Focused Care At Mount Pleasant in Mount Pleasant, Titus County, Texas

Mount Pleasant, Titus County, Texas 75455

Status Medicare and Medicaid certifiedMedicare CCN 455900

HHSC license rosteras of November 9, 2026CMS nursing home filerelease October 28, 2026; processing date October 1, 2026CMS processing date for this home October 1, 2026

Verify on TULIP View on Medicare.gov

Location and contact

Address: 1606 Memorial Ave
Mount Pleasant, TX 75455
Open map (OpenStreetMap)
Phone: (903) 572-3618
HHSC facility ID: 005020
License number: 148896

Medicare ratings

Star ratings below are copied from the CMS Provider Information file (official release October 28, 2026; processing date October 1, 2026). They are not assigned by NursingCareLookup. See how to read ratings and CMS Five-Star documentation.

Overall: 1 of 5Overall: 1 of 5 stars
Health inspection: 1 of 5Health inspection: 1 of 5 stars
Staffing: 1 of 5Staffing: 1 of 5 stars
Quality measures: 2 of 5Quality measures: 2 of 5 stars
Long-stay quality measures: 4 of 5Long-stay quality measures: 4 of 5 stars
Short-stay quality measures: 1 of 5Short-stay quality measures: 1 of 5 stars

Flags in the CMS file

This home has an abuse icon in the CMS file. That is a CMS designation, not a finding we added. Read the explainer and the official complaint channels in the footer.

Staffing hours

Hours are the facility’s reported nurse staffing hours per resident per day from the CMS file. The Texas average is computed on this site from Texas rows in that same file that include a numeric value. It is not copied from another website. Method: Methodology.

Staffing hours per resident per day
Measure	This facility	Texas average (this site)
Total nurse staffing	2.88 hours	3.42 hours n=1,152
Registered nurse	0.43 hours	0.44 hours
LPN	0.62 hours	0.95 hours
Nurse aide	1.83 hours	2.03 hours
Weekend nurse staffing	2.54 hours	2.99 hours

0.53 hours below this site’s computed Texas average.

Total nursing staff turnover: 50.7% (Texas average computed on this site: 50.8%, n=1,096)
RN turnover: 58.3%
Average residents per day: 81.5
Certified beds (CMS): 122

Penalties in the CMS Provider Information file: 5 finestotaling $199,421; 1 payment denial; 6 total penalties. These are the figures CMS published in this release. Confirm current figures on Medicare.gov.

Fines and payment denials

Individual fines and payment denials below come from the CMS Penalties file (official release October 28, 2026; processing date October 1, 2026). Dates and amounts are copied as published. They can lag later actions or successful appeals. Confirm current figures on Medicare.gov.

CMS fines and payment denials
Date	Type	Fine amount	Payment denial
August 28, 2026	Fine · Fine ID 145255	$27,378	—
June 25, 2025	Fine · Fine ID 133831	$16,149	—
June 25, 2025	Fine · Fine ID 133829	$16,149	—
June 25, 2025	Payment Denial	—	Start July 25, 2025; 7 days
May 24, 2024	Fine · Fine ID 112920	$127,486	—
February 14, 2024	Fine · Fine ID 112356	$12,259	—

MDS quality measures

These figures are the four-quarter averages published in the CMS MDS Quality Measures file (official release October 28, 2026; measure period 2025Q3-2026Q2; processing date October 1, 2026). They are not a grade this site assigned. A “used in Five-Star” flag is the published CMS field that says whether that measure feeds the quality-measure star rating. Quarterly scores are collapsed under each measure. Official definitions are on the CMS Five-Star page.

CMS MDS quality measures, four-quarter averages
Measure	Stay	Four-quarter average	Used in Five-Star QM rating
Percentage of long-stay residents whose need for help with daily activities has increased Quarterly scores Q1 45.2% · Q2 22.9% · Q3 17.0% · Q4 11.3% · Period 2025Q3-2026Q2 · Measure code 401	Long Stay	23.2%	Yes, as published by CMS
Percentage of long-stay residents with a catheter inserted and left in their bladder Quarterly scores Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · Period 2025Q3-2026Q2 · Measure code 406	Long Stay	0.0%	Yes, as published by CMS
Percentage of long-stay residents with a urinary tract infection Quarterly scores Q1 1.6% · Q2 0.0% · Q3 0.0% · Q4 0.0% · Period 2025Q3-2026Q2 · Measure code 407	Long Stay	0.4%	Yes, as published by CMS
Percentage of long-stay residents experiencing one or more falls with major injury Quarterly scores Q1 3.2% · Q2 3.0% · Q3 1.4% · Q4 2.7% · Period 2025Q3-2026Q2 · Measure code 410	Long Stay	2.6%	Yes, as published by CMS
Percentage of long-stay residents whose ability to walk independently worsened Quarterly scores Q1 11.0% · Q2 11.9% · Q3 0.0% · Q4 0.0% · Period 2025Q3-2026Q2 · Measure code 451	Long Stay	6.0%	Yes, as published by CMS
Percentage of long-stay residents with pressure ulcers Quarterly scores Q1 3.3% · Q2 3.0% · Q3 2.8% · Q4 3.9% · Period 2025Q3-2026Q2 · Measure code 479	Long Stay	3.2%	Yes, as published by CMS
Percentage of long-stay residents who received an antipsychotic medication Quarterly scores Q1 10.3% · Q2 6.5% · Q3 4.8% · Q4 11.1% · Period 2025Q3-2026Q2 · Measure code 481	Long Stay	8.5%	Yes, as published by CMS
Percentage of long-stay residents who lose too much weight Quarterly scores Q1 8.9% · Q2 6.1% · Q3 8.5% · Q4 1.9% · Period 2025Q3-2026Q2 · Measure code 404	Long Stay	6.2%	No, as published by CMS
Percentage of long-stay residents who have depressive symptoms Quarterly scores Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · Period 2025Q3-2026Q2 · Measure code 408	Long Stay	0.0%	No, as published by CMS
Percentage of long-stay residents who were physically restrained Quarterly scores Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · Period 2025Q3-2026Q2 · Measure code 409	Long Stay	0.0%	No, as published by CMS
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine Quarterly scores Q1 95.2% · Q2 93.9% · Q3 100.0% · Q4 91.8% · Period 2025Q3-2026Q2 · Measure code 415	Long Stay	95.2%	No, as published by CMS
Percentage of long-stay residents who received an antianxiety or hypnotic medication Quarterly scores Q1 20.0% · Q2 18.4% · Q3 7.8% · Q4 5.6% · Period 2025Q3-2026Q2 · Measure code 452	Long Stay	12.6%	No, as published by CMS
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine Quarterly scores Q1 — (CMS footnote 28) · Q2 — (CMS footnote 28) · Q3 — (CMS footnote 28) · Q4 — (CMS footnote 28) · Period 2025Q3-2026Q2 · Measure code 454	Long Stay	97.3%	No, as published by CMS
Percentage of long-stay residents with new or worsened bowel or bladder incontinence Quarterly scores Q1 6.3% · Q2 14.1% · Q3 10.8% · Q4 9.8% · Period 2025Q3-2026Q2 · Measure code 480	Long Stay	10.3%	No, as published by CMS
Percentage of short-stay residents who newly received an antipsychotic medication Quarterly scores Q1 — (CMS footnote 9) · Q2 — (CMS footnote 9) · Q3 — (CMS footnote 9) · Q4 — (CMS footnote 9) · Period 2025Q3-2026Q2 · Measure code 434	Short Stay	5.7%	Yes, as published by CMS
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine Quarterly scores Q1 36.6% · Q2 25.0% · Q3 17.1% · Q4 17.5% · Period 2025Q3-2026Q2 · Measure code 430	Short Stay	24.0%	No, as published by CMS
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine Quarterly scores Q1 — (CMS footnote 28) · Q2 — (CMS footnote 28) · Q3 — (CMS footnote 28) · Q4 — (CMS footnote 28) · Period 2025Q3-2026Q2 · Measure code 472	Short Stay	22.0%	No, as published by CMS

Inspection citations

84 health citations in the CMS file (35 from complaint surveys). Highest scope/severity letter in the file: J — Isolated, immediate jeopardy.

The list below is drawn from the CMS Health Deficiencies file. We show the tag, a plain-language reading of the scope and severity letter, whether the survey was a standard or complaint survey, the survey date, and whether CMS recorded a correction. We do not reprint the official deficiency narrative here. Read that text on TULIP or Medicare.gov. A facility may appeal a finding; a successful appeal can alter or remove a citation.

Scope and severity letters (A–L)

CMS assigns one letter from a grid of scope (how widely a problem was found) and severity (how serious the harm was or could be). The short labels below are our wording of that grid, not a different rating system.

Scope and severity letters used in CMS health citations
Severity	Isolated	Pattern	Widespread
Potential for minimal harm	A	B	C
No actual harm, potential for more than minimal harm	D	E	F
Actual harm	G	H	I
Immediate jeopardy	J	K	L

2026 — 3 citations

Tag 0921D

D — Isolated, potential for more than minimal harm

Complaint survey

Survey date: May 20, 2026

CMS records a correction date (June 12, 2026)

More detail

Environmental Deficiencies

Survey type in the file: Health

Survey cycle in the file: 1

Tag 0880D

D — Isolated, potential for more than minimal harm

Complaint survey

Survey date: May 20, 2026

CMS records a correction date (June 12, 2026)

More detail

Infection Control Deficiencies

Survey type in the file: Health

Survey cycle in the file: 1

Tag 0602D

D — Isolated, potential for more than minimal harm

Complaint survey

Survey date: January 13, 2026

CMS records a correction date (February 2, 2026)

More detail

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Survey type in the file: Health

Survey cycle in the file: 1

2025 — 19 citations

Tag 0842D

D — Isolated, potential for more than minimal harm

Complaint survey

Survey date: November 26, 2025

CMS records a correction date (December 19, 2025)

More detail

Resident Assessment and Care Planning Deficiencies

Survey type in the file: Health

Survey cycle in the file: 1

Tag 0690D

D — Isolated, potential for more than minimal harm

Complaint survey

Survey date: November 26, 2025

CMS records a correction date (November 27, 2025)

More detail

Quality of Life and Care Deficiencies

Survey type in the file: Health

Survey cycle in the file: 1

Tag 0684E

E — Pattern, potential for more than minimal harm

Complaint survey

Survey date: November 26, 2025

CMS records a correction date (December 19, 2025)

More detail

Quality of Life and Care Deficiencies

Survey type in the file: Health

Survey cycle in the file: 1

Tag 0656E

E — Pattern, potential for more than minimal harm

Complaint survey

Survey date: November 26, 2025

CMS records a correction date (December 19, 2025)

More detail

Resident Assessment and Care Planning Deficiencies

Survey type in the file: Health

Survey cycle in the file: 1

Tag 0641D

D — Isolated, potential for more than minimal harm

Complaint survey

Survey date: November 26, 2025

CMS records a correction date (December 19, 2025)

More detail

Resident Assessment and Care Planning Deficiencies

Survey type in the file: Health

Survey cycle in the file: 1

Tag 0550D

D — Isolated, potential for more than minimal harm

Complaint survey

Survey date: November 26, 2025

CMS records a correction date (December 19, 2025)

More detail

Resident Rights Deficiencies

Survey type in the file: Health

Survey cycle in the file: 1

Tag 0925E

E — Pattern, potential for more than minimal harm

Complaint survey

Survey date: September 8, 2025

CMS records a correction date (October 1, 2025)

More detail

Environmental Deficiencies

Survey type in the file: Health

Survey cycle in the file: 2

Tag 0926D

D — Isolated, potential for more than minimal harm

Standard survey

Survey date: July 2, 2025

CMS records a correction date (August 1, 2025)

More detail

Environmental Deficiencies

Survey type in the file: Health

Survey cycle in the file: 1

Tag 0908F

F — Widespread, potential for more than minimal harm

Standard survey

Survey date: July 2, 2025

CMS records a correction date (August 1, 2025)

More detail

Environmental Deficiencies

Survey type in the file: Health

Survey cycle in the file: 1

Tag 0880D

D — Isolated, potential for more than minimal harm

Standard survey

Survey date: July 2, 2025

CMS records a correction date (August 1, 2025)

More detail

Infection Control Deficiencies

Survey type in the file: Health

Survey cycle in the file: 1

Tag 0812F

F — Widespread, potential for more than minimal harm

Standard survey

Survey date: July 2, 2025

CMS records a correction date (August 1, 2025)

More detail

Nutrition and Dietary Deficiencies

Survey type in the file: Health

Survey cycle in the file: 1

Tag 0804E

E — Pattern, potential for more than minimal harm

Standard survey

Survey date: July 2, 2025

CMS records a correction date (August 1, 2025)

More detail

Nutrition and Dietary Deficiencies

Survey type in the file: Health

Survey cycle in the file: 1

Tag 0726D

D — Isolated, potential for more than minimal harm

Standard survey

Survey date: July 2, 2025

CMS records a correction date (August 1, 2025)

More detail

Nursing and Physician Services Deficiencies

Survey type in the file: Health

Survey cycle in the file: 1

Tag 0695D

D — Isolated, potential for more than minimal harm

Standard survey

Survey date: July 2, 2025

CMS records a correction date (August 1, 2025)

More detail

Quality of Life and Care Deficiencies

Survey type in the file: Health

Survey cycle in the file: 1

Tag 0584D

D — Isolated, potential for more than minimal harm

Standard survey

Survey date: July 2, 2025

CMS records a correction date (August 1, 2025)

More detail

Resident Rights Deficiencies

Survey type in the file: Health

Survey cycle in the file: 1

Tag 0689J

J — Isolated, immediate jeopardy

Complaint survey

Survey date: June 25, 2025

CMS records a correction date (June 26, 2025)

More detail

Quality of Life and Care Deficiencies

Survey type in the file: Health

Survey cycle in the file: 2

Tag 0600J

J — Isolated, immediate jeopardy

Complaint survey

Survey date: June 25, 2025

Past non-compliance, as recorded by CMS (June 24, 2025)

More detail

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Survey type in the file: Health

Survey cycle in the file: 2

Tag 0755D

D — Isolated, potential for more than minimal harm

Complaint survey

Survey date: April 17, 2025

CMS records a correction date (April 22, 2025)

More detail

Pharmacy Service Deficiencies

Survey type in the file: Health

Survey cycle in the file: 2

Tag 0600E

E — Pattern, potential for more than minimal harm

Complaint survey

Survey date: February 13, 2025

CMS records a correction date (March 10, 2025)

More detail

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Survey type in the file: Health

Survey cycle in the file: 2

2024 — 33 citations

Tag 0600D

D — Isolated, potential for more than minimal harm

Complaint survey

Survey date: December 19, 2024

Past non-compliance, as recorded by CMS (September 27, 2024)

More detail

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Survey type in the file: Health

Survey cycle in the file: 2

Tag 0925E

E — Pattern, potential for more than minimal harm

Standard survey

Survey date: May 24, 2024

CMS records a correction date (June 25, 2024)

More detail

Environmental Deficiencies

Survey type in the file: Health

Survey cycle in the file: 2

Tag 0881E

E — Pattern, potential for more than minimal harm

Complaint survey, Standard survey

Survey date: May 24, 2024

CMS records a correction date (June 25, 2024)

More detail

Infection Control Deficiencies

Survey type in the file: Health

Survey cycle in the file: 2

Tag 0880E

E — Pattern, potential for more than minimal harm

Complaint survey, Standard survey

Survey date: May 24, 2024

CMS records a correction date (June 25, 2024)

More detail

Infection Control Deficiencies

Survey type in the file: Health

Survey cycle in the file: 2

Tag 0849D

D — Isolated, potential for more than minimal harm

Standard survey

Survey date: May 24, 2024

CMS records a correction date (June 25, 2024)

More detail

Administration Deficiencies

Survey type in the file: Health

Survey cycle in the file: 2

Tag 0847D

D — Isolated, potential for more than minimal harm

Complaint survey, Standard survey

Survey date: May 24, 2024

CMS records a correction date (June 25, 2024)

More detail

Administration Deficiencies

Survey type in the file: Health

Survey cycle in the file: 2

Tag 0812E

E — Pattern, potential for more than minimal harm

Standard survey

Survey date: May 24, 2024

CMS records a correction date (June 25, 2024)

More detail

Nutrition and Dietary Deficiencies

Survey type in the file: Health

Survey cycle in the file: 2

Tag 0803D

D — Isolated, potential for more than minimal harm

Standard survey

Survey date: May 24, 2024

CMS records a correction date (June 25, 2024)

More detail

Nutrition and Dietary Deficiencies

Survey type in the file: Health

Survey cycle in the file: 2

Tag 0802E

E — Pattern, potential for more than minimal harm

Standard survey

Survey date: May 24, 2024

CMS records a correction date (June 25, 2024)

More detail

Nutrition and Dietary Deficiencies

Survey type in the file: Health

Survey cycle in the file: 2

Tag 0760D

D — Isolated, potential for more than minimal harm

Standard survey

Survey date: May 24, 2024

CMS records a correction date (June 25, 2024)

More detail

Pharmacy Service Deficiencies

Survey type in the file: Health

Survey cycle in the file: 2

Tag 0759E

E — Pattern, potential for more than minimal harm

Standard survey

Survey date: May 24, 2024

CMS records a correction date (June 25, 2024)

More detail

Pharmacy Service Deficiencies

Survey type in the file: Health

Survey cycle in the file: 2

Tag 0699D

D — Isolated, potential for more than minimal harm

Standard survey

Survey date: May 24, 2024

CMS records a correction date (June 25, 2024)

More detail

Quality of Life and Care Deficiencies

Survey type in the file: Health

Survey cycle in the file: 2

Tag 0698D

D — Isolated, potential for more than minimal harm

Standard survey

Survey date: May 24, 2024

CMS records a correction date (June 25, 2024)

More detail

Quality of Life and Care Deficiencies

Survey type in the file: Health

Survey cycle in the file: 2

Tag 0695D

D — Isolated, potential for more than minimal harm

Standard survey

Survey date: May 24, 2024

CMS records a correction date (June 25, 2024)

More detail

Quality of Life and Care Deficiencies

Survey type in the file: Health

Survey cycle in the file: 2

Tag 0690D

D — Isolated, potential for more than minimal harm

Standard survey

Survey date: May 24, 2024

CMS records a correction date (June 25, 2024)

More detail

Quality of Life and Care Deficiencies

Survey type in the file: Health

Survey cycle in the file: 2

Tag 0688D

D — Isolated, potential for more than minimal harm

Standard survey

Survey date: May 24, 2024

CMS records a correction date (June 25, 2024)

More detail

Quality of Life and Care Deficiencies

Survey type in the file: Health

Survey cycle in the file: 2

Tag 0678J

J — Isolated, immediate jeopardy

Standard survey

Survey date: May 24, 2024

CMS records a correction date (May 25, 2024)

More detail

Quality of Life and Care Deficiencies

Survey type in the file: Health

Survey cycle in the file: 2

Tag 0657E

E — Pattern, potential for more than minimal harm

Standard survey

Survey date: May 24, 2024

CMS records a correction date (June 25, 2024)

More detail

Resident Assessment and Care Planning Deficiencies

Survey type in the file: Health

Survey cycle in the file: 2

Tag 0584D

D — Isolated, potential for more than minimal harm

Complaint survey, Standard survey

Survey date: May 24, 2024

CMS records a correction date (June 25, 2024)

More detail

Resident Rights Deficiencies

Survey type in the file: Health

Survey cycle in the file: 2

Tag 0583J

J — Isolated, immediate jeopardy

Standard survey

Survey date: May 24, 2024

CMS records a correction date (May 25, 2024)

More detail

Resident Rights Deficiencies

Survey type in the file: Health

Survey cycle in the file: 2

13 more 2024 citations

Tag 0578D

D — Isolated, potential for more than minimal harm

Complaint survey, Standard survey

Survey date: May 24, 2024

CMS records a correction date (June 25, 2024)

More detail

Resident Rights Deficiencies

Survey type in the file: Health

Survey cycle in the file: 2

Tag 0573D

D — Isolated, potential for more than minimal harm

Complaint survey, Standard survey

Survey date: May 24, 2024

CMS records a correction date (June 25, 2024)

More detail

Resident Rights Deficiencies

Survey type in the file: Health

Survey cycle in the file: 2

Tag 0552E

E — Pattern, potential for more than minimal harm

Complaint survey, Standard survey

Survey date: May 24, 2024

CMS records a correction date (June 25, 2024)

More detail

Resident Rights Deficiencies

Survey type in the file: Health

Survey cycle in the file: 2

Tag 0550D

D — Isolated, potential for more than minimal harm

Complaint survey, Standard survey

Survey date: May 24, 2024

CMS records a correction date (June 25, 2024)

More detail

Resident Rights Deficiencies

Survey type in the file: Health

Survey cycle in the file: 2

Tag 0684D

D — Isolated, potential for more than minimal harm

Complaint survey

Survey date: March 24, 2024

CMS records a correction date (April 23, 2024)

More detail

Quality of Life and Care Deficiencies

Survey type in the file: Health

Survey cycle in the file: 3

Tag 0602D

D — Isolated, potential for more than minimal harm

Complaint survey

Survey date: March 24, 2024

CMS records a correction date (April 23, 2024)

More detail

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Survey type in the file: Health

Survey cycle in the file: 3

Tag 0840D

D — Isolated, potential for more than minimal harm

Complaint survey

Survey date: February 14, 2024

CMS records a correction date (March 14, 2024)

More detail

Administration Deficiencies

Survey type in the file: Health

Survey cycle in the file: 3

Tag 0757G

G — Isolated, actual harm

Complaint survey

Survey date: February 14, 2024

CMS records a correction date (March 14, 2024)

More detail

Pharmacy Service Deficiencies

Survey type in the file: Health

Survey cycle in the file: 3

Tag 0692D

D — Isolated, potential for more than minimal harm

Complaint survey

Survey date: February 14, 2024

CMS records a correction date (March 14, 2024)

More detail

Quality of Life and Care Deficiencies

Survey type in the file: Health

Survey cycle in the file: 3

Tag 0610D

D — Isolated, potential for more than minimal harm

Complaint survey

Survey date: February 14, 2024

CMS records a correction date (March 14, 2024)

More detail

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Survey type in the file: Health

Survey cycle in the file: 3

Tag 0584E

E — Pattern, potential for more than minimal harm

Complaint survey

Survey date: February 14, 2024

CMS records a correction date (March 14, 2024)

More detail

Resident Rights Deficiencies

Survey type in the file: Health

Survey cycle in the file: 3

Tag 0580D

D — Isolated, potential for more than minimal harm

Complaint survey

Survey date: February 14, 2024

CMS records a correction date (March 14, 2024)

More detail

Resident Rights Deficiencies

Survey type in the file: Health

Survey cycle in the file: 3

Tag 0558D

D — Isolated, potential for more than minimal harm

Complaint survey

Survey date: February 14, 2024

CMS records a correction date (March 14, 2024)

More detail

Resident Rights Deficiencies

Survey type in the file: Health

Survey cycle in the file: 3

2023 — 29 citations

Tag 0880L

L — Widespread, immediate jeopardy

Complaint survey

Survey date: October 9, 2023

CMS records a correction date (November 30, 2023)

More detail

Infection Control Deficiencies

Survey type in the file: Health

Survey cycle in the file: 3

Tag 0761D

D — Isolated, potential for more than minimal harm

Complaint survey

Survey date: October 9, 2023

CMS records a correction date (November 2, 2023)

More detail

Pharmacy Service Deficiencies

Survey type in the file: Health

Survey cycle in the file: 3

Tag 0689D

D — Isolated, potential for more than minimal harm

Complaint survey

Survey date: October 9, 2023

CMS records a correction date (November 2, 2023)

More detail

Quality of Life and Care Deficiencies

Survey type in the file: Health

Survey cycle in the file: 3

Tag 0883D

D — Isolated, potential for more than minimal harm

Standard survey

Survey date: March 9, 2023

CMS records a correction date (March 10, 2023)

More detail

Infection Control Deficiencies

Survey type in the file: Health

Survey cycle in the file: 3

Tag 0880E

E — Pattern, potential for more than minimal harm

Standard survey

Survey date: March 9, 2023

CMS records a correction date (March 10, 2023)

More detail

Infection Control Deficiencies

Survey type in the file: Health

Survey cycle in the file: 3

Tag 0842D

D — Isolated, potential for more than minimal harm

Standard survey

Survey date: March 9, 2023

CMS records a correction date (March 10, 2023)

More detail

Resident Assessment and Care Planning Deficiencies

Survey type in the file: Health

Survey cycle in the file: 3

Tag 0813E

E — Pattern, potential for more than minimal harm

Standard survey

Survey date: March 9, 2023

CMS records a correction date (March 10, 2023)

More detail

Nutrition and Dietary Deficiencies

Survey type in the file: Health

Survey cycle in the file: 3

Tag 0812E

E — Pattern, potential for more than minimal harm

Standard survey

Survey date: March 9, 2023

CMS records a correction date (March 10, 2023)

More detail

Nutrition and Dietary Deficiencies

Survey type in the file: Health

Survey cycle in the file: 3

Tag 0808D

D — Isolated, potential for more than minimal harm

Standard survey

Survey date: March 9, 2023

CMS records a correction date (March 10, 2023)

More detail

Nutrition and Dietary Deficiencies

Survey type in the file: Health

Survey cycle in the file: 3

Tag 0804E

E — Pattern, potential for more than minimal harm

Standard survey

Survey date: March 9, 2023

CMS records a correction date (March 10, 2023)

More detail

Nutrition and Dietary Deficiencies

Survey type in the file: Health

Survey cycle in the file: 3

Tag 0761D

D — Isolated, potential for more than minimal harm

Standard survey

Survey date: March 9, 2023

CMS records a correction date (March 10, 2023)

More detail

Pharmacy Service Deficiencies

Survey type in the file: Health

Survey cycle in the file: 3

Tag 0759D

D — Isolated, potential for more than minimal harm

Standard survey

Survey date: March 9, 2023

CMS records a correction date (March 10, 2023)

More detail

Pharmacy Service Deficiencies

Survey type in the file: Health

Survey cycle in the file: 3

Tag 0698D

D — Isolated, potential for more than minimal harm

Standard survey

Survey date: March 9, 2023

CMS records a correction date (March 10, 2023)

More detail

Quality of Life and Care Deficiencies

Survey type in the file: Health

Survey cycle in the file: 3

Tag 0697D

D — Isolated, potential for more than minimal harm

Standard survey

Survey date: March 9, 2023

CMS records a correction date (March 10, 2023)

More detail

Quality of Life and Care Deficiencies

Survey type in the file: Health

Survey cycle in the file: 3

Tag 0695D

D — Isolated, potential for more than minimal harm

Standard survey

Survey date: March 9, 2023

CMS records a correction date (March 10, 2023)

More detail

Quality of Life and Care Deficiencies

Survey type in the file: Health

Survey cycle in the file: 3

Tag 0689D

D — Isolated, potential for more than minimal harm

Standard survey

Survey date: March 9, 2023

CMS records a correction date (March 10, 2023)

More detail

Quality of Life and Care Deficiencies

Survey type in the file: Health

Survey cycle in the file: 3

Tag 0688E

E — Pattern, potential for more than minimal harm

Standard survey

Survey date: March 9, 2023

CMS records a correction date (March 10, 2023)

More detail

Quality of Life and Care Deficiencies

Survey type in the file: Health

Survey cycle in the file: 3

Tag 0677E

E — Pattern, potential for more than minimal harm

Standard survey

Survey date: March 9, 2023

CMS records a correction date (March 10, 2023)

More detail

Quality of Life and Care Deficiencies

Survey type in the file: Health

Survey cycle in the file: 3

Tag 0676D

D — Isolated, potential for more than minimal harm

Standard survey

Survey date: March 9, 2023

CMS records a correction date (March 10, 2023)

More detail

Quality of Life and Care Deficiencies

Survey type in the file: Health

Survey cycle in the file: 3

Tag 0656E

E — Pattern, potential for more than minimal harm

Standard survey

Survey date: March 9, 2023

CMS records a correction date (March 10, 2023)

More detail

Resident Assessment and Care Planning Deficiencies

Survey type in the file: Health

Survey cycle in the file: 3

9 more 2023 citations

Tag 0655D

D — Isolated, potential for more than minimal harm

Standard survey

Survey date: March 9, 2023

CMS records a correction date (March 10, 2023)

More detail

Resident Assessment and Care Planning Deficiencies

Survey type in the file: Health

Survey cycle in the file: 3

Tag 0641D

D — Isolated, potential for more than minimal harm

Standard survey

Survey date: March 9, 2023

CMS records a correction date (March 10, 2023)

More detail

Resident Assessment and Care Planning Deficiencies

Survey type in the file: Health

Survey cycle in the file: 3

Tag 0636E

E — Pattern, potential for more than minimal harm

Standard survey

Survey date: March 9, 2023

CMS records a correction date (March 10, 2023)

More detail

Resident Assessment and Care Planning Deficiencies

Survey type in the file: Health

Survey cycle in the file: 3

Tag 0610E

E — Pattern, potential for more than minimal harm

Standard survey

Survey date: March 9, 2023

CMS records a correction date (March 10, 2023)

More detail

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Survey type in the file: Health

Survey cycle in the file: 3

Tag 0585D

D — Isolated, potential for more than minimal harm

Standard survey

Survey date: March 9, 2023

CMS records a correction date (March 10, 2023)

More detail

Resident Rights Deficiencies

Survey type in the file: Health

Survey cycle in the file: 3

Tag 0584D

D — Isolated, potential for more than minimal harm

Standard survey

Survey date: March 9, 2023

CMS records a correction date (March 10, 2023)

More detail

Resident Rights Deficiencies

Survey type in the file: Health

Survey cycle in the file: 3

Tag 0582D

D — Isolated, potential for more than minimal harm

Standard survey

Survey date: March 9, 2023

CMS records a correction date (March 10, 2023)

More detail

Resident Rights Deficiencies

Survey type in the file: Health

Survey cycle in the file: 3

Tag 0552D

D — Isolated, potential for more than minimal harm

Standard survey

Survey date: March 9, 2023

CMS records a correction date (March 10, 2023)

More detail

Resident Rights Deficiencies

Survey type in the file: Health

Survey cycle in the file: 3

Tag 0550E

E — Pattern, potential for more than minimal harm

Standard survey

Survey date: March 9, 2023

CMS records a correction date (March 10, 2023)

More detail

Resident Rights Deficiencies

Survey type in the file: Health

Survey cycle in the file: 3

License and identity (HHSC)

License effective: February 1, 2024
License expires: February 1, 2027
Initial license date: August 30, 1974
Facility licensed: Yes
Facility certified (HHSC): Yes
Service type: MEDICARE/MEDICAID
Total licensed capacity: 122 beds
Bed mix (HHSC): Licensed only 0; Medicaid only 0; Medicare only 31; Medicare/Medicaid 91; ICF/IID 0
Alzheimer capacity: 0
Administrator: Kelvin Hazel
Management company: Focused Post Acute Care Partners Management, LLC

Ownership

Ownership below comes from the CMS file when a row joined on this home’s Medicare number. HHSC also records an owner and entity type; those appear after the CMS data. The HHSC entity type “HOSPITAL DISTRICT/AUTHORITY” is very common in the state roster and may not describe day-to-day control. It is not used as a headline here.

CMS ownership type: For profit - Limited Liability company · Affiliated / chain name in the file: FOCUSED POST ACUTE CARE PARTNERS (25 facilities in the chain, as listed)

CMS ownership records
Name	Role	Type	Share	Associated
FPACP MOUNT PLEASANT LLC	5% OR GREATER DIRECT OWNERSHIP INTEREST	Organization	100%	since 02/01/2017
FOCUSED POST ACUTE CARE PARTNERS LLC	DIRECT OWNERSHIP INTEREST	Organization	NOT APPLICABLE	since 02/01/2017
CONLEY, SHAWN	CORPORATE OFFICER	Individual	NOT APPLICABLE	since 02/01/2017
MCKENZIE, MARK	CORPORATE OFFICER	Individual	NOT APPLICABLE	since 07/01/2018
STRUBBE, LORETTA	CORPORATE OFFICER	Individual	NOT APPLICABLE	since 07/01/2018
FOCUSED POST ACUTE CARE PARTNERS LLC	OPERATIONAL/MANAGERIAL CONTROL	Organization	NOT APPLICABLE	since 02/01/2017
FOCUSED POST ACUTE CARE PARTNERS MANAGEMENT, LLC	OPERATIONAL/MANAGERIAL CONTROL	Organization	NOT APPLICABLE	since 02/01/2017
FPACP MOUNT PLEASANT LLC	OPERATIONAL/MANAGERIAL CONTROL	Organization	NOT APPLICABLE	since 02/01/2017
CONLEY, SHAWN	OPERATIONAL/MANAGERIAL CONTROL	Individual	NOT APPLICABLE	since 02/01/2017
EASLEY, ADRIEANNIA	OPERATIONAL/MANAGERIAL CONTROL	Individual	NOT APPLICABLE	since 10/01/2023
MCKENZIE, MARK	OPERATIONAL/MANAGERIAL CONTROL	Individual	NOT APPLICABLE	since 02/01/2017
ONEY, WHITNEY	OPERATIONAL/MANAGERIAL CONTROL	Individual	NOT APPLICABLE	since 09/04/2020

8 more CMS ownership records

Additional CMS ownership records
Name	Role	Type	Share	Associated
STRUBBE, LORETTA	OPERATIONAL/MANAGERIAL CONTROL	Individual	NOT APPLICABLE	since 07/01/2018
WILLARD, LORI	OPERATIONAL/MANAGERIAL CONTROL	Individual	NOT APPLICABLE	since 10/09/2024
ZARCONE, GREGORY	OPERATIONAL/MANAGERIAL CONTROL	Individual	NOT APPLICABLE	since 07/19/2021
FOCUSED POST ACUTE CARE PARTNERS LLC	ADP OF THE SNF	Organization	NOT APPLICABLE	since 04/11/2025
FOCUSED POST ACUTE CARE PARTNERS MANAGEMENT, LLC	ADP OF THE SNF	Organization	NOT APPLICABLE	since 04/11/2025
ONEY, WHITNEY	ADP OF THE SNF	Individual	NOT APPLICABLE	since 09/04/2020
WILLARD, LORI	ADP OF THE SNF	Individual	NOT APPLICABLE	since 04/14/2025
ZARCONE, GREGORY	ADP OF THE SNF	Individual	NOT APPLICABLE	since 07/19/2021

HHSC owner fields

Owner (HHSC): Fpacp Mount Pleasant LLC
Type of entity (HHSC): Limited Liability Company (LLC)

Public data compiled by NursingCareLookup, not an endorsement or a recommendation, and not medical or legal advice. This site is not affiliated with HHSC, CMS, or Medicare. Figures can lag events at the facility, including surveys, corrections, and successful appeals (an appeal can alter or remove a citation). Verify current facts on TULIP and Medicare.gov, and visit in person before you decide. HHSC roster as of November 9, 2026 (America/Chicago). CMS file: official release October 28, 2026; processing date October 1, 2026.