Above average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at River Pointe Of Trinity Healthcare And Rehabilitat during CMS and state inspections, most recent first.
A resident with vascular dementia and severely impaired cognition was admitted to hospice, but the facility did not complete a significant change MDS assessment within the required timeframe. The MDS Resource Nurse said the assessment should have been completed and was missed, while the DON and Administrator said the hospice admission was not communicated to the MDS team.
A resident with Huntington's disease and severe cognitive impairment had a significant change MDS that incorrectly coded hospice services even though hospice had already been discontinued and the resident was not on hospice when he returned from the hospital. The MDS Resource Nurse acknowledged the hospice code should not have been included, and the DON and Administrator said the hospice discharge was not communicated to the MDS team.
A resident with an indwelling Foley catheter and severe cognitive impairment had the urinary drainage bag observed touching the floor while staff performed wound care and again after the bed was lowered. The ADON and DON acknowledged that allowing the bag to touch the floor was an infection control issue and could lead to infections, and the DON stated the facility did not have a specific catheter management policy.
A resident with Parkinson's disease and moderate cognitive impairment had a CPAP order for bedtime and PRN use, and the care plan directed staff to clean the tubing and mask weekly. Surveyors observed the CPAP mask unbagged, unlabeled, undated, and visibly dirty with brown particles and hair fibers, and it remained dirty when later found stored in a bag. The DON said charge nurses were responsible for weekly cleaning, and the Administrator said improperly cleaned masks might not work correctly.
Unlocked Medication Cart Left Unattended: A medication aide left a med cart unlocked and unattended in a hallway while obtaining vital signs in a resident's room, and residents were observed walking past it. MA A stated the cart should always be locked when unattended, and the DON and Administrator confirmed carts were expected to remain locked or attended by authorized personnel. Facility policy required medication carts and supplies to be locked or attended by authorized staff.
A resident with dementia, type 2 DM, bowel/bladder incontinence, and a Stage 4 sacral pressure ulcer, who required total assistance with toileting and lower body dressing, did not receive appropriate incontinence care. During observed care, two CNAs placed a clean brief under the resident, then repositioned her, causing her to urinate on the brief; despite recognizing it was wet, they blotted the urine with wipes and applied the same wet brief instead of replacing it. Facility staff, including an RN, ADON, LCSW, DON, and ADM, stated that residents should be rounded on at least every two hours and that placing a wet brief on a resident was not acceptable, and facility policy required donning a new disposable brief after incontinence episodes.
A deficiency was cited when a facility area was not kept free from accident hazards and supervision was inadequate to prevent accidents. The environment and oversight did not meet required standards to minimize accident risks.
The facility did not provide and implement an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
Surveyors identified that the facility's kitchen failed to maintain proper food storage temperatures, with a walk-in freezer operating at 40°F and containing multiple thawed food items. Additionally, kitchen staff did not consistently wear hair nets that fully covered their hair, as required by policy and FDA standards. Staff interviews confirmed lapses in monitoring freezer temperatures and proper use of hair restraints.
A resident with severe cognitive impairment and a physician-ordered pureed diet was served meals that were not of the required smooth, pudding-like consistency. Observations and staff interviews confirmed that pureed foods, including meat and vegetables, were served with a chunky or thick texture, and recipes and consistency checks were not properly followed.
A CNA failed to sanitize or wash hands between glove changes while providing supra-pubic catheter care to a resident with chronic medical conditions and impaired cognition. This lapse in infection control was observed during care, despite facility policy and prior training requiring proper hand hygiene after glove removal.
A resident reported being shaken by a CNA in the shower room, but the facility failed to properly investigate the allegation and allowed the CNA to return to work the next day. The resident, who had no cognitive impairment and required assistance with daily activities, was given a discharge notice shortly after reporting the incident. Interviews with facility staff revealed disbelief in the resident's allegations, and the facility justified the discharge by stating the resident exhausted staff resources. The resident was transferred to another facility, where she adjusted well.
The facility's governing body failed to appoint a licensed Administrator, with CO serving as an unlicensed Interim Administrator. Staff identified CO as the acting Administrator, and CO stated he was working under a preceptor's license while awaiting his own certification. The Administrator confirmed CO's interim role, and a review showed CO's internship was approved under a different preceptor. The facility's Governing Body policy was not provided upon request.
A resident was discharged from an LTC facility with her belongings packed into trash bags, leading to feelings of disrespect and mistreatment. Despite having no cognitive impairment, her possessions, including clothes and food, were mixed together, causing distress. Staff at the new facility confirmed the improper handling of her belongings, which contradicted the facility's policy on resident rights.
A resident was improperly discharged from a facility without adequate reason or proper documentation, following her report of abuse by an aide. The facility failed to provide the resident's representative the opportunity to appeal the discharge decision, contrary to policy. The resident, who had no cognitive impairment and was compliant with care, was moved to a new facility with her belongings packed in trash bags, leaving her feeling devalued.
Missed Significant Change MDS After Hospice Admission
Penalty
Summary
The facility failed to complete a comprehensive significant change MDS assessment for Resident #58 within 14 days after the resident was admitted to hospice. Resident #58 was a female resident with vascular dementia and a BIMS score of 00 on the quarterly MDS, indicating severely impaired cognition. Her care plan, revised on 5/18/2026, documented a terminal prognosis and hospice admission, and the order summary showed an order to admit to hospice dated 5/15/2026. Review of the electronic record showed there was no significant change in condition MDS assessment completed within 14 days of the hospice admission. During interview, the MDS Resource Nurse stated that she and other corporate MDS nurses were completing MDS assessments and oversight because the facility did not have an in-house MDS nurse at the time. She said Resident #58 should have had a Significant Change MDS assessment completed within 14 days of hospice admission and acknowledged it was missed. The DON stated she was responsible for communicating changes in condition or orders requiring a new MDS assessment and said the team met weekly to review MDS assessments due, but Resident #58's hospice admission was somehow missed. The Administrator stated the resource nurses had been responsible for MDS completion from April to present and said the hospice admission was not communicated.
Inaccurate MDS Coding for Hospice Status
Penalty
Summary
The facility failed to ensure that one resident received an accurate assessment when a significant change MDS assessment coded hospice services even though the resident had been discharged from hospice. Resident #1 was a male with Huntington's disease and severely impaired cognition, as shown by a BIMS score of 00 on the significant change MDS assessment. Record review showed the resident had been discharged to the hospital and off hospice services on 3/30/2026, and a discontinued order summary indicated hospice was discontinued on 3/31/2026. The resident returned to the facility on 4/06/2026, but the significant change MDS completed on 4/17/2026 still captured hospice services. The comprehensive care plan revision dated 4/6/2026 indicated the resident did not have hospice. During interview, the MDS Resource Nurse stated the assessment should not have included hospice because the resident had been discharged from hospice. The DON and Administrator stated the hospice discharge was not communicated to the MDS Resource Nurse and that the MDS was coded incorrect.
Improper Foley Drainage Bag Positioning
Penalty
Summary
The facility failed to ensure appropriate catheter care for Resident #13, a male resident admitted with benign prostatic hyperplasia and severe cognitive impairment, who had an indwelling urinary catheter with a closed urinary drainage system ordered. The resident’s care plan identified the Foley catheter and included monitoring, recording, and reporting signs and symptoms of urinary tract infection. During an observation while wound care was being performed, the urinary drainage bag was seen hanging on the side of the bed with the bottom of the bag touching the floor when the bed was in the lowest position. After the wound care was completed and the bed was lowered again, the drainage bag was again allowed to touch the floor. The ADON stated this was an infection control issue and that allowing the bag to touch the floor could introduce bacteria and cause infections. The DON later stated the facility did not have a specific catheter management policy and that all nursing staff were responsible for keeping drainage bags properly positioned.
Dirty CPAP Mask Observed for Resident with Respiratory Therapy Order
Penalty
Summary
The facility failed to ensure safe and appropriate respiratory care for Resident #39 by not keeping his CPAP mask clean. Resident #39 was an older male admitted with Parkinson's disease, had a BIMS score of 10 indicating moderate cognitive impairment, and had an order to wear CPAP at bedtime and as needed. His care plan included an intervention to clean the tubing and mask each Sunday. During an observation on 6/14/26, the resident's CPAP mask was seen on the bedside table and was not bagged, labeled, or dated; it appeared dirty with thick brown particles and hair fibers on the inside and outside. During another observation on 6/15/26, the mask was found in a bag in the drawer but was still dirty in appearance. The DON stated charge nurses were responsible for ensuring CPAP masks were cleaned at least weekly, and the Administrator stated that if masks were not cleaned appropriately, they might not work correctly.
Unlocked Medication Cart Left Unattended
Penalty
Summary
The facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and to limit access to authorized personnel for 1 of 3 medication aide carts reviewed. During an observation on 6/15/26 at 8:27 am, MA A was in a resident's room obtaining vital signs while the medication cart was left unlocked and unattended in the hallway outside the room. Residents were seen walking past the cart on their way to the therapy room at the end of the hallway. During an interview later that morning, MA A stated she did not realize she had left the cart unlocked and unattended and said the cart should always be locked when unattended because the medications could be taken by anyone walking by. The DON stated on 6/16/26 that staff were expected to always lock medication carts when unattended so residents or anyone else would not have access to medications. The Administrator also stated that residents and visitors could have unauthorized access to carts if they were left unlocked and unattended. Record review showed the facility policy required medication rooms, carts, and medication supplies to be locked or attended by persons with authorized access.
Improper Incontinence Care and Use of Wet Brief on Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary ADL assistance and proper incontinence care to maintain good personal hygiene for a resident with significant care needs. The resident was an elderly female with dementia, type 2 diabetes, bowel and bladder incontinence related to impaired mobility, and a Stage 4 sacral pressure ulcer present on admission. Her MDS assessment showed severely impaired cognition (BIMS of 1) and a need for total assistance with toileting hygiene, shower/bathing, and lower body dressing. Care plans documented the sacral pressure ulcer and bowel/bladder incontinence, with interventions including repositioning, incontinence checks and care, and wound care as ordered. During an observed incontinence care episode, two CNAs placed a clean brief under the resident while providing care and repositioning her. As they rolled her onto her left side, the resident urinated on the clean brief that had been positioned under her buttocks. One CNA confirmed to the other that the resident had urinated on the brief, and the CNA blotted the standing urine on the brief with wet wipes. Despite recognizing that the brief had become wet, both CNAs continued and applied the same wet brief to the resident instead of replacing it with a new, dry brief. Both CNAs later stated they rounded on residents every two hours and acknowledged that placing a wet brief on a resident was not acceptable practice. Multiple staff interviews, including with an RN, ADON, LCSW, DON, and the ADM, confirmed that the facility’s expectation and policy were that incontinent residents be rounded on at least every two hours and that it was not acceptable to put a wet brief on a resident. Staff stated that such practice could lead to skin integrity issues or infection, and the facility’s incontinence care policy required assisting the resident with donning a new disposable incontinent brief. The DON and ADM each minimized the risk in the case of a small amount of urine, but still acknowledged that the resident dribbled urine whenever turned and that the resident had a Stage 4 sacral ulcer deemed clinically unavoidable. A family member reported having frequently found the resident wet in the past, though without specific dates, while noting that care had recently improved. Skills checklists showed both CNAs had previously been checked off on incontinent care without concerns.
Failure to Maintain Accident-Free Environment and Provide Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment was not maintained in a manner that would minimize the risk of accidents, and supervision protocols were insufficient to prevent such incidents from occurring. No additional details regarding the specific individuals involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required program for preventing and controlling infections was either not established or not effectively put into practice. The report does not provide further details regarding specific actions, inactions, or events, nor does it mention any particular residents or staff involved in the deficiency.
Food Storage and Hair Restraint Deficiencies in Kitchen
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. During observations, it was found that the walk-in freezer was not maintaining appropriate temperatures, registering at 40 degrees Fahrenheit, which is above the required freezing point. Multiple thawed food items, including meats, vegetables, desserts, and dairy products, were found in the freezer, indicating that they had not been kept frozen as required. Staff interviews revealed that the freezer had a history of malfunctioning, with maintenance issues occurring during heavy rains and wind, causing the pressure switch to turn off the freezer. Staff were not consistently monitoring the freezer temperature on each shift, and some were unaware of the current malfunction. Additionally, the facility failed to ensure that kitchen staff, including the Cook, DA, and DM, wore hair nets effectively to cover all hair. Observations showed that hair was exposed on the sides and back of their heads while working in the kitchen. Staff interviews confirmed that all hair should be covered to prevent contamination, but this was not consistently practiced. The facility's policies and FDA guidelines require proper hair restraints to prevent physical contaminants from entering food during preparation and service. Record reviews of facility policies and FDA Food Code standards confirmed the requirements for proper food storage temperatures and the use of effective hair restraints. The failure to maintain the freezer at the correct temperature and to ensure proper use of hair coverings by staff were directly observed and acknowledged by staff and administration. These deficiencies were identified during the survey and were not in line with professional standards for food safety and kitchen sanitation.
Failure to Provide Properly Prepared Pureed Diet
Penalty
Summary
The facility failed to ensure that food prepared for a resident on a pureed diet was of the appropriate consistency as required by the resident's care plan and physician's orders. Observations revealed that the pureed meals served, including soft beef tacos, brownies, steak fingers, and mixed vegetables, were not of a smooth or pudding-like consistency, but instead had a coarse or chunky texture. Staff interviews confirmed that the food did not meet the required standards for pureed diets, and that the consistency was not physically tested before serving. The dietary manager and other staff acknowledged that menus and recipes, which specified the need for a smooth, creamy texture, were not followed for the preparation of pureed foods. The resident involved had severe cognitive impairment, was dependent for activities of daily living including feeding, and had a history of ataxia, dementia, malnutrition, and risk for aspiration. The care plan and physician's orders specified a pureed diet with thin liquids, and the facility's policy required adherence to therapeutic diet recipes and consistency checks. Despite these requirements, the resident was served food that did not meet the prescribed texture, as confirmed by both staff and administrative personnel during interviews and direct observation.
Failure to Perform Hand Hygiene Between Glove Changes During Catheter Care
Penalty
Summary
A deficiency was identified when a certified nursing assistant (CNA) failed to perform proper hand hygiene during care for a resident with a supra-pubic catheter. Specifically, after removing gloves following incontinent care and wiping the resident's rectum, the CNA did not sanitize or wash her hands before donning a new pair of gloves to continue with Foley catheter care. This lapse in infection control was directly observed by surveyors during care provided to a male resident with chronic respiratory failure, chronic kidney disease, type 2 diabetes, and moderately impaired cognition, who was dependent on staff for toileting and personal hygiene. The resident's care plan included a goal to remain free of urinary tract infections, and facility policy required hand hygiene after glove removal. The CNA acknowledged forgetting to sanitize her hands between glove changes, and the Director of Nursing and Administrator both confirmed that staff are expected to follow hand hygiene protocols as outlined in facility policy. Review of the CNA's skills checklist indicated she had previously been deemed proficient in hand washing.
Failure to Implement Abuse Prevention Policies
Penalty
Summary
The facility failed to implement its written policies and procedures regarding prohibiting and preventing abuse for a resident who reported being shaken by a CNA in the shower room. The resident, who had no cognitive impairment, was given a discharge notice shortly after reporting the incident. The facility allowed the CNA to return to work the day after the abuse allegation was made, without a thorough investigation, which could place residents at risk for further abuse and psychosocial harm. The resident had a history of muscle weakness, diabetes, dysphagia, and dementia, among other conditions, and required assistance with various activities of daily living. Despite these needs, the facility issued a discharge notice, claiming they could not meet the resident's needs. The resident's power of attorney reported that the facility retaliated against the resident by allowing the accused CNA to continue working and by issuing a discharge notice. Interviews with facility staff revealed a lack of belief in the resident's allegations and a failure to properly investigate the claims. The facility's business office manager and assistant manager expressed disbelief in the resident's report, which could discourage residents from voicing concerns. The facility's administrator and social worker acknowledged the resident's allegations but justified the discharge by stating that the resident exhausted staff resources. The resident was ultimately transferred to another facility, where she adjusted well and did not exhibit the alleged behaviors.
Unlicensed Interim Administrator Appointment
Penalty
Summary
The governing body of the facility failed to appoint a licensed Administrator, as required by state regulations. The Interim Administrator, identified as CO, was not licensed in Texas, which was confirmed through observations, interviews, and record reviews. During the survey, CO was identified as the acting Administrator by multiple staff members, including a CNA and an LVN, who were unsure of any other Administrator's presence. CO himself stated that he was working under the license of an Executive Director, who was his preceptor, and that he had completed his training hours and submitted an application for his license. The Administrator, who was also the Regional Administrator, confirmed that CO was serving as an interim Administrator and was awaiting his certification. A review of CO's personnel file indicated that his internship was approved under a different preceptor at another facility, and no request to change preceptor or facility had been received. Additionally, a request for the facility's Governing Body policy was made, but the policy was not provided before the survey exit.
Resident's Belongings Disrespected During Discharge
Penalty
Summary
The facility failed to treat a resident with dignity and respect regarding her personal possessions during her discharge process. The resident, who had no cognitive impairment as indicated by a BIMS score of 15, was discharged with her belongings packed into trash bags. This action was taken after the resident received a 30-day discharge notice, which her Power of Attorney felt was retaliatory. Upon arrival at the new facility, the resident's belongings, including clothes and food items, were found mixed together in trash bags, leading to stained clothing and feelings of disrespect and mistreatment. Interviews with staff at the new facility confirmed that the resident was left with about 10 large trash bags of her belongings, which were left in the hallway without assistance. The resident expressed feeling like she was treated as trash, and staff at the new facility noted her distress and frequent inquiries about her belongings. The facility's policy on resident rights emphasizes the importance of treating residents with respect and dignity, including the proper handling of personal possessions, which was not adhered to in this case.
Improper Discharge of Resident Without Adequate Reason
Penalty
Summary
The facility failed to ensure that a resident was not transferred or discharged without adequate reason and proper documentation. A resident was given a discharge letter after reporting an incident of abuse by an aide, which listed shower administration as a reason for discharge. The facility discharged the resident prior to the 30-day notice date and did not provide the resident's representative the opportunity to appeal the discharge decision. This action was contrary to the facility's policy, which states that residents have the right to appeal a facility-initiated transfer or discharge and should not be transferred or discharged while the appeal is pending. The resident involved was a female with a history of muscle weakness, type 2 diabetes, dysphagia, gait abnormalities, dementia, and anxiety, among other conditions. Her BIMS assessment indicated no cognitive impairment, and her discharge Minimum Data Set showed no behavior symptoms or rejection of care. Despite this, the facility claimed that the resident's needs could not be met, citing issues with activities of daily living and medication administration. The resident's representative reported feeling retaliated against after the resident reported abuse by a shower aide, and the facility allowed the aide to continue working while issuing a discharge notice to the resident. Interviews with the resident, her representative, and staff revealed that the resident felt mistreated and was not given a fair opportunity to appeal the discharge. The resident's belongings were reportedly packed in trash bags and moved to a new facility without proper assistance, leaving her feeling devalued. The facility's staff claimed that the resident exhausted available resources and staff, leading to the discharge decision. However, the resident and her representative disputed these claims, stating that the resident was compliant with care and did not refuse treatment based on staff race.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Trinity
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Trinity Rehabilitation & Healthcare Center | 0.7 mi | ★★★★★ | 37 | 3 |
| Groveton Nursing Home | 16.4 mi | ★★★★★ | 0 | 0 |
| Huntsville Health Care Center | 19.1 mi | ★★★★★ | 5 | 0 |
| Focused Care At Huntsville | 19.6 mi | ★★★★★ | 9 | 0 |
| Mrc Creekside | 20.1 mi | ★★★★★ | 5 | 0 |
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