Health inspection·November 20, 2025

F 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 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. Based on interview and record review, the facility failed to ensure the DON did not serve as a charge nurse or CNA when the facility had an average daily occupancy of 60 or more residents for 16 of 30 days reviewed for DON coverage. 1. The facility failed to ensure the DON did not serve as a charge nurse on 10/28/25. 2. The facility failed to ensure the DON did not serve as a CNA on 10/1/25, 10/4/25, 10/09/25, 10/10/25, 10/12/25, 10/15/25, 10/17/25, 10/18/25, 10/19/25, 10/23/25, 10/24/25, 10/25/25, 10/26/25, 10/28/25, 10/29/25, and 10/30/25. 3. The facility did not ensure the DON was able to do her designated duty of DON in a 40 hour/week due to performing nurse and CNA duties. These failures could leave residents without the nursing administrative oversight that only the DON can provide.Findings include:Record review of the detailed census report dated 11/4/25 reflected the census was between 66-72 for the month of October 2025.Record review of the ADL task sheet dated October 2025 reflected the DON documenting care activities on 10/1/25, 10/04/25, 10/09/25, 10/10/25, 10/12/25, 10/15/25, 10/17/25, 10/18/25, 10/19/25, 10/23/25, 10/24/25, 10/25/25, 10/26/25, 10/28/25, 10/29/25, and 10/30/25. An attempted interview on 08/05/25 at 7:58 a.m. with CNA D, the CNA for the 10p-6a shift, was unsuccessful.During a telephone interview on 11/05/25 at 7:59 a.m., LVN A stated the DON had come in to help when their short staff. LVN A stated she takes on the role of a CNA such as providing incontinent care and rounding. When asked how often she comes, LVN A stated, 2-3 times a week depending on how short staff they were when someone called in.During a telephone interview on 11/05/25 at 8:03 a.m., LVN B stated the DON did come on the 10p-6a shift doing CNA work such as providing incontinent care, getting them dressed when it was time for them to get up and rounding. LVN B stated she comes in at least 2-3 times a week due to short staff related to call-ins.An attempted interview on 08/05/25 at 8:09 a.m. with CNA C, the CNA for the 10p-6a shift, was unsuccessful. During an interview on 11/05/25 at 9:00 a.m., the ADON stated she works on the floor every day to help the nurses and CNAs out. The ADON stated she will provide incontinent care if needed, pass out water and assist others that may need help. The ADON stated she has had to come in to work as an aide due to call ins. The ADON stated it was usually few and far between. The ADON stated they were hiring and the ones that were hired get trained and call in. The ADON stated, when there is a call-off, when we take call, we must work the floor for whichever staff member called off, whether it be the nurse or aide. The ADON stated she was on call every three weeks. During an interview on 11/05/25 at 9:35 a.m., the DON stated she was not aware that she could not work as a CNA or charge nurse when the census was above 60. The DON stated if she were responsible for the care of the residents, why would she not provide care? The DON stated her duties were to oversee the CNAs and nurses, which meant if there were not enough staff, it was her responsibility to work the floor so the residents could be taken care of. The DON stated she had called and begged/pleaded for staff to help, but if they could not come in, she would come in and help on the floor. The DON stated she would take a hall and double team with other CNAs if someone needed help. The DON stated for the month of (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 455532 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455532 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasant Springs Healthcare Center 2003 N Edwards St Mount Pleasant, TX 75455 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)