Pleasant Springs Healthcare Center Inspection Report, Violations & Safety Grade (Mount Pleasant, Texas)

2003 North Edwards Avenue, Mount Pleasant, Texas 75455

Phone: 9035725511

CMS Overall:1/5

Overview & Bed Count

Certified Beds

Avg Residents/Day

62.7

Ownership

For profit - Limited Liability company

Provider Type

Medicare and Medicaid

County

Titus

Sprinkler Systems

Yes

Special Focus

SFF Candidate

Abuse Icon

Yes

CMS Star Ratings

Overall1/5

Health1/5

Staffing1/5

Quality3/5

Nurse Staffing Check

Metric	This Facility	Texas Avg	Difference
RN Hours per Resident per Day	0.39	0.44	-0.05
Total Nurse Hours per Resident per Day	2.97	3.42	-0.45
CMS Staffing Rating	1/5	1.9/5	-
Nursing Staff Turnover	61.8%	50.8%	-

Health Citation History

72 health citations on record

Date	Category	Description	Severity
2026-08-07	Nursing and Physician Services Deficiencies	Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.	E – Moderate Harm Potential
2026-08-07	Nursing and Physician Services Deficiencies	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.	E – Moderate Harm Potential
2026-08-07	Freedom from Abuse, Neglect, and Exploitation Deficiencies	Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.	D – Moderate Harm Potential
2026-08-07	Quality of Life and Care Deficiencies	Provide appropriate pressure ulcer care and prevent new ulcers from developing.	D – Moderate Harm Potential
2026-08-07	Pharmacy Service Deficiencies	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 – Moderate Harm Potential
2026-08-07	Infection Control Deficiencies	Provide and implement an infection prevention and control program.	D – Moderate Harm Potential
2026-06-04	Freedom from Abuse, Neglect, and Exploitation Deficiencies	Develop and implement policies and procedures to prevent abuse, neglect, and theft.	J – Immediate Jeopardy
2026-06-04	Freedom from Abuse, Neglect, and Exploitation Deficiencies	Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.	G – Actual Harm
2026-06-04	Quality of Life and Care Deficiencies	Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.	G – Actual Harm
2026-06-04	Resident Rights Deficiencies	Honor the resident's right to organize and participate in resident/family groups in the facility.	E – Moderate Harm Potential
2026-06-04	Quality of Life and Care Deficiencies	Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	E – Moderate Harm Potential
2026-06-04	Pharmacy Service Deficiencies	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.	E – Moderate Harm Potential
2026-06-04	Nutrition and Dietary Deficiencies	Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.	E – Moderate Harm Potential
2026-06-04	Infection Control Deficiencies	Provide and implement an infection prevention and control program.	E – Moderate Harm Potential
2026-06-04	Resident Rights Deficiencies	Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.	D – Moderate Harm Potential
2026-06-04	Resident Rights Deficiencies	Reasonably accommodate the needs and preferences of each resident.	D – Moderate Harm Potential
2026-06-04	Freedom from Abuse, Neglect, and Exploitation Deficiencies	Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.	D – Moderate Harm Potential
2026-06-04	Freedom from Abuse, Neglect, and Exploitation Deficiencies	Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.	D – Moderate Harm Potential
2026-06-04	Quality of Life and Care Deficiencies	Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.	D – Moderate Harm Potential
2026-06-04	Quality of Life and Care Deficiencies	Provide care and assistance to perform activities of daily living for any resident who is unable.	D – Moderate Harm Potential
2026-06-04	Quality of Life and Care Deficiencies	Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.	D – Moderate Harm Potential
2026-06-04	Quality of Life and Care Deficiencies	Provide safe and appropriate respiratory care for a resident when needed.	D – Moderate Harm Potential
2026-06-04	Pharmacy Service Deficiencies	Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.	D – Moderate Harm Potential
2026-06-04	Administration Deficiencies	Provide timely, quality laboratory services/tests to meet the needs of residents.	D – Moderate Harm Potential
2026-06-04	Nutrition and Dietary Deficiencies	Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.	D – Moderate Harm Potential
2026-06-04	Nutrition and Dietary Deficiencies	Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.	D – Moderate Harm Potential
2026-04-01	Quality of Life and Care Deficiencies	Provide care or services that was trauma informed and/or culturally competent.	D – Moderate Harm Potential
2026-02-23	Quality of Life and Care Deficiencies	Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	J – Immediate Jeopardy
2026-02-23	Resident Rights Deficiencies	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 – Moderate Harm Potential
2026-02-23	Freedom from Abuse, Neglect, and Exploitation Deficiencies	Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.	E – Moderate Harm Potential
2026-02-23	Freedom from Abuse, Neglect, and Exploitation Deficiencies	Develop and implement policies and procedures to prevent abuse, neglect, and theft.	E – Moderate Harm Potential
2026-02-23	Pharmacy Service Deficiencies	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.	E – Moderate Harm Potential
2026-02-23	Nutrition and Dietary Deficiencies	Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.	E – Moderate Harm Potential
2026-02-23	Resident Rights Deficiencies	Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.	D – Moderate Harm Potential
2026-02-23	Resident Rights Deficiencies	Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.	D – Moderate Harm Potential
2026-02-23	Infection Control Deficiencies	Provide and implement an infection prevention and control program.	D – Moderate Harm Potential
2026-02-23	Nursing and Physician Services Deficiencies	Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.	B – Minimal Harm Potential
2026-01-12	Pharmacy Service Deficiencies	Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.	D – Moderate Harm Potential
2025-11-20	Nursing and Physician Services Deficiencies	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.	F – Moderate Harm Potential
2025-02-27	Resident Rights Deficiencies	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 – Moderate Harm Potential
2025-02-27	Resident Assessment and Care Planning Deficiencies	Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.	E – Moderate Harm Potential
2025-02-27	Quality of Life and Care Deficiencies	Provide safe and appropriate respiratory care for a resident when needed.	E – Moderate Harm Potential
2025-02-27	Pharmacy Service Deficiencies	Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.	E – Moderate Harm Potential
2025-02-27	Nutrition and Dietary Deficiencies	Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.	E – Moderate Harm Potential
2025-02-27	Administration Deficiencies	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.	E – Moderate Harm Potential
2025-02-27	Resident Rights Deficiencies	Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.	D – Moderate Harm Potential
2025-02-27	Resident Rights Deficiencies	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.	D – Moderate Harm Potential
2025-02-27	Resident Assessment and Care Planning Deficiencies	Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted	D – Moderate Harm Potential
2025-02-27	Quality of Life and Care Deficiencies	Provide care and assistance to perform activities of daily living for any resident who is unable.	D – Moderate Harm Potential
2025-02-27	Quality of Life and Care Deficiencies	Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	D – Moderate Harm Potential

Showing 50 of 72 citations.

Fire Safety Citation History

5 fire safety citations on record

Date	Category	Description	Severity
2026-06-04	Smoke Deficiencies	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.	E – Moderate Harm Potential
2026-06-04	Smoke Deficiencies	Provide properly protected cooking facilities.	E – Moderate Harm Potential
2026-06-04	Smoke Deficiencies	Ensure smoke barriers are constructed to a 1 hour fire resistance rating.	E – Moderate Harm Potential
2025-02-27	Gas, Vacuum, and Electrical Systems Deficiencies	Have generator or other power source capable of supplying service within 10 seconds.	C – Minimal Harm Potential
2024-01-11	Emergency Preparedness Deficiencies	Develop and maintain an Emergency Preparedness Program (EP).	F – Moderate Harm Potential

Total Penalties & Fines

$65,650

Total Fine Amount (CMS)

Number of Fines

Total Penalties

Date	Type	Fine Amount	Payment Denial
2026-06-04	Fine	$21,302	-
2026-02-23	Fine	$11,193	-
2024-12-03	Fine	$15,945	-
2024-01-02	Fine	$17,210	-

Need Help Finding Safe Care?

Our family advisors can help you find vetted, top-rated facilities in the Mount Pleasant area at no cost.

Find Safe, Vetted Facilities Near Mount Pleasant
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)

Advisor service is free for families. We may receive referral compensation.

Need Help Finding Safe Care?

Our family advisors can help you find vetted, top-rated facilities in the Mount Pleasant area at no cost.

Find Safe, Vetted Facilities Near Mount Pleasant
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)

Advisor service is free for families. We may receive referral compensation.