13 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Mount Pleasant, TX
1-star overall rating with 1-star inspections with $150,506 in total fines with 13 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
2530 Greenhill Rd, Mount Pleasant, TX
(903) 572-0974
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Beds
150
Certified beds
Average residents
79
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Creative Solutions In Healthcare
Operator or chain grouping
Approved since
2009-12-22
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
149 facilities
Chain averages 3 overall / 3 health / 2 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Hospital-based
Yes
CMS reports the provider resides in a hospital
Staffing
RN hours / resident day
0.25
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.76
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
2.17
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.17
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.01
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.77
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.20
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.29
CMS adjusted RN staffing hours
Adjusted total hours
3.76
CMS adjusted total nurse staffing hours
Case-mix index
1.15
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
49%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Program rank
13,438
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
5.21
Composite VBP score used to determine payment impact.
Payment multiplier
0.9805
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
0.71
Baseline 21.05% · Performance 21.10% · Measure score 0.71 · Achievement 0.71 · Improvement 0
Healthcare-associated infections
0
Baseline 6.89% · Performance 8.13% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
1.38
Baseline 66.67% · Performance 58.82% · Measure score 1.38 · Achievement 1.19 · Improvement 1.38
Adjusted total nurse staffing
0
Baseline 3.44 hours · Performance 2.95 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.83% |
10.72%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 77 · Observed rate 10.39% · Lower 95% interval 7.58% |
| Discharge to community | 56.26% |
50.57%
5.7 pts better
|
No Different than the National Rate · Eligible stays 62 · Observed rate 51.61% · Lower 95% interval 46.68% |
| Medicare spending per beneficiary | 1.35 |
1.02
0.3 pts worse
|
|
| Drug regimen review with follow-up | 97.92% |
95.27%
2.7 pts better
|
Numerator 47 · Denominator 48 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 48 |
| Discharge self-care score | 44.44% |
53.69%
9.2 pts worse
|
Numerator 12 · Denominator 27 |
| Discharge mobility score | 25.93% |
50.94%
25 pts worse
|
Numerator 7 · Denominator 27 |
| Pressure ulcers or injuries, new or worsened | 2.08% |
2.29%
0.2 pts better
|
Numerator 1 · Denominator 48 · Adjusted rate 1.91% |
| Healthcare-associated infections requiring hospitalization | 8.13% |
7.12%
1 pts worse
|
No Different than the National Rate · Eligible stays 47 · Observed rate 12.77% · Lower 95% interval 4.77% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 90 |
| Staff flu vaccination coverage | 25.98% |
42%
16 pts worse
|
Numerator 33 · Denominator 127 |
| Discharge function score | 33.33% |
56.45%
23.1 pts worse
|
Numerator 9 · Denominator 27 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 100% |
25.2%
74.8 pts better
|
Numerator 20 · Denominator 20 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.3 |
2.1
0.2 pts worse
|
1.9
0.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 2.5 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 4.5 |
2.1
2.4 pts worse
|
1.8
2.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 4.5 · Observed 5.3 · Expected 1.9 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
97.1%
2.9 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
97.9%
2.1 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.4% |
3.3%
3.1 pts worse
|
3.3%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.6% · Q2 9.5% · Q3 4.5% · Q4 4.2% · 4Q avg 6.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.5% |
2.7%
0.2 pts better
|
11.4%
8.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 0.0% · Q3 0.0% · Q4 8.2% · 4Q avg 2.5% |
| Percentage of long-stay residents who lose too much weight | 4.4% |
3.3%
1.1 pts worse
|
5.4%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.7% · Q2 4.9% · Q3 2.3% · Q4 2.0% · 4Q avg 4.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 22.3% |
18.9%
3.4 pts worse
|
19.6%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.5% · Q2 23.3% · Q3 20.5% · Q4 20.0% · 4Q avg 22.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.3% |
10.8%
1.5 pts worse
|
16.7%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 9.1% · Q3 16.7% · Q4 16.7% · 4Q avg 12.3% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 15.9% |
15.4%
0.5 pts worse
|
16.3%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.7% · Q2 8.4% · Q3 7.5% · Q4 26.0% · 4Q avg 15.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.9% |
16.1%
3.2 pts better
|
14.9%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.5% · Q2 13.5% · Q3 7.5% · Q4 13.0% · 4Q avg 12.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
0.5%
0.2 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.3% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.4% |
0.8%
0.4 pts better
|
1.7%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.6% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 28.6% |
15.0%
13.6 pts worse
|
19.8%
8.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.4% · Q2 27.0% · Q3 36.3% · Q4 28.5% · 4Q avg 28.6% |
| Percentage of long-stay residents with pressure ulcers | 3.7% |
4.2%
0.5 pts better
|
5.1%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 4.0% · Q3 2.7% · Q4 2.8% · 4Q avg 3.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
89.7%
10.3 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 20.7% |
12.0%
8.7 pts worse
|
12.0%
8.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 20.7% · Observed 23.1% · Expected 12.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.7% |
1.5%
2.2 pts worse
|
1.6%
2.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q2 0.0% · Q3 4.2% · 4Q avg 3.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
88.0%
12 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 34.2% |
25.9%
8.3 pts worse
|
23.9%
10.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 34.2% · Observed 35.9% · Expected 25.0% · Used in QM five-star |
Survey summary
Top issue: Quality of Life and Care (5 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Top issue: Quality of Life and Care (7 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Top issue: Quality of Life and Care (5 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-06-18
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-06-18
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-06-18
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-06-26
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-06-26
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-06-26
Inspection history
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-12-05
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-10-31
Health
Provide and implement an infection prevention and control program.
Corrected 2025-10-31
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-06-20
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-06-20
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-06-20
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2025-06-20
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-06-20
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-06-20
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-06-20
Health
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.
Corrected 2025-06-20
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-20
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2025-06-20
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-08-23
Health
Let each resident or the resident's legal representative access or purchase copies of all the resident's records.
Corrected 2025-02-20
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-10-10
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-09-10
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-09-10
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-09-10
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-09-10
Health
Respond appropriately to all alleged violations.
Corrected 2024-09-10
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-05-22
Health
Provide and implement an infection prevention and control program.
Corrected 2024-05-22
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-05-22
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-05-22
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-05-22
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-05-22
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-05-09
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-05-09
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-03-23
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2023-07-27
Health
Provide and implement an infection prevention and control program.
Corrected 2023-07-28
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-04-03
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-03-30
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-03-30
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-03-30
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-03-30
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2023-03-30
Health
Provide and implement an infection prevention and control program.
Corrected 2023-03-30
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-03-30
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2023-03-30
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2023-03-30
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-03-30
Health
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.
Corrected 2023-03-30
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-03-30
Health
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.
Corrected 2023-03-30
Penalties and ownership
Fine · fine $12,640
Fine
Fine · fine $114,592
Fine
Fine · fine $10,245
Fine
Fine · fine $13,029
Fine
5% Or Greater Direct Ownership Interest · Organization
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Operational/Managerial Control · Organization
Corporate Officer · Individual
Corporate Director · Individual
Nearby options
Mount Pleasant, TX
1-star overall rating with 1-star inspections with abuse icon flag with $240,688 in total fines with 17 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
Mount Pleasant, TX
2-star overall rating with 2-star inspections with $33,155 in total fines with 13 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
Pittsburg, TX
3-star overall rating with 2-star inspections with abuse icon flag with $106,220 in total fines with 10 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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