01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2025-07-02 | 18 | 2025-07-02 | 4 |
| Cycle 2 | 2024-05-24 | 26 | 2024-05-24 | 2 |
| Cycle 3 | 2023-03-09 | 38 | 2023-03-09 | 4 |
CMS CCN 4559002026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Focused Care At Mount Pleasant
1606 Memorial Ave · Mount Pleasant, TX 75455 · Titus County
Certified beds122CMS provider file
Recent citation rows92current CMS citation release
Penalty rows7current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
92 rows in the current release
4 rows carry G–L scope/severity codes; 3 carry J–L. 23 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2026-05-20 · HEALTHF0880Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2026-06-12 · complaint2026-05-20 · HEALTHF0921Severity D · isolated; potential for more than minimal harm
Environmental Deficiencies
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Correction field: Deficient, Provider has date of correction · 2026-06-12 · complaint2026-01-13 · HEALTHF0602Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from the wrongful use of the resident's belongings or money.
Correction field: Deficient, Provider has date of correction · 2026-02-02 · complaint2025-11-26 · HEALTHF0550Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Correction field: Deficient, Provider has date of correction · 2025-12-19 · complaint2025-11-26 · HEALTHF0641Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
Correction field: Deficient, Provider has date of correction · 2025-12-19 · complaint2025-11-26 · HEALTHF0656Severity E · pattern; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2025-12-19 · complaint2025-11-26 · HEALTHF0684Severity E · pattern; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Correction field: Deficient, Provider has date of correction · 2025-12-19 · complaint2025-11-26 · HEALTHF0690Severity D · isolated; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2025-11-27 · complaint2025-11-26 · HEALTHF0842Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Correction field: Deficient, Provider has date of correction · 2025-12-19 · complaint2025-09-08 · HEALTHF0925Severity E · pattern; potential for more than minimal harm
Environmental Deficiencies
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Correction field: Deficient, Provider has date of correction · 2025-10-01 · complaint2025-07-02 · HEALTHF0584Severity D · isolated; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2025-08-012025-07-02 · HEALTHF0695Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
Correction field: Deficient, Provider has date of correction · 2025-08-012025-07-02 · HEALTHF0726Severity D · isolated; potential for more than minimal harm
Nursing and Physician Services Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2025-08-012025-07-02 · HEALTHF0804Severity E · pattern; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Correction field: Deficient, Provider has date of correction · 2025-08-012025-07-02 · HEALTHF0812Severity F · widespread; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Correction field: Deficient, Provider has date of correction · 2025-08-012025-07-02 · HEALTHF0880Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2025-08-012025-07-02 · HEALTHF0908Severity F · widespread; potential for more than minimal harm
Environmental Deficiencies
Keep all essential equipment working safely.
Correction field: Deficient, Provider has date of correction · 2025-08-012025-07-02 · HEALTHF0926Severity D · isolated; potential for more than minimal harm
Environmental Deficiencies
Have policies on smoking.
Correction field: Deficient, Provider has date of correction · 2025-08-012025-07-02 · FIREK0345Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Have approved installation, maintenance and testing program for fire alarm systems.
Correction field: Deficient, Provider has date of correction · 2025-08-152025-07-02 · FIREK0511Severity D · isolated; potential for more than minimal harm
Services Deficiencies
Have properly installed electrical wiring and gas equipment.
Correction field: Deficient, Provider has date of correction · 2025-08-152025-07-02 · FIREK0521Severity C · widespread; potential for minimal harm
Services Deficiencies
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Correction field: Deficient, Provider has no plan of correction2025-07-02 · FIREK0929Severity E · pattern; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
Correction field: Deficient, Provider has date of correction · 2025-08-152025-04-17 · HEALTHF0755Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Correction field: Deficient, Provider has date of correction · 2025-04-22 · complaint2025-02-13 · HEALTHF0600Severity E · pattern; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2025-03-10 · complaint03 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| 2025-06-25 | Fine | $16,149 | 0 |
| 2025-06-25 | Fine | $16,149 | 0 |
| 2025-06-25 | Payment Denial | $0 | 7 |
| 2024-05-24 | Fine | $127,486 | 0 |
| 2024-02-14 | Fine | $12,259 | 0 |
| 2023-10-09 | Fine | $51,253 | 0 |
| 2023-10-09 | Payment Denial | $0 | 22 |
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- FPACP MOUNT PLEASANT LLCOrganization · 5% OR GREATER DIRECT OWNERSHIP INTEREST100% · since 02/01/2017
- FOCUSED POST ACUTE CARE PARTNERS LLCOrganization · DIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 02/01/2017
- CONLEY, SHAWNIndividual · CORPORATE OFFICERNOT APPLICABLE · since 02/01/2017
- MCKENZIE, MARKIndividual · CORPORATE OFFICERNOT APPLICABLE · since 07/01/2018
- STRUBBE, LORETTAIndividual · CORPORATE OFFICERNOT APPLICABLE · since 07/01/2018
- FOCUSED POST ACUTE CARE PARTNERS LLCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 02/01/2017
- FOCUSED POST ACUTE CARE PARTNERS MANAGEMENT, LLCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 02/01/2017
- FPACP MOUNT PLEASANT LLCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 02/01/2017
- CONLEY, SHAWNIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 02/01/2017
- EASLEY, ADRIEANNIAIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 10/01/2023
- MCKENZIE, MARKIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 02/01/2017
- ONEY, WHITNEYIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 09/04/2020
- STRUBBE, LORETTAIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 07/01/2018
- WILLARD, LORIIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 10/09/2024
- ZARCONE, GREGORYIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 07/19/2021
- FOCUSED POST ACUTE CARE PARTNERS LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 04/11/2025
- FOCUSED POST ACUTE CARE PARTNERS MANAGEMENT, LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 04/11/2025
- ONEY, WHITNEYIndividual · ADP OF THE SNFNOT APPLICABLE · since 09/04/2020
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours3.16per resident day
RN hours0.38per resident day
Weekend nurse hours2.92per resident day
Staff turnover48.4%CMS reported field
06 / LOCAL RECORDS
Open the Mount Pleasant ledger →