staff should be making sure the facility did not have offensive odors.
The DON said it was important to keep the facility free of offensive odors because I don't like to smell bad odors.
Record review of the facility's undated policy titled, Resident Rights , indicated, Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible.clean bed and bath linens that are in good condition.The facility staff and management minimizes, to the extent possible, the characteristics of the facility that reflect a depersonalized, institutional setting.
These characteristics include: . institutional odors.
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Pleasant Springs Healthcare Center 2003 N Edwards St Mount Pleasant, TX 75455
guardians, friends, or other individuals.
The facility will provide and ensure the promotion and
misappropriation of resident property abuse and situations that may constitute abuse or neglect to
caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being.
Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse. 5.
Physical Abuse: Includes, hitting, slapping, pinching and kicking.
It also includes controlling behavior through corporal punishment. 6.
Mental Abuse: Includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation.
Neglect: is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.
The facility will provide the residents, families, and staff an environment free from abuse and neglect. 3.
All reports of abuse or suspicion of abuse/neglect or potentially criminal behavior will be investigated as per facility protocol.
Investigations will be reviewed by the facility administrator and/or Abuse Preventionist within 24 hours of complaint.
Appropriate notification to state and home office will be the responsibility of the administrator and per policy.
The facility will identify and investigate events that may constitute abuse/neglect.
The facility will determine the direction of the investigation based on a thorough examination of events.
Opportunities to prevent abuse/neglect will be managed accordingly. 1.
Any person having reasonable cause to believe an elderly or incapacitated adult is suffering from abuse, neglect or exploitation must report this to the DON, administrator, state and/or adult protective services.
State law mandates that citizens report all suspected cases of abuse, neglect or financial exploitation of the elderly and incapacitated persons.
When a suspected abused, neglected, exploited, mistreated or potential victim of misappropriation of property comes to the attention of any employee, that employee will make an immediate verbal report to the Abuse Preventionist or designee. If the discovery occurs outside of normal business hours, the Abuse Preventionist and/or designee will be called. 3.
Facility employees must report all allegations of: abuse, neglect, exploitation. mistreatment of residents, misappropriation of resident property or injury of unknown source to the facility administrator.
The facility administrator or designee will report to HHSC all incidents that meet the criteria of Provider Letter 2024-14 8/29/24. a. If the allegations involve abuse or result in serious bodily injury, the report is to be made within 2 hours of the allegation b. If the allegation does not involve abuse or serious bodily injury, the report must be made within 24 hours of the allegation.
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Pleasant Springs Healthcare Center 2003 N Edwards St Mount Pleasant, TX 75455
abuse or suspicion of abuse/neglect or potentially criminal behavior will be investigated as per
the responsibility of the administrator and per policy.
The facility will identify and investigate events
on a thorough examination of events.
Opportunities to prevent abuse/neglect will be managed accordingly. 1.
Any person having reasonable cause to believe an elderly or incapacitated adult is suffering from abuse, neglect or exploitation must report this to the DON, administrator, state and/or adult protective services.
State law mandates that citizens report all suspected cases of abuse, neglect or financial exploitation of the elderly and incapacitated persons.
When a suspected abused, neglected, exploited, mistreated or potential victim of misappropriation of property comes to the attention of any employee, that employee will make an immediate verbal report to the Abuse Preventionist or designee. If the discovery occurs outside of normal business hours, the Abuse Preventionist and/or designee will be called. 3.
Facility employees must report all allegations of: abuse, neglect, exploitation. mistreatment of residents, misappropriation of resident property or injury of unknown source to the facility administrator.
The facility administrator or designee will report to HHSC all incidents that meet the criteria of Provider Letter 2024-14, 8/29/24. a. If the allegations involve abuse or result in serious bodily injury, the report is to be made within 2 hours of the allegation b. If the allegation does not involve abuse or serious bodily injury, the report must be made within 24 hours of the allegation.
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Pleasant Springs Healthcare Center 2003 N Edwards St Mount Pleasant, TX 75455
of discharge to the resident and resident representative and will also send a copy of the discharge
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Pleasant Springs Healthcare Center 2003 N Edwards St Mount Pleasant, TX 75455
should be kept in a cabinet out of access to the residents.
The Administrator said the shower door
jeopardy to resident health or safety
During an interview on 02/23/2026 at 11:18 AM, the Administrator said they did not have a policy regarding accidents/supervision or to address the shower room and storage of cleaning supplies.
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Pleasant Springs Healthcare Center 2003 N Edwards St Mount Pleasant, TX 75455
Record review of the Facility Assessment reviewed 07/24/2025 indicated the PPD for nursing direct
minimal harm did not know how to generate the facility hours worked for the full month of January 2026 and February 2026.
Record review of the Facility Hours dated 02/09/2026, 02/13/2026, 02/14/2026,
02/20/2026.
The Facility Hours for the whole months of January 2026 and February 2026 were requested but not provided upon exit of the facility.
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Pleasant Springs Healthcare Center 2003 N Edwards St Mount Pleasant, TX 75455
the medication cart.
The Administrator said unlocked medication carts and medications on top of the
03/2025, indicated, Medications and biologicals are stored safely, securely, and properly following
license nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. 2.
Only licensed nurses, the Consultant Pharmacist, and those lawfully authorized to administer medications (e.g. medication aides) are allowed unsupervised access to medications.
Medication rooms, carts, and medication supplies are locked or attended to by persons with authorized access.
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Pleasant Springs Healthcare Center 2003 N Edwards St Mount Pleasant, TX 75455
During an interview on 02/23/2026 at 8:06 AM, the Dietary Manager said bags of bread should be tied closed, after they were opened.
The Dietary Manager said the carboard box with mushrooms in the refrigerator was stored properly.
The Dietary Manager said dented cans should not be stored on the rack with the undented cans.
The Dietary Manager said food should be stored properly for food safety, and if food items were not sealed properly, they could go bad and cause stomach issues and food borne illness.
The Dietary Manager said dented cans altered the seams and could cause bacteria to get into the cans, and this could make the residents sick.
The Dietary Manager said she looked through the kitchen to ensure food was properly stored daily, and she had not noticed any issues.
During an interview on 02/23/2026 at 2:37 PM, [NAME] D said when a bag of bread was opened it should be stored with a twist tie on it or knotted off to ensure it was sealed properly and air was not allowed to enter the package. [NAME] D said he did not know why the loaves of bread were not properly stored. [NAME] D said the carboard box with mushrooms inside of it was stored properly in the refrigerator. [NAME] D said not properly sealing food items could result in them going bad and they did not want to make anybody sick. [NAME] D said dented cans should not be placed alongside the undented cans. He said they should be removed and returned to the vendor because dented cans could grow bacteria in the dents. [NAME] D said the cook in charge every shift or the Dietary Manager were responsible for ensuring food was stored properly.
During an interview on 02/23/2026 at 8:17 PM, the Administrator said her expectations were cardboard boxes with food should not be stored on top of food items because cardboard boxes were dirty and could contaminate other items.
The Administrator said everything in the refrigerator should be sealed and dated.
The Administrator said dented cans should not be stored alongside the undented cans.
The Administrator said the dietary manager was responsible for ensuring food was properly stored.
The Administrator said it was important for the food to be stored properly for infection control and so the food did not get germs on it.
Record review of the facility's policy titled, Food Storage and Supplies, from the Dietary Services Policy and Procedure Manual 2012, indicated, All facility storage areas will be maintained in an orderly manner that preserves the condition of food and supplies.4.
Open packages of food are stored in closed containers with covers or in sealed bags and dated as to when opened.
Record review of the FDA Food Code 2022, FOOD packages shall be in good condition and protect the integrity of the contents so that the FOOD is not exposed to ADULTERATION or potential contaminants. this section, storing the food in packages, covered containers, or Rusted and pitted or dented cans may also present a serious potential hazard.
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Pleasant Springs Healthcare Center 2003 N Edwards St Mount Pleasant, TX 75455
During an interview on 02/23/2026 at 07:11 PM, the Administrator said it was important
expected the clinical management staff to oversee and monitor the direct care staff to ensure proper procedures were followed while incontinent care was provided to decrease the chances of the residents developing an infection. 2.
During an observation on 02/18/2026 at 10:32 PM, the communal shower room located on Hall C door was open and unoccupied.
There were four wet towels spread out on the floor.
The shower stall railing had two soiled wet wash cloths hanging off of it.
The lidded trash bin was unable to close due to trash hanging out at the top and sides, with a folded gown laying on top of the lid.
During an interview on 02/18/2026 at 10:40 PM, LVN U said she was not aware of any resident that had received a bath/shower since she arrived for her shift at 6:00 PM. LVN U said the baths/showers were not scheduled on the 6PM -6AM shift. LVN U said the used supplies should have been picked up and the shower room cleaned after use to prevent cross contamination by the aide that had completed the resident's shower.
During an interview on 02/18/2026 at 10:45 PM, CNA T said she worked Hall C. CNA T said she had not assisted any residents with any baths/showers on her shift. CNA T said she had no knowledge of the shower room being used. CNA T said dirty supplies should be picked up to prevent cross contamination. CNA T said the aide that completed the resident's shower would pick up and properly dispose of the dirty/soiled items.
During an interview on 02/23/2026 at 6:04 PM, the DON said she had noticed upon her arrival the evening of 02/18/2026, evening the shower room had soiled linens on the floor and was not aware why or when that had occurred.
The DON said she expected the nursing staff to pick up and dispose of any dirty supplies properly immediately after using them to prevent the spread of infections.
The DON said that all staff were responsible for ensuring the facility was clean.
During an interview on 02/23/2026 at 07:11 PM, the Administrator said items should not be left in the shower room due to cross contamination and risk of infections.
The Administrator said clinical staff were responsible for ensuring dirty linens were picked up properly. 3.
During an observation and interview on 02/23/2026 at 12:06 PM, the linen cart was uncovered on Hall A. CNA Y said she may have gotten busy and forgot to close the cover over the linen cart on Hall A. CNA Y said the linen cart should remain covered to prevent cross contamination and decrease the chances of the residents getting an infection.
During an interview on 02/23/2026 at 6:04 PM, the DON said she expected all staff to prevent cross contamination by keeping the linen carts covered.
The DON said that she and the ADON were always on the floor to observe, monitor and instruct staff as needed.
During an interview on 02/23/2026 at 07:11 PM, the Administrator said all clinical staff were responsible for ensuring the linen carts remained covered when not in use to prevent cross contamination.
Record review of the facility policy Perineal Care with or without a catheter, effective 05/11/2022 indicated, An incontinent resident of urine and/or bowel should be identified, assessed, and provided appropriate treatment and services.
This procedure aims to maintain the resident dignity and self-worth and reduce embarrassment by providing cleanliness and comfort to the resident, preventing infections and skin irritation, and observing the resident's skin condition. If heavily soiled, use an incontinence pad, brief, towel, or wipes to remove soiling, from front to back, prior to performing perineal care Do not wipe more than once with the same surface Doffing and discarding of gloves are required if visibly soiled Always perform hand hygiene before and after glove use.
Record review of the facility policy Infection Control Plan: Overview updated on 3/2024 indicated, The facility will establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection.
Linens - Personnel will handle, store, process and transport linens so as to prevent the spread of infection.