Focused Care at Mount Pleasant

In the surveyor’s words

From the most serious findings on record at Focused Care at Mount Pleasant, in the surveyor’s own words.

• Immediate jeopardy, widespreadF880Oct 9, 2023

  Based on observations, interviews, and record reviews the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 5 of 5 residents (Residents #1, #2, #3, #4 and #5) and 6 out of 11 nondedicated and contracted staff (MA A, CNA B, CNA F, CNA CC, Hospice Aide and X-ray Technician) in the facility reviewed for infection control practices and transmission-based precautions. 1. The facility failed to report the COVID-19 outbreak to both the local health department and HHSC. 2. […]

• Immediate jeopardy, isolatedF600Jun 25, 2025

  Based on interview and record review the facility failed to ensure residents were free from abuse for 1 of 8 residents (Resident's #1) reviewed for resident abuse. The facility failed to ensure Resident #1 was free from physical abuse on 11/21/24, when Resident #2 hit Resident #1 numerous times with the foot pedal of a wheelchair. The physical assault on Resident #1 resulted in worsening of a brain bleed with a midline shift (increased pressure in the brain). The noncompliance was identified as PNC. The immediate jeopardy (IJ) began on 11/21/24 and ended on 11/21/24. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of serious injury, physical harm, serious impairment, or death. The findings included: 1. […]

• Immediate jeopardy, isolatedF689Jun 25, 2025

  Based on observations, interviews, and record review the facility failed to ensure the resident environment remained free of accident hazards as possible, and each resident received adequate supervision to prevent incident and accidents for 2 of 8 residents (Resident #1 and Resident #3) reviewed for accident hazards and supervision. 1. The facility failed to ensure adequate supervision was provided to prevent a resident-to-resident physical altercation on 11/21/24. Resident #2 repeatedly hit Resident #1 with a metal wheelchair pedal, which resulted in worsening of a brain bleed with a midline shift (increased pressure in the brain). 2. The facility failed to ensure adequate supervision was provided to prevent Resident #3 from falling, which resulted in a nasal fracture on 06/02/25. […]

• Immediate jeopardy, isolatedF583May 24, 2024

  Based on observation, interview and record review, the facility failed to provide residents with personal privacy and confidentiality of his or her personal and medical records for 1 of 20 (Resident #40) residents reviewed for resident rights. 1. LVN A video recorded Resident #40 on [DATE] when he was in an emergent situation using her personal device and then shared the video with RN B on [DATE]. 2. RN B shared the [DATE] video recording with the ADON, and the BOM on [DATE]. 3. Resident #23 overheard LVN A having a telephone discussion on her personal cell phone of the video recording on [DATE] of Resident #40 while in a common area on her personal cell phone. 4. LVN A and RN B were in possession of the video recording on their personal devices from [DATE] - [DATE]. 5. […]

• Immediate jeopardy, isolatedF678May 24, 2024

  Based on observation, interview and record review the facility failed to ensure procedures were in place to document a resident's choice regarding CPR for 1 of 20 residents (Resident #114) reviewed for CPR. 1. The facility performed CPR on Resident #114 on [DATE], after failing to accurately assess Resident #114's representative's choice for DNR code status on or before admission. 2. The facility failed to have a system in place to ensure staff maintained accurate CPR certifications. The SW failed to accurately document Resident #1's code status on the social service assessment. These failures resulted in an identification of an Immediate Jeopardy (IJ) on [DATE] . The IJ template was provide to the facility on [DATE] at 4:43 p.m. […]