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| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J4 | K· | L1 |
| Actual harm | G1 | H· | I· |
| Potential harm | D54 | E27 | F3 |
| Minimal | A· | B· | C4 |
CMS publishes about the three most recent standard surveys plus complaint and infection-control inspections from the prior three years. Older findings leave the dataset; their absence is not evidence they never happened.
Federal certification and the state license are different records. A nursing home is licensed by the state and, separately, certified by CMS to bill Medicare and/or Medicaid. We link them by the CCN when the state publishes it; otherwise by exact address, house number and street, or exact name within the same ZIP, and label that link as inferred. Never by name alone.
| Date | Domain | Survey types | Citations | Most severe | Open | |
|---|---|---|---|---|---|---|
| May 20, 2026 | Health | Health Complaint | 2 | Potential harm | — | Open → |
| Jan 13, 2026 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Nov 26, 2025 | Health | Health Complaint | 6 | Potential harm | — | Open → |
| Sep 8, 2025 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Jul 2, 2025 | Fire safety | Fire Safety Standard | 4 | Potential harm | 1 | Open → |
| Jul 2, 2025 | Health | Health Standard | 8 | Potential harm | — | Open → |
| Jun 25, 2025 | Health | Health Complaint | 2 | Immediate jeopardy | — | Open → |
| Apr 17, 2025 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Feb 13, 2025 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Dec 19, 2024 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| May 24, 2024 | Fire safety | Fire Safety Standard | 2 | Potential harm | — | Open → |
| May 24, 2024 | Health | Health Complaint, Health Standard | 23 | Immediate jeopardy | — | Open → |
| Mar 24, 2024 | Health | Health Complaint | 2 | Potential harm | — | Open → |
| Feb 14, 2024 | Health | Health Complaint | 7 | Actual harm | — | Open → |
| Oct 9, 2023 | Health | Health Complaint | 3 | Immediate jeopardy | — | Open → |
| Mar 9, 2023 | Fire safety | Fire Safety Standard | 4 | Potential harm | — | Open → |
| Mar 9, 2023 | Health | Health Standard | 26 | Potential harm | — | Open → |
| Date | Type | Amount | Payment denial | Record |
|---|---|---|---|---|
| Aug 28, 2026 | Civil money penalty (fine) | $27,378 | — | 455900|Fine|145255 |
| Jun 25, 2025 | Denial of payment for new admissions | — | Jul 25, 2025 · 7 days | 455900|Payment Denial|2025-07-25 |
| Jun 25, 2025 | Civil money penalty (fine) | $16,149 | — | 455900|Fine|133829 |
| Jun 25, 2025 | Civil money penalty (fine) | $16,149 | — | 455900|Fine|133831 |
| May 24, 2024 | Civil money penalty (fine) | $127,486 | — | 455900|Fine|112920 |
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J4 | K· | L1 |
| Actual harm | G1 | H· | I· |
| Potential harm | D54 | E27 | F3 |
| Minimal | A· | B· | C4 |
| Date | Tag | Deficiency | Scope / severity | Correction | Flags |
|---|---|---|---|---|---|
| May 20, 2026 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected Jun 12, 2026 | Complaint |
| May 20, 2026 | F-0921 | Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Environmental Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Jun 12, 2026 | Complaint |
“Corrected” does not erase a citation: the historical finding stays listed with its disposition. Narrative statements of deficiencies are not part of the CMS dataset; see Care Compare for the official inspection report.
CMS ratings apply to CMS-certified nursing homes only and are relative within each state. They are not a guarantee of any individual resident’s experience.
CMS legal business name of the certified provider. Operates this facility only.
25 facilities in 1 states. CMS chain ID 224.
Chain average overall rating (CMS): 2
| Name | Type | Role (Carefield group) | CMS role text | Share | Since |
|---|---|---|---|---|---|
| Fpacp Mount Pleasant LLC | Organization | Direct owner | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | Feb 1, 2017 |
| Focused Post Acute Care Partners LLC | Organization | Direct owner | DIRECT OWNERSHIP INTEREST | not provided | Feb 1, 2017 |
| Name | Type | Role (Carefield group) | CMS role text | Share | Since |
|---|---|---|---|---|---|
| Fpacp Mount Pleasant LLC | Organization | Direct owner | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | Feb 1, 2017 |
| Focused Post Acute Care Partners LLC | Organization | Direct owner | DIRECT OWNERSHIP INTEREST | not provided | Feb 1, 2017 |
| Focused Post Acute Care Partners LLC | Organization | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Feb 1, 2017 |
| Focused Post Acute Care Partners Management, LLC | Organization | Operational / managerial control |
| Facility | Beds | CMS overall | Last inspection | Citations (window) | Fines |
|---|---|---|---|---|---|
| Focused Care of Waxahachie 1413 W Main St, Waxahachie, TX 75165 CCN 455591Abuse icon | 152 | Aug 14, 2026 | 433 IJ1 harm1 open |
Coordinates as published by CMS.
| Facility | Distance | Beds | CMS overall | Last inspection | Citations (window) | Fines |
|---|---|---|---|---|---|---|
| Pleasant Springs Healthcare Center 2003 North Edwards Avenue, Mount Pleasant, TX 75455 CCN 455532SFF CandidateAbuse icon | 0.4 km | 90 | Aug 7, 2026 | 774 IJ2 harm | $66k | |
| Greenhill Villas 2530 Greenhill Rd, Mount Pleasant, TX 75455 CCN 676241 | 2.3 km | 150 | Sep 3, 2026 | 572 IJ2 harm | $171k | |
| Avir at Pittsburg 123 Pecan Blvd., Pittsburg, TX 75686 CCN 675037 | 14.6 km | 102 | Feb 11, 2026 | 423 IJ | $15k |
| Source | Record | Facts | Evidence | Source release | Retrieved |
|---|---|---|---|---|---|
| CMS Provider Information US-CMS | 455900 | name, address, phone, certification, certified_beds, ownership_type, legal_business_name, chain | Verified | Oct 1, 2026 | Nov 7, 2026 |
| CMS Provider Information US-CMS | 455900 | ratings, staffing, health_survey_score Five-Star ratings and PBJ staffing apply to the CMS-certified universe only. | Verified | Oct 1, 2026 | Nov 7, 2026 |
First seen by Carefield Nov 7, 2026 · last changed Nov 7, 2026. This record as JSON · Report a correction
| Feb 14, 2024 | Civil money penalty (fine) | $12,259 | — | 455900|Fine|112356 |
| Jan 13, 2026 | F-0602 | Protect each resident from the wrongful use of the resident's belongings or money. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Feb 2, 2026 | Complaint |
| Nov 26, 2025 | F-0550 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Dec 19, 2025 | Complaint |
| Nov 26, 2025 | F-0641 | Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Dec 19, 2025 | Complaint |
| Nov 26, 2025 | F-0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Dec 19, 2025 | Complaint |
| Nov 26, 2025 | F-0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Dec 19, 2025 | Complaint |
| Nov 26, 2025 | F-0690 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Nov 27, 2025 | Complaint |
| Nov 26, 2025 | F-0842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Dec 19, 2025 | Complaint |
| Sep 8, 2025 | F-0925 | Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Environmental Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Oct 1, 2025 | Complaint |
| Jul 2, 2025 | K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Aug 15, 2025 |
| Jul 2, 2025 | K-0511 | Have properly installed electrical wiring and gas equipment. Services Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Aug 15, 2025 |
| Jul 2, 2025 | K-0929 | Ensure precautions for handling oxygen cylinders and equipment are correctly followed. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Aug 15, 2025 |
| Jul 2, 2025 | F-0584 | Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Aug 1, 2025 |
| Jul 2, 2025 | F-0695 | Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Aug 1, 2025 |
| Jul 2, 2025 | F-0726 | Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Nursing and Physician Services Deficiencies · Staffing & supervision | D · Potential harm Isolated | Corrected Aug 1, 2025 |
| Jul 2, 2025 | F-0804 | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | E · Potential harm Pattern | Corrected Aug 1, 2025 |
| Jul 2, 2025 | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | F · Potential harm Widespread | Corrected Aug 1, 2025 |
| Jul 2, 2025 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected Aug 1, 2025 |
| Jul 2, 2025 | F-0908 | Keep all essential equipment working safely. Environmental Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Aug 1, 2025 |
| Jul 2, 2025 | F-0926 | Have policies on smoking. Environmental Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Aug 1, 2025 |
| Jul 2, 2025 | K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. Services Deficiencies · Environment & life safety | C · Minimal Widespread | No plan of correction |
| Jun 25, 2025 | F-0600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | J · Immediate jeopardy Isolated | Past non-compliance Jun 24, 2025 | Complaint |
| Jun 25, 2025 | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Clinical care | J · Immediate jeopardy Isolated | Corrected Jun 26, 2025 | Complaint |
| Apr 17, 2025 | F-0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Apr 22, 2025 | Complaint |
| Feb 13, 2025 | F-0600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Mar 10, 2025 | Complaint |
| Dec 19, 2024 | F-0600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Past non-compliance Sep 27, 2024 | Complaint |
| May 24, 2024 | F-0583 | Keep residents' personal and medical records private and confidential. Resident Rights Deficiencies · Resident rights & abuse/neglect | J · Immediate jeopardy Isolated | Corrected May 25, 2024 |
| May 24, 2024 | F-0678 | Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives. Quality of Life and Care Deficiencies · Clinical care | J · Immediate jeopardy Isolated | Corrected May 25, 2024 |
| May 24, 2024 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Jul 5, 2024 |
| May 24, 2024 | F-0550 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Jun 25, 2024 | Complaint |
| May 24, 2024 | F-0552 | Ensure that residents are fully informed and understand their health status, care and treatments. Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Jun 25, 2024 | Complaint |
| May 24, 2024 | F-0573 | Let each resident or the resident's legal representative access or purchase copies of all the resident's records. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Jun 25, 2024 | Complaint |
| May 24, 2024 | F-0578 | Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Jun 25, 2024 | Complaint |
| May 24, 2024 | F-0584 | Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Jun 25, 2024 | Complaint |
| May 24, 2024 | F-0657 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Resident Assessment and Care Planning Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Jun 25, 2024 |
| May 24, 2024 | F-0688 | Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jun 25, 2024 |
| May 24, 2024 | F-0690 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jun 25, 2024 |
| May 24, 2024 | F-0695 | Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jun 25, 2024 |
| May 24, 2024 | F-0698 | Provide safe, appropriate dialysis care/services for a resident who requires such services. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jun 25, 2024 |
| May 24, 2024 | F-0699 | Provide care or services that was trauma informed and/or culturally competent. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jun 25, 2024 |
| May 24, 2024 | F-0759 | Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies · Medication management | E · Potential harm Pattern | Corrected Jun 25, 2024 |
| May 24, 2024 | F-0760 | Ensure that residents are free from significant medication errors. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Jun 25, 2024 |
| May 24, 2024 | F-0802 | Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | E · Potential harm Pattern | Corrected Jun 25, 2024 |
| May 24, 2024 | F-0803 | Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | D · Potential harm Isolated | Corrected Jun 25, 2024 |
| May 24, 2024 | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | E · Potential harm Pattern | Corrected Jun 25, 2024 |
| May 24, 2024 | F-0847 | Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. Administration Deficiencies · Administration & records | D · Potential harm Isolated | Corrected Jun 25, 2024 | Complaint |
| May 24, 2024 | F-0849 | Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. Administration Deficiencies · Administration & records | D · Potential harm Isolated | Corrected Jun 25, 2024 |
| May 24, 2024 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | E · Potential harm Pattern | Corrected Jun 25, 2024 | Complaint |
| May 24, 2024 | F-0881 | Implement a program that monitors antibiotic use. Infection Control Deficiencies · Infection prevention | E · Potential harm Pattern | Corrected Jun 25, 2024 | Complaint |
| May 24, 2024 | F-0925 | Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Environmental Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Jun 25, 2024 |
| May 24, 2024 | K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. Services Deficiencies · Environment & life safety | C · Minimal Widespread | Waiver granted |
| Mar 24, 2024 | F-0602 | Protect each resident from the wrongful use of the resident's belongings or money. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Apr 23, 2024 | Complaint |
| Mar 24, 2024 | F-0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Apr 23, 2024 | Complaint |
| Feb 14, 2024 | F-0757 | Ensure each resident’s drug regimen must be free from unnecessary drugs. Pharmacy Service Deficiencies · Medication management | G · Actual harm Isolated | Corrected Mar 14, 2024 | Complaint |
| Feb 14, 2024 | F-0558 | Reasonably accommodate the needs and preferences of each resident. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Mar 14, 2024 | Complaint |
| Feb 14, 2024 | F-0580 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Mar 14, 2024 | Complaint |
| Feb 14, 2024 | F-0584 | Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Mar 14, 2024 | Complaint |
| Feb 14, 2024 | F-0610 | Respond appropriately to all alleged violations. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Mar 14, 2024 | Complaint |
| Feb 14, 2024 | F-0692 | Provide enough food/fluids to maintain a resident's health. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Mar 14, 2024 | Complaint |
| Feb 14, 2024 | F-0840 | Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service. Administration Deficiencies · Administration & records | D · Potential harm Isolated | Corrected Mar 14, 2024 | Complaint |
| Oct 9, 2023 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | L · Immediate jeopardy Widespread | Corrected Nov 30, 2023 | Complaint |
| Oct 9, 2023 | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Nov 2, 2023 | Complaint |
| Oct 9, 2023 | F-0761 | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Nov 2, 2023 | Complaint |
| Mar 9, 2023 | K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Apr 19, 2023 |
| Mar 9, 2023 | K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Apr 19, 2023 |
| Mar 9, 2023 | F-0550 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Mar 10, 2023 |
| Mar 9, 2023 | F-0552 | Ensure that residents are fully informed and understand their health status, care and treatments. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Mar 10, 2023 |
| Mar 9, 2023 | F-0582 | Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Mar 10, 2023 |
| Mar 9, 2023 | F-0584 | Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Mar 10, 2023 |
| Mar 9, 2023 | F-0585 | Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Mar 10, 2023 |
| Mar 9, 2023 | F-0610 | Respond appropriately to all alleged violations. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Mar 10, 2023 |
| Mar 9, 2023 | F-0636 | Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. Resident Assessment and Care Planning Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Mar 10, 2023 |
| Mar 9, 2023 | F-0641 | Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Mar 10, 2023 |
| Mar 9, 2023 | F-0655 | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Mar 10, 2023 |
| Mar 9, 2023 | F-0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Mar 10, 2023 |
| Mar 9, 2023 | F-0676 | Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Mar 10, 2023 |
| Mar 9, 2023 | F-0677 | Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Mar 10, 2023 |
| Mar 9, 2023 | F-0688 | Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Quality of Life and Care Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Mar 10, 2023 |
| Mar 9, 2023 | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Mar 10, 2023 |
| Mar 9, 2023 | F-0695 | Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Mar 10, 2023 |
| Mar 9, 2023 | F-0697 | Provide safe, appropriate pain management for a resident who requires such services. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Mar 10, 2023 |
| Mar 9, 2023 | F-0698 | Provide safe, appropriate dialysis care/services for a resident who requires such services. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Mar 10, 2023 |
| Mar 9, 2023 | F-0759 | Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Mar 10, 2023 |
| Mar 9, 2023 | F-0761 | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Mar 10, 2023 |
| Mar 9, 2023 | F-0804 | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | E · Potential harm Pattern | Corrected Mar 10, 2023 |
| Mar 9, 2023 | F-0808 | Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | D · Potential harm Isolated | Corrected Mar 10, 2023 |
| Mar 9, 2023 | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | E · Potential harm Pattern | Corrected Mar 10, 2023 |
| Mar 9, 2023 | F-0813 | Have a policy regarding use and storage of foods brought to residents by family and other visitors. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | E · Potential harm Pattern | Corrected Mar 10, 2023 |
| Mar 9, 2023 | F-0842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Mar 10, 2023 |
| Mar 9, 2023 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | E · Potential harm Pattern | Corrected Mar 10, 2023 |
| Mar 9, 2023 | F-0883 | Develop and implement policies and procedures for flu and pneumonia vaccinations. Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected Mar 10, 2023 |
| Mar 9, 2023 | K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. Services Deficiencies · Environment & life safety | C · Minimal Widespread | Waiver granted |
| Mar 9, 2023 | K-0918 | Have generator or other power source capable of supplying service within 10 seconds. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | C · Minimal Widespread | Corrected Apr 19, 2023 |
Reported from Payroll-Based Journal (PBJ) data, as published by CMS. Case-mix adjusted total: 2.49 (case-mix index 1.62).
| OPERATIONAL/MANAGERIAL CONTROL |
| not provided |
| Feb 1, 2017 |
| Fpacp Mount Pleasant LLC | Organization | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Feb 1, 2017 |
| Shawn Conley | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Feb 1, 2017 |
| Adrieannia Easley | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Oct 1, 2023 |
| Mark Mckenzie | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Feb 1, 2017 |
| Whitney Oney | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Sep 4, 2020 |
| Loretta Strubbe | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Jul 1, 2018 |
| Lori Willard | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Oct 9, 2024 |
| Gregory Zarcone | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Jul 19, 2021 |
| Shawn Conley | Individual | Corporate officer / director | CORPORATE OFFICER | not provided | Feb 1, 2017 |
| Mark Mckenzie | Individual | Corporate officer / director | CORPORATE OFFICER | not provided | Jul 1, 2018 |
| Loretta Strubbe | Individual | Corporate officer / director | CORPORATE OFFICER | not provided | Jul 1, 2018 |
| Focused Post Acute Care Partners LLC | Organization | Additional disclosable party | ADP OF THE SNF | not provided | Apr 11, 2025 |
| Focused Post Acute Care Partners Management, LLC | Organization | Additional disclosable party | ADP OF THE SNF | not provided | Apr 11, 2025 |
| Whitney Oney | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Sep 4, 2020 |
| Lori Willard | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Apr 14, 2025 |
| Gregory Zarcone | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Jul 19, 2021 |
| $21k |
| Focused Care at Lamesa 1201 N 15th St, Lamesa, TX 79331 CCN 455936 | 80 | Jul 28, 2026 | 282 IJ | $11k |
| Focused Care at Clarksville 2407 West Main St., Clarksville, TX 75426 CCN 455944 | 120 | Feb 25, 2026 | 401 harm | $5,211 |
| Focused Care at Beechnut 12777 Beechnut St, Houston, TX 77072 CCN 675000 | 146 | Apr 17, 2026 | 3910 IJ | $90k |
| Focused Care at Allenbrook 4109 Allenbrook Dr, Baytown, TX 77521 CCN 675079 | 120 | Mar 13, 2026 | 201 IJ1 harm | $8,400 |
| Focused Care at Sherman 817 W Center, Sherman, TX 75090 CCN 675089 | 116 | Jul 28, 2026 | 678 IJ | $120k |
| Focused Care at Humble 93 Isaacks Rd, Humble, TX 77338 CCN 675127Abuse icon | 134 | Jul 15, 2026 | 385 IJ1 harm | $98k |
| Focused Care at Hamilton 1315 E State Hwy 22, Hamilton, TX 76531 CCN 675140 | 78 | Aug 6, 2026 | 18 | — |