Federal inspection record · CMS data as of October 1, 2026
Focused Care at Mount Pleasant
1606 Memorial Ave, Mount Pleasant, TX · (903) 572-3618
- Cited for abuse (CMS abuse icon)
- Certified beds
- 122
- Residents per day
- 82
- Ownership
- For-Profit
- Chain
- Focused Post Acute Care Partners
- Medicare / Medicaid
- Medicare + Medicaid
- Certified since
- November 12, 1990
1
How this home got 1 star
The overall rating isn't an average. CMS starts from the inspection rating and nudges it at most two steps. Here is the arithmetic for this home, using CMS's own rules.
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Health inspections
★★★★★starting point
Everything starts from what state inspectors found on site. This is a ranking against other homes in Texas.
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Staffing
★★★★★no change (already 1)
Only a 5-star staffing rating adds a star, and only a 1-star rating removes one. Ratings of 2 to 4 change nothing.
-
Quality measures
★★★★★no change
Same rule: 5 stars adds one, 1 star takes one away. These measures are mostly reported by the home itself.
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Overall
★★★★★1 of 5
Matches the rating CMS publishes on Care Compare.
This home carries CMS's abuse icon, which caps its inspection rating at 2 stars and so its overall rating at 4.
2
Where it sits among Texas homes
Focused Care at Mount Pleasant carries 221.5 inspection points. That is fewer than 8% of Texas's 1,166 rated homes.
Inspectors' citations earn points by how serious and how widespread they were (the grid below). CMS then ranks every home in Texas: the 10% with the fewest points get 5 stars, the 20% with the most get 1 star, and the middle 70% split evenly into 2, 3 and 4.
- 5★ 0–26 pts
- 4★ 26–51 pts
- 3★ 51–85 pts
- 2★ 85–145.75 pts
- 1★ over 145.75 pts
Bars show every rated home in Texas by its weighted inspection score. CMS recalibrates the cut points monthly but holds a home's rating until its own score changes, so a home can sit just outside today's band.
3
What inspectors found
84 health citations on record since 2023. Each one gets a letter: the row says how badly residents were affected, the column how many.
Immediate jeopardyResidents at risk of serious injury or death
Actual harmA resident was hurt
Potential for harmNo one was hurt, but could have been
Minimal harmPaperwork-level problems
Read the rows, not the total. Most citations nationwide are a D: one problem, nobody hurt. Rows G–I mean a resident was harmed; J–L mean inspectors found residents in immediate danger of serious injury or death.
Small numbers in each cell are the inspection points CMS assigns per citation. Those points are what the state curve above ranks.
Harm and immediate-jeopardy citations (6)
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J
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
-
J
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
-
J
Keep residents' personal and medical records private and confidential.
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J
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
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G
Ensure each resident’s drug regimen must be free from unnecessary drugs.
-
L
Provide and implement an infection prevention and control program.
Everything else, by area of care
Quality of Life and Care18E
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
- D
Provide safe and appropriate respiratory care for a resident when needed.
- D
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.
- D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
- D
Provide safe and appropriate respiratory care for a resident when needed.
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
- D
Provide care or services that was trauma informed and/or culturally competent.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- D
Provide enough food/fluids to maintain a resident's health.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
- E
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.
- D
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- D
Provide safe and appropriate respiratory care for a resident when needed.
- D
Provide safe, appropriate pain management for a resident who requires such services.
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Resident Rights15E
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- D
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.
- E
Ensure that residents are fully informed and understand their health status, care and treatments.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- D
Let each resident or the resident's legal representative access or purchase copies of all the resident's records.
- D
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.
- D
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.
- E
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.
- D
Reasonably accommodate the needs and preferences of each resident.
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
- E
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- D
Ensure that residents are fully informed and understand their health status, care and treatments.
- D
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
- D
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.
- D
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 Assessment and Care Planning9E
- E
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- D
Ensure each resident receives an accurate assessment.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
- E
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- E
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
- E
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- D
Ensure each resident receives an accurate assessment.
- D
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Nutrition and Dietary9F
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
- E
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- D
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.
- E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- E
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
- D
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.
Infection Control6E
- D
Provide and implement an infection prevention and control program.
- D
Provide and implement an infection prevention and control program.
- E
Provide and implement an infection prevention and control program.
- E
Implement a program that monitors antibiotic use.
- E
Provide and implement an infection prevention and control program.
- D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Freedom from Abuse, Neglect, and Exploitation6E
- D
Protect each resident from the wrongful use of the resident's belongings or money.
- E
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
- D
Protect each resident from the wrongful use of the resident's belongings or money.
- D
Respond appropriately to all alleged violations.
- E
Respond appropriately to all alleged violations.
Pharmacy Service6E
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- E
Ensure medication error rates are not 5 percent or greater.
- D
Ensure that residents are free from significant medication errors.
- D
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.
- D
Ensure medication error rates are not 5 percent or greater.
- D
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.
Environmental5F
- D
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
- E
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
- F
Keep all essential equipment working safely.
- D
Have policies on smoking.
- E
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Administration3D
- D
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
- D
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.
- D
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.
Nursing and Physician Services1D
- D
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.
Inspection history
2025-07-02
17 health deficiencies · 4 fire-safety deficiencies
Top issue: Environmental (3 deficiencies)
2024-05-24
29 health deficiencies · 2 fire-safety deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
2023-03-09
38 health deficiencies · 4 fire-safety deficiencies
Top issue: Quality of Life and Care (10 deficiencies)
4
Nursing time per resident, per day
Each resident here gets about 2 h 53 min of nursing staff time a day, 26 min of it from a registered nurse.
This home
2 h 53 min
Texas average
3 h 25 min
U.S. average
3 h 54 min
- Registered nurse
- Licensed practical nurse
- Nurse aide
Turnover: 51% of nursing staff and 58% of registered nurses left in the past year.
Reported hours from payroll data the home submits to CMS, divided by its daily resident count. Not adjusted for how sick residents are.
5
Fines and payment denials
$199,421 in federal fines on record over the past three years.
| Date | Penalty | Amount |
|---|---|---|
| 2026-08-28 | Fine | $27,378 |
| 2025-06-25 | Fine | $16,149 |
| 2025-06-25 | Fine | $16,149 |
| 2025-06-25 | Payment Denial · 7 day denial | $0 |
| 2024-05-24 | Fine | $127,486 |
| 2024-02-14 | Fine | $12,259 |
6
Resident outcomes
Quality measures compared with state and national averages. Most come from assessments the home itself reports.
| Measure | This home | State | U.S. |
|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine1.2 pts worse | 95.2% | 96.4% | 93.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine0.3 pts better | 97.3% | 97.0% | 95.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury0.6 pts better | 2.6% | 3.2% | 3.2% |
| Percentage of long-stay residents who have depressive symptoms2.3 pts better | 0.0% | 2.3% | 13.5% |
| Percentage of long-stay residents who lose too much weight3.3 pts worse | 6.2% | 2.9% | 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication5.2 pts better | 12.6% | 17.8% | 19.5% |
| Percentage of long-stay residents who received an antipsychotic medication1.3 pts better | 8.5% | 9.8% | 15.4% |
| Percentage of long-stay residents who were physically restrainedAbout the same | 0.0% | 0.0% | 0.1% |
| Percentage of long-stay residents whose ability to walk independently worsened6.9 pts better | 6.0% | 12.9% | 12.7% |
| Percentage of long-stay residents whose need for help with daily activities has increased7.4 pts worse | 23.2% | 15.8% | 13.5% |
| Percentage of long-stay residents with a catheter inserted and left in their bladder0.3 pts better | 0.0% | 0.3% | 0.7% |
| Percentage of long-stay residents with a urinary tract infection0.4 pts better | 0.4% | 0.8% | 1.5% |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence2.2 pts better | 10.3% | 12.5% | 18.3% |
| Percentage of long-stay residents with pressure ulcers0.5 pts better | 3.2% | 3.7% | 4.5% |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine64.7 pts worse | 24.0% | 88.7% | 82.3% |
| Percentage of short-stay residents who newly received an antipsychotic medication4.3 pts worse | 5.7% | 1.4% | 1.5% |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine63.4 pts worse | 22.0% | 85.4% | 80.1% |
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Who owns and runs it
20 owners and managers reported to CMS. The last column counts how many nursing homes each one is tied to.
Show ownership list
| Name | Role | Share | Homes |
|---|---|---|---|
| Fpacp Mount Pleasant LLC | 5% Or Greater Direct Ownership Interest · Organization | 100% | 1 facilities |
| Conley, Shawn | Corporate Officer · Individual | 0% | 25 facilities |
| Conley, Shawn | Operational/Managerial Control · Individual | 0% | 25 facilities |
| Easley, Adrieannia | Operational/Managerial Control · Individual | 0% | 1 facilities |
| Focused Post Acute Care Partners LLC | Direct Ownership Interest · Organization | 0% | 23 facilities |
| Focused Post Acute Care Partners LLC | Operational/Managerial Control · Organization | 0% | 23 facilities |
| Focused Post Acute Care Partners LLC | Adp Of The SNF · Organization | 0% | 23 facilities |
| Focused Post Acute Care Partners Management, LLC | Operational/Managerial Control · Organization | 0% | 25 facilities |
| Focused Post Acute Care Partners Management, LLC | Adp Of The SNF · Organization | 0% | 25 facilities |
| Fpacp Mount Pleasant LLC | Operational/Managerial Control · Organization | 0% | 1 facilities |
| Mckenzie, Mark | Corporate Officer · Individual | 0% | 25 facilities |
| Mckenzie, Mark | Operational/Managerial Control · Individual | 0% | 25 facilities |
| Oney, Whitney | Operational/Managerial Control · Individual | 0% | 1 facilities |
| Oney, Whitney | Adp Of The SNF · Individual | 0% | 1 facilities |
| Strubbe, Loretta | Corporate Officer · Individual | 0% | 25 facilities |
| Strubbe, Loretta | Operational/Managerial Control · Individual | 0% | 25 facilities |
| Willard, Lori | Operational/Managerial Control · Individual | 0% | 1 facilities |
| Willard, Lori | Adp Of The SNF · Individual | 0% | 1 facilities |
| Zarcone, Gregory | Operational/Managerial Control · Individual | 0% | 5 facilities |
| Zarcone, Gregory | Adp Of The SNF · Individual | 0% | 5 facilities |
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Fire safety
10 life-safety citations (sprinklers, exits, alarms). These don't count toward the star rating.
Smoke4F
- F
Have approved installation, maintenance and testing program for fire alarm systems.
- D
Inspect, test, and maintain automatic sprinkler systems.
- E
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- E
Have approved installation, maintenance and testing program for fire alarm systems.
Services4D
- D
Have properly installed electrical wiring and gas equipment.
- C
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
- C
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
- C
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Gas, Vacuum, and Electrical Systems2E
- E
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
- C
Have generator or other power source capable of supplying service within 10 seconds.
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Other homes nearby
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Pleasant Springs Healthcare Center
Mount Pleasant, TX · Creative Solutions In Healthcare · Special Focus · Abuse icon
★★★★★- Worst citation, 3 yrs
- K
- Nursing / resident / day
- 2 h 58 min
- Fines
- $65,650
-
Greenhill Villas
Mount Pleasant, TX · Creative Solutions In Healthcare
★★★★★- Worst citation, 3 yrs
- K
- Nursing / resident / day
- 3 h 11 min
- Fines
- $170,927
-
Avir at Pittsburg
Pittsburg, TX · Avir Health Group
★★★★★- Worst citation, 3 yrs
- J
- Nursing / resident / day
- 3 h 24 min
- Fines
- $15,119