River Pointe of Trinity Healthcare and Rehabilitat

Inspectors wroteBased on interview and record review, the facility failed to conduct a comprehensive assessment of a resident within 14 days after the facility determines or should have determined that there had been a significant change in the resident's physical or mental condition for 1 of 6 residents (Resident #58) reviewed for comprehensive assessments and timing. The facility failed to ensure an MDS significant change assessment for Resident #58 was completed within 14 days after hospice admission. This failure could place residents at risk for improper or incorrect care and services necessary for their physical, mental, and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure that each resident received an accurate assessment, reflective of the resident's status at the time of the assessment for 1 of 6 residents (Resident #1) reviewed for accuracy of assessments. The facility failed to accurately assess Resident #1 by inaccurately recording hospice services on a significant change MDS assessment dated [DATE]. This failure could place residents at risk of not receiving needed care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident who is incontinent of bladder receives appropriate treatment and services to prevent infections and to restore continence to the extent possible for 1 of 3 (Resident #13) residents reviewed for quality of care. The facility failed to ensure the urinary drainage bag was kept off the floor for Resident #13 on 6/15/26. This failure could place residents at risk for bacterial infections from improper catheter care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that respiratory care was provided consistent with professional standards of practice for 1 (Resident #39) of 3 residents reviewed for quality of care. The facility failed to ensure Resident #39's CPAP mask was clean on 6/14/26 and 6/15/26. This failure could place residents at risk of respiratory complications or respiratory infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for 1 of 3 (medication aide cart) carts reviewed for pharmacy services. The facility failed to ensure the medication cart was locked and secured by MA A on 6/15/2026. This deficient practice could place residents at risk for adverse reactions to medications and misappropriation of medications.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents who are unable to carry out activities of daily living received the necessary services to maintain good personal hygiene for 1 of 5 residents (Resident #1) reviewed for ADL care in that: The facility failed to ensure Resident #1 was provided appropriate incontinent care when CNA A and CNA B put a wet brief on her after providing incontinent care. This failure could place all residents at risk of loss of dignity, skin breakdown, infection, and hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents' environment remained free from accident hazards and the residents received adequate supervision and assistance to prevent accidents for 1 of 11 residents (Resident #2) reviewed for accidents. The facility failed to ensure a safe transfer of Resident #2 using a mechanical lift with two staff. On 6/21/2025 Resident #2 was being transferred from her bed to a wheelchair and CNA A failed to ensure all 4 straps were secured and Resident #2 flipped out of the mechanical lift to the floor and hit her head that resulted in a golf ball sized bump to the back of her head. Hospitality aide B sat in a recliner in the room and talked on a phone during the transfer. On 6/29/2025 x-ray conducted in the facility revealed a displaced right proximal femur fracture (hip fracture). [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to establish and 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 1 of 6 residents (Resident #4) and 2 of 4 staff (CNA C and CNA D) reviewed for infection control. 1. The facility failed to ensure CNA C and CNA D followed EBP (enhanced barrier precautions) for Resident #4 when providing care on 7/28/2025. 2. The facility failed to ensure CNA D changed gloves and washed or sanitized her hands when providing care to Resident #4 on 7/28/2025. These failures could place residents at risk of exposure to infectious diseases due to improper infection control practices.

Inspectors wroteBased on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for food safety requirements and kitchen sanitation. 1. The facility failed to ensure items were stored at appropriate temperatures in 1 walk-in freezer. 2. The facility failed to ensure the Cook, DA and DM effectively wore hair nets to cover all hair on 4/28/2025 and on 4/29/2025. Hair was uncovered on the back and sides of their heads. These failures could place residents at risk of foodborne illness and food contamination. Findings Include: During an observation on 4/28/2025 at 8:50am, revealed DM, [NAME] and DA had hair from under hair covering on the sides and back of their heads. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident received and the facility provided food prepared in a form designed to meet individual needs for 1 of 2 (Residents #29) residents reviewed for puree diets. The facility failed to prepare the pureed diet to the consistency required for Resident #29. This failure could place residents who received puree diets at risk of not having nutritional needs met by consuming foods that could be difficult to swallow, decreased meal intake, possibly resulting in choking or aspiration (the accidental inhalation of foreign material, such as food, liquid, or saliva, into the lower airways (trachea and lungs)

Inspectors wroteBased on observations, interviews, and record review the facility failed to establish and 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 1 of 6 residents (Resident #3) and 1 of 2 staff (CNA A) reviewed for infection control. The facility failed to ensure CNA A appropriately sanitized or washed her hands between glove changes while providing supra-pubic catheter (a device that's inserted into your bladder to drain urine if you can't urinate on your own. It is inserted through a small hole in your lower abdomen and into your bladder) care to Resident #3 on 4/29/25. The failure could place residents at risk of exposure to infectious diseases due to improper infection control practices.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement their written policies and procedures regarding prohibiting and preventing abuse for one (Resident #1) of 4 residents reviewed for developing and implementing abuse and neglect policies, in that: Resident #1 was provided a discharge notice on 03/05/24 after reporting CNA A shook her shoulders in the shower room on 02/29/24 and alleged MA B gave her medications she did not recognize that made her sick in January 2024. The facility failed to provide Resident #1 safety after CNA A was allowed to return to the facility on [DATE], one day after abuse allegations were made by Resident #1. These failures could place residents at risk for psychosocial harm, being fearful of staff, being uncomfortable, impaired quality of life and further abuse.

Inspectors wroteBased on observation, interview, and record review, the governing body failed to appoint an Administrator who is licensed by the State for 1 of 4 Facility Administrators reviewed for governing body. The Interim Administrator was not licensed in Texas. This failure could place residents at risk of not being provided care and services by licensed and unlicensed staff being overseen by an Administrator who was not licensed by the State of Texas and familiar with Texas rulles and regulations for nursing facilities.

Inspectors wroteBased on interview and record review the facility failed to treat Resident #1 with dignity and respect of personal possessions for 1 of 4 residents (Resident #1) reviewed for resident rights in that: The facility staff packed Resident #1's belongings into trash bags and placed them in the hall of the new facility. The facility staff failed to respect Resident #1's belongings when placing everything in trash bags upon her discharge. This failure could place the residents at risk for mistreatment, uncomfortable feelings and disrespect.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure residents were permitted to remain in the facility, and not transfer or discharge the resident from the facility, unless the transfer or discharge was necessary for the resident's welfare and the resident's needs could not be met in the facility and failed to ensure a resident was not transferred or discharged while the appeal was pending for 1 of 3 residents (Resident #1) reviewed for discharges, in that: Resident #1 was given a discharge letter after reporting an incident of abuse by an aide that listed shower administration on the form. The facility discharged Resident #1 prior to her 30-day notice date of 4/6/24 and did not give the RP the opportunity to appeal the discharge decision. This failure could place residents at risk of being discharged /transferred improperly.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store and distribute food in accordance with professional standards for food service safety in the facility's only kitchen. The facility failed to date opened items, remove expired and rotten foods from the refrigerator and walk in cooler. These failures could place residents who ate the food from the kitchen at risk for food-borne illness.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure an accurate MDS was completed for 1 of 5 residents (Residents #45) reviewed for MDS assessment accuracy. The facility incorrectly coded Resident #45 as having a diagnosis of bipolar (extreme mood swings) on her MDS assessment. This failure could place residents at risk for not receiving the appropriate care and services to maintain the highest level of well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents' environment remains as free of accident hazards as possible for 2 of 6 residents reviewed for accident hazards, (Resident #29 and Resident #36) in that: The facility failed to 1. develop and implement a policy and procedure including interventions to inspect the Hoyer sling for signs of damage before each use, 2. remove damaged mechanical lift slings from service and 3. obtain physicians orders for Hoyer lift transfers. This deficient practice could result in a loss of quality of life due to injuries if the damaged lift sling broke during transfer for residents that use a Hoyer lift for transfers and inappropriate use of Hoyer lifts for transfers if an order is obtained by the physician.