Mount Pleasant, TX

Pleasant Springs Healthcare Center

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

2003 N Edwards St, Mount Pleasant, TX

(903) 572-5511

Compare this facility

Overall

2 / 5

CMS overall stars

Health inspections

2 / 5

Survey and complaint cycles

Staffing

3 / 5

RN + nurse staffing

Quality measures

4 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

Certified beds

Average residents

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Creative Solutions In Healthcare

Operator or chain grouping

Approved since

1985-07-26

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

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.63

Registered nurse staffing · state 0.44 · national 0.68

LPN hours / resident day

0.43

Licensed practical nurse staffing · state 0.95 · national 0.87

Aide hours / resident day

1.69

Nurse aide staffing · state 2.01 · national 2.35

Total nurse hours

2.75

All reported nurse hours · state 3.40 · national 3.89

Licensed hours

1.06

RN + LPN hours · state 1.38 · national 1.54

Weekend hours

2.28

Weekend nurse staffing · state 2.99 · national 3.43

Weekend RN hours

0.50

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

0.72

CMS adjusted RN staffing hours

Adjusted total hours

3.11

CMS adjusted total nurse staffing hours

Case-mix index

1.21

Higher values indicate more complex resident acuity

RN turnover

17%

Annual RN turnover · state 52% · national 45%

Total nurse turnover

45%

Annual nurse turnover · state 52% · national 46%

SNF VBP

Value-based purchasing

Program rank

11,978

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

14.44

Composite VBP score used to determine payment impact.

Payment multiplier

0.9813

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Baseline 21.28% · Performance 21.74% · Measure score 0 · Achievement 0 · Improvement 0

Healthcare-associated infections

1.95

Baseline 6.13% · Performance 7.25% · Measure score 1.95 · Achievement 1.95 · Improvement 0

Total nurse turnover

3.83

Baseline 71.01% · Performance 51.02% · Measure score 3.83 · Achievement 3.10 · Improvement 3.83

Adjusted total nurse staffing

Baseline 3.38 hours · Performance 3.08 hours · Measure score 0 · Achievement 0 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	10.82%	10.72% 0.1 pts worse	No Different than the National Rate · Eligible stays 96 · Observed rate 11.46% · Lower 95% interval 7.64%
Discharge to community	48.52%	50.57% 2 pts worse	No Different than the National Rate · Eligible stays 71 · Observed rate 43.66% · Lower 95% interval 35.58%
Medicare spending per beneficiary	1.17	1.02 0.1 pts worse
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 55 · Denominator 55
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 55
Discharge self-care score	50%	53.69% 3.7 pts worse	Numerator 15 · Denominator 30
Discharge mobility score	40%	50.94% 10.9 pts worse	Numerator 12 · Denominator 30
Pressure ulcers or injuries, new or worsened	3.64%	2.29% 1.4 pts worse	Numerator 2 · Denominator 55 · Adjusted rate 3.25%
Healthcare-associated infections requiring hospitalization	7.25%	7.12% 0.1 pts worse	No Different than the National Rate · Eligible stays 49 · Observed rate 8.16% · Lower 95% interval 4.46%
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 81
Staff flu vaccination coverage	33.06%	42% 8.9 pts worse	Numerator 40 · Denominator 121
Discharge function score	50%	56.45% 6.5 pts worse	Numerator 15 · Denominator 30
Transfer of health information to provider	100%	95.95% 4 pts better	Numerator 31 · Denominator 31
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	48.28%	25.2% 23.1 pts better	Numerator 14 · Denominator 29

Quality measures

Resident outcomes and process scores

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 2.1 · Expected 1.7 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	3.5	2.1 1.4 pts worse	1.8 1.7 pts worse	Long Stay · 20240701-20250630 · Adjusted 3.5 · Observed 3.4 · Expected 1.6 · 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	2.9%	3.3% 0.4 pts better	3.3% 0.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 3.3% · Q3 3.2% · Q4 3.1% · 4Q avg 2.9% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	4.4%	2.7% 1.7 pts worse	11.4% 7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 6.7% · Q3 5.2% · Q4 3.5% · 4Q avg 4.4%
Percentage of long-stay residents who lose too much weight	5.4%	3.3% 2.1 pts worse	5.4% About the same	Long Stay · 2024Q4-2025Q3 · Q1 9.3% · Q2 6.5% · Q3 0.0% · Q4 6.0% · 4Q avg 5.4%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	9.4%	18.9% 9.5 pts better	19.6% 10.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 8.7% · Q2 10.4% · Q3 8.3% · Q4 10.0% · 4Q avg 9.4%
Percentage of long-stay residents who received an antipsychotic medication	8.7%	10.8% 2.1 pts better	16.7% 8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 8.1% · Q2 10.0% · Q3 5.1% · Q4 11.1% · 4Q avg 8.7% · 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	13.9%	15.4% 1.5 pts better	16.3% 2.4 pts better	Long Stay · 2024Q4-2025Q3 · Q2 22.3% · 4Q avg 13.9% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	9.3%	16.1% 6.8 pts better	14.9% 5.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 8.9% · Q3 8.7% · Q4 12.2% · 4Q avg 9.3% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.0%	0.5% 0.5 pts better	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% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.8%	0.8% About the same	1.7% 0.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 1.7% · Q3 0.0% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	15.4%	15.0% 0.4 pts worse	19.8% 4.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 13.0% · Q2 14.7% · Q3 17.0% · Q4 16.5% · 4Q avg 15.4%
Percentage of long-stay residents with pressure ulcers	2.1%	4.2% 2.1 pts better	5.1% 3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 3.1% · Q3 1.2% · Q4 2.7% · 4Q avg 2.1% · 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	23.8%	12.0% 11.8 pts worse	12.0% 11.8 pts worse	Short Stay · 20240701-20250630 · Adjusted 23.8% · Observed 23.3% · Expected 10.9% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	1.8%	1.5% 0.3 pts worse	1.6% 0.2 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 2.6% · Q3 2.4% · Q4 0.0% · 4Q avg 1.8% · 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	13.5%	25.9% 12.4 pts better	23.9% 10.4 pts better	Short Stay · 20240701-20250630 · Adjusted 13.5% · Observed 11.6% · Expected 20.5% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-02-27 · Fire 2025-02-27

13 health deficiencies

Top issue: Quality of Life and Care (3 deficiencies)

1 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)

Cycle 2 Health 2024-01-11 · Fire 2024-01-11

21 health deficiencies

Top issue: Pharmacy Service (5 deficiencies)

1 fire-safety deficiencies

Top issue: Emergency Preparedness (1 deficiency)

Cycle 3 Health 2022-11-09 · Fire 2022-11-09

9 health deficiencies

Top issue: Quality of Life and Care (4 deficiencies)

5 fire-safety deficiencies

Top issue: Smoke (4 deficiencies)

Fire safety

Fire-safety citations

C · Minimal harm 2025-02-27

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2025-02-26

F · Potential for more than minimal harm 2024-01-11

E4 · Emergency Preparedness Deficiencies

Fire Safety

Develop and maintain an Emergency Preparedness Program (EP).

Corrected 2024-07-05

F · Potential for more than minimal harm 2022-11-09

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2023-01-10

F · Potential for more than minimal harm 2022-11-09

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2023-01-10

E · Potential for more than minimal harm 2022-11-09

K321 · Smoke Deficiencies

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 2023-01-10

E · Potential for more than minimal harm 2022-11-09

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2023-01-10

E · Potential for more than minimal harm 2022-11-09

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2023-01-10

Inspection history

Recent health citations

D · Potential for more than minimal harm 2026-01-12

F755 · Pharmacy Service Deficiencies

Health

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected 2026-01-13

F · Potential for more than minimal harm 2025-11-20

F727 · Nursing and Physician Services Deficiencies

Health

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

Corrected 2025-11-21

E · Potential for more than minimal harm 2025-02-27

F584 · Resident Rights Deficiencies

Health

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.

Corrected 2025-03-04

E · Potential for more than minimal harm 2025-02-27

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2025-03-04

E · Potential for more than minimal harm 2025-02-27

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2025-03-04

E · Potential for more than minimal harm 2025-02-27

F755 · Pharmacy Service Deficiencies

Health

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected 2025-03-04

E · Potential for more than minimal harm 2025-02-27

F804 · Nutrition and Dietary Deficiencies

Health

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Corrected 2025-03-04

E · Potential for more than minimal harm 2025-02-27

F838 · Administration Deficiencies

Health

Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.

Corrected 2025-03-04

D · Potential for more than minimal harm 2025-02-27

F550 · Resident Rights Deficiencies

Health

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected 2025-03-04

D · Potential for more than minimal harm 2025-02-27

F585 · Resident Rights Deficiencies

Health

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.

Corrected 2025-03-04

D · Potential for more than minimal harm 2025-02-27

F655 · Resident Assessment and Care Planning Deficiencies

Health

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Corrected 2025-03-04

D · Potential for more than minimal harm 2025-02-27

F677 · Quality of Life and Care Deficiencies

Health

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected 2025-03-04

D · Potential for more than minimal harm 2025-02-27

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2025-03-04

E · Potential for more than minimal harm 2025-01-27

F755 · Pharmacy Service Deficiencies

Health

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected 2025-01-28

J · Immediate jeopardy 2024-12-03

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2024-11-27

F · Potential for more than minimal harm 2024-01-11

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2024-01-11

E · Potential for more than minimal harm 2024-01-11

F584 · Resident Rights Deficiencies

Health

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.

Corrected 2024-01-11

E · Potential for more than minimal harm 2024-01-11

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2024-01-11

E · Potential for more than minimal harm 2024-01-11

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2024-01-11

E · Potential for more than minimal harm 2024-01-11

F804 · Nutrition and Dietary Deficiencies

Health

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Corrected 2024-01-11

E · Potential for more than minimal harm 2024-01-11