F52

Focused Care at Mount Pleasant

Grade F 52/100 composite score

For profit - Limited Liability companyAbuse Citation

CMS Star Ratings

Overall
1/5
Health Insp.
1/5
Quality
3/5
Staffing
2/5
RN Staffing
Not rated

Certified Beds

122

Ownership

For profit - Limited Liability company

Total Fines

$254,684

Last Survey

N/A

1606 Memorial Ave, Mount Pleasant, TX 75455
9035723618

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Staffing Hours & Turnover

Hours per Resident per Day (PBJ)

RN
0.65h
LPN
0.61h
CNA
2.21h
Total
3.47h
Facility
State Average

Turnover Rates

RN Turnover
N/A
Total Nurse Turnover
N/A
Admin Turnover
N/A

Ownership

FOCUSED POST ACUTE CARE PARTNERS LLC

Organization5% OR GREATER DIRECT OWNERSHIP INTERESTSince Dec 2016

FPACP MOUNT PLEASANT LLC

Organization5% OR GREATER DIRECT OWNERSHIP INTERESTSince Feb 2017

CONLEY, SHAWN

Individual5% OR GREATER INDIRECT OWNERSHIP INTERESTSince Jul 2018

15%

MCKENZIE, MARK

Individual5% OR GREATER INDIRECT OWNERSHIP INTERESTSince Jul 2018

70%

STRUBBE, LORETTA

Individual5% OR GREATER INDIRECT OWNERSHIP INTERESTSince Jul 2018

15%

FOCUSED POST ACUTE CARE PARTNERS LLC

OrganizationOPERATIONAL/MANAGERIAL CONTROLSince Feb 2017

FOCUSED POST ACUTE CARE PARTNERS MANAGEMENT, LLC

OrganizationOPERATIONAL/MANAGERIAL CONTROLSince Feb 2017

FPACP MOUNT PLEASANT LLC

OrganizationOPERATIONAL/MANAGERIAL CONTROLSince Feb 2017

CONLEY, SHAWN

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Feb 2017

EASLEY, ADRIEANNIA

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Oct 2023

MCKENZIE, MARK

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Feb 2017

ONEY, WHITNEY

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Sep 2020

STRUBBE, LORETTA

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Jul 2018

WILLARD, LORI

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Oct 2024

ZARCONE, GREGORY

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Jul 2021

CONLEY, SHAWN

IndividualCORPORATE OFFICERSince Feb 2017

MCKENZIE, MARK

IndividualCORPORATE OFFICERSince Jul 2018

STRUBBE, LORETTA

IndividualCORPORATE OFFICERSince Jul 2018

Penalties & Fines (8)

$254,684total fines
DateTypeDescriptionAmount
Jun 25, 2025Fine$24,845
Jun 25, 2025Fine$24,845
Jun 25, 2025Payment Denial
May 24, 2024Fine$127,486
Feb 14, 2024Fine$12,259
Oct 9, 2023Fine$51,253
Oct 9, 2023Payment Denial
Mar 3, 2023Fine$13,996

Health Inspection Deficiencies (85)

November 26, 2025Health6 deficiencies
0550DMinimal harm, Isolated

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

Resident Rights Deficiencies

Corrected Dec 19, 2025
0641DMinimal harm, Isolated

Ensure each resident receives an accurate assessment.

Resident Assessment and Care Planning Deficiencies

Corrected Dec 19, 2025
0656EMinimal harm, Pattern

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

Corrected Dec 19, 2025
0684EMinimal harm, Pattern

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies

Corrected Dec 19, 2025
0690DMinimal harm, Isolated

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

Corrected Nov 27, 2025
0842DMinimal harm, Isolated

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

Corrected Dec 19, 2025
September 8, 2025Health1 deficiency
0925EMinimal harm, Pattern

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Environmental Deficiencies

Corrected Oct 1, 2025
July 2, 2025Health8 deficiencies
0584DMinimal harm, Isolated

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

Corrected Aug 1, 2025
0695DMinimal harm, Isolated

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

Quality of Life and Care Deficiencies

Corrected Aug 1, 2025
0726DMinimal harm, Isolated

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

Corrected Aug 1, 2025
0804EMinimal harm, Pattern

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

Nutrition and Dietary Deficiencies

Corrected Aug 1, 2025
0812FMinimal harm, Widespread

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

Nutrition and Dietary Deficiencies

Corrected Aug 1, 2025
0880DMinimal harm, Isolated

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Corrected Aug 1, 2025
0908FMinimal harm, Widespread

Keep all essential equipment working safely.

Environmental Deficiencies

Corrected Aug 1, 2025
0926DMinimal harm, Isolated

Have policies on smoking.

Environmental Deficiencies

Corrected Aug 1, 2025
June 25, 2025Health2 deficiencies2 severe
0600JImmediate jeopardy, Isolated

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

Corrected Jun 24, 2025
0689JImmediate jeopardy, Isolated

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

Quality of Life and Care Deficiencies

Corrected Jun 26, 2025
April 17, 2025Health1 deficiency
0755DMinimal harm, Isolated

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

Pharmacy Service Deficiencies

Corrected Apr 22, 2025
February 13, 2025Health1 deficiency
0600EMinimal harm, Pattern

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

Corrected Mar 10, 2025
December 19, 2024Health1 deficiency
0600DMinimal harm, Isolated

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

Corrected Sep 27, 2024
May 24, 2024Health23 deficiencies2 severe
0583JImmediate jeopardy, Isolated

Keep residents' personal and medical records private and confidential.

Resident Rights Deficiencies

Corrected May 25, 2024
0657EMinimal harm, Pattern

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

Corrected Jun 25, 2024
0678JImmediate jeopardy, Isolated

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

Corrected May 25, 2024
0688DMinimal harm, Isolated

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

Corrected Jun 25, 2024
0690DMinimal harm, Isolated

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

Corrected Jun 25, 2024
0695DMinimal harm, Isolated

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

Quality of Life and Care Deficiencies

Corrected Jun 25, 2024
0698DMinimal harm, Isolated

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Quality of Life and Care Deficiencies

Corrected Jun 25, 2024
0699DMinimal harm, Isolated

Provide care or services that was trauma informed and/or culturally competent.

Quality of Life and Care Deficiencies

Corrected Jun 25, 2024
0759EMinimal harm, Pattern

Ensure medication error rates are not 5 percent or greater.

Pharmacy Service Deficiencies

Corrected Jun 25, 2024
0760DMinimal harm, Isolated

Ensure that residents are free from significant medication errors.

Pharmacy Service Deficiencies

Corrected Jun 25, 2024
0802EMinimal harm, Pattern

Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.

Nutrition and Dietary Deficiencies

Corrected Jun 25, 2024
0803DMinimal harm, Isolated

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

Corrected Jun 25, 2024
0812EMinimal harm, Pattern

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

Nutrition and Dietary Deficiencies

Corrected Jun 25, 2024
0849DMinimal harm, Isolated

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

Corrected Jun 25, 2024
0925EMinimal harm, Pattern

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Environmental Deficiencies

Corrected Jun 25, 2024
0550DMinimal harm, Isolated

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

Resident Rights Deficiencies

Corrected Jun 25, 2024
0552EMinimal harm, Pattern

Ensure that residents are fully informed and understand their health status, care and treatments.

Resident Rights Deficiencies

Corrected Jun 25, 2024
0573DMinimal harm, Isolated

Let each resident or the resident's legal representative access or purchase copies of all the resident's records.

Resident Rights Deficiencies

Corrected Jun 25, 2024
0578DMinimal harm, Isolated

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

Corrected Jun 25, 2024
0584DMinimal harm, Isolated

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

Corrected Jun 25, 2024
0847DMinimal harm, Isolated

Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.

Administration Deficiencies

Corrected Jun 25, 2024
0880EMinimal harm, Pattern

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Corrected Jun 25, 2024
0881EMinimal harm, Pattern

Implement a program that monitors antibiotic use.

Infection Control Deficiencies

Corrected Jun 25, 2024
March 24, 2024Health2 deficiencies
0602DMinimal harm, Isolated

Protect each resident from the wrongful use of the resident's belongings or money.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Apr 23, 2024
0684DMinimal harm, Isolated

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies

Corrected Apr 23, 2024
February 14, 2024Health7 deficiencies1 severe
0558DMinimal harm, Isolated

Reasonably accommodate the needs and preferences of each resident.

Resident Rights Deficiencies

Corrected Mar 14, 2024
0580DMinimal harm, Isolated

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

Corrected Mar 14, 2024
0584EMinimal harm, Pattern

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

Corrected Mar 14, 2024
0610DMinimal harm, Isolated

Respond appropriately to all alleged violations.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Mar 14, 2024
0692DMinimal harm, Isolated

Provide enough food/fluids to maintain a resident's health.

Quality of Life and Care Deficiencies

Corrected Mar 14, 2024
0757GActual harm, Isolated

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Pharmacy Service Deficiencies

Corrected Mar 14, 2024
0840DMinimal harm, Isolated

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

Corrected Mar 14, 2024
October 9, 2023Health3 deficiencies1 severe
0689DMinimal harm, Isolated

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

Quality of Life and Care Deficiencies

Corrected Nov 2, 2023
0761DMinimal harm, Isolated

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

Corrected Nov 2, 2023
0880LImmediate jeopardy, Widespread

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Corrected Nov 30, 2023
March 25, 2023Health3 deficiencies
0585DMinimal harm, Isolated

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

Corrected Mar 25, 2023
0607DMinimal harm, Isolated

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Mar 25, 2023
0609DMinimal harm, Isolated

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Mar 25, 2023
March 9, 2023Health26 deficiencies
0552DMinimal harm, Isolated

Ensure that residents are fully informed and understand their health status, care and treatments.

Resident Rights Deficiencies

Corrected Mar 10, 2023
0582DMinimal harm, Isolated

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Resident Rights Deficiencies

Corrected Mar 10, 2023
0584DMinimal harm, Isolated

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

Corrected Mar 10, 2023
0585DMinimal harm, Isolated

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

Corrected Mar 10, 2023
0636EMinimal harm, Pattern

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

Corrected Mar 10, 2023
0641DMinimal harm, Isolated

Ensure each resident receives an accurate assessment.

Resident Assessment and Care Planning Deficiencies

Corrected Mar 10, 2023
0655DMinimal harm, Isolated

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

Corrected Mar 10, 2023
0656EMinimal harm, Pattern

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

Corrected Mar 10, 2023
0676DMinimal harm, Isolated

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

Corrected Mar 10, 2023
0677EMinimal harm, Pattern

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

Quality of Life and Care Deficiencies

Corrected Mar 10, 2023
0688EMinimal harm, Pattern

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

Corrected Mar 10, 2023
0689DMinimal harm, Isolated

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

Quality of Life and Care Deficiencies

Corrected Mar 10, 2023
0695DMinimal harm, Isolated

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

Quality of Life and Care Deficiencies

Corrected Mar 10, 2023
0697DMinimal harm, Isolated

Provide safe, appropriate pain management for a resident who requires such services.

Quality of Life and Care Deficiencies

Corrected Mar 10, 2023
0698DMinimal harm, Isolated

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Quality of Life and Care Deficiencies

Corrected Mar 10, 2023
0759DMinimal harm, Isolated

Ensure medication error rates are not 5 percent or greater.

Pharmacy Service Deficiencies

Corrected Mar 10, 2023
0761DMinimal harm, Isolated

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

Corrected Mar 10, 2023
0804EMinimal harm, Pattern

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

Nutrition and Dietary Deficiencies

Corrected Mar 10, 2023
0808DMinimal harm, Isolated

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

Corrected Mar 10, 2023
0812EMinimal harm, Pattern

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

Nutrition and Dietary Deficiencies

Corrected Mar 10, 2023
0813EMinimal harm, Pattern

Have a policy regarding use and storage of foods brought to residents by family and other visitors.

Nutrition and Dietary Deficiencies

Corrected Mar 10, 2023
0842DMinimal harm, Isolated

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

Corrected Mar 10, 2023
0883DMinimal harm, Isolated

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Infection Control Deficiencies

Corrected Mar 10, 2023
0550EMinimal harm, Pattern

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

Resident Rights Deficiencies

Corrected Mar 10, 2023
0610EMinimal harm, Pattern

Respond appropriately to all alleged violations.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Mar 10, 2023
0880EMinimal harm, Pattern

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Corrected Mar 10, 2023
March 3, 2023Health1 deficiency1 severe
0689JImmediate jeopardy, Isolated

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

Quality of Life and Care Deficiencies

Corrected Mar 4, 2023

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Frequently Asked Questions

What is the CareGrader rating for Focused Care at Mount Pleasant?

Focused Care at Mount Pleasant in Mount Pleasant, Texas has a CareGrader grade of F (Poor), with a composite score of 52.3 out of 100. This grade is based on health inspections, staffing levels, quality measures, and penalty history from official CMS government data.

What is the CMS star rating for Focused Care at Mount Pleasant?

Focused Care at Mount Pleasant has an overall CMS star rating of 1 out of 5, a health inspection rating of 1/5, and a staffing rating of 2/5. CareGrader combines this with additional data to calculate an A-F grade.

How many health deficiencies does Focused Care at Mount Pleasant have?

Focused Care at Mount Pleasant has 85 health deficiencies on record from CMS health inspection surveys. Deficiencies are rated from A (minimal harm potential) to L (immediate jeopardy, widespread). This facility has abuse citations on record. View the full inspection timeline above for details on each deficiency.

Has Focused Care at Mount Pleasant been fined?

Yes. Focused Care at Mount Pleasant has $254,684 in total fines from CMS enforcement actions across 8 penalties.

How many beds does Focused Care at Mount Pleasant have?

Focused Care at Mount Pleasant has 122 certified beds with approximately 69 current residents (57% occupancy). The facility is located at 1606 Memorial Ave, Mount Pleasant, Texas 75455. It is a for profit - limited liability company facility.

Data Disclaimer

Inspection data, staffing levels, and star ratings are sourced from CMS Medicare Nursing Home Compare and are largely self-reported by facilities. A 2019 GAO study found that 43% of facilities under-reported falls. CareGrader provides this data for informational purposes only and is not affiliated with CMS or Medicare. Always visit facilities in person before making a decision.