314 E. Caroline St., Trinity, TX 75862 · Trinity County · (936) 744-1300
76 certified beds, about 56 residents a day · Government - Hospital district · Medicare and Medicaid since 2018
CMS Care Compare ratings, data as of September 1, 2026 · CCN 676439 · See it on Medicare.gov · Compare with other homes
At its most recent standard inspection, on April 15, 2026, inspectors cited 15 health deficiencies (the Texas average is 9.4, the national average 9.2).
Of 66 health citations since November 2023, 9 were rated as actual harm or immediate jeopardy to residents (6 immediate jeopardy).
CMS lists 4 fines totaling $262,204 in the last three years; the largest was $168,714, and the latest is dated January 28, 2026.
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 66 health citations on file.
Inspectors wroteBased on interview and record review, the facility failed to provide effective communications mandatory training for 6 of 17 direct care staff (CNA K, CNA F, LVN A, LVN L, LVN M and the ADON) reviewed for training requirements. The facility failed to ensure effective communication training was provided to CNA K, CNA F, LVN A, LVN L, LVN M and ADON.This failure could affect residents and place them at risk of miscommunication and social isolation due to lack of staff training.
Inspectors wroteBased on interviews and record review, the facility failed to provide the mandatory training on standards, policies, and procedures for an infection prevention and control program for 9 of 17 direct care staff (CNA K, CNA F, CNA E, LVN A, LVN L, LVN M, the Dietary Manager, the Activity Director and the ADON) reviewed for training requirements. The facility failed to ensure mandatory training on standards, policies, and procedures for an infection prevention and control program effectively was provided to CNA K, CNA F, CNA E, LVN A, LVN L, LVN M, Dietary Manager, Activity Director and the ADONThis failure could place residents at risk of illness or spread of infections due to lack of staff training.
Inspectors wroteBased on interviews and record review, the facility failed to provide mandatory behavioral health training for 9 of 17 direct care staff (CNA K, CNA F, CNA E, LVN A, LVN L, LVN M, the Dietary Manager, the Activity Director and the ADON) reviewed for training requirements. The facility failed to ensure effective communication training was provided to CNA K, CNA F, CNA E, LVN A, LVN L, LVN M, the Dietary Manager, the Activity Director and the ADONThis failure could place residents with behaviors at risk of not receiving care to attain or maintain their highest practicable physical, mental, and psychosocial well-being due to lack of staff training.
Inspectors wroteBased on interview and record review, the facility failed to ensure residents have the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the option he or she prefers for 1 of 4 residents (Resident #1) reviewed for resident rights. The facility failed to ensure Resident #1 had a signed medication consent form for Olanzapine (an antipsychotic medication) when ordered on 10/15/25. This failure could place residents at risk for treatment or services provided without their informed consent.
Inspectors wroteBased on interview and record review, the facility failed to ensure the facility coordinated with the appropriate, State-designated authority, to ensure that individuals with a mental disorder, intellectual disability or a related condition for 1 of 3 residents (Residents #45) reviewed for resident assessments. The facility did not refer Resident #45 to the appropriate state-designated mental health authority for review when she received a new diagnosis of bipolar disorder. This failure could affect residents with psychiatric diagnoses at risk of not receiving beneficial and needed services and care.
Inspectors wroteBased on interview and record review, the facility failed to provide the resident and or the resident representative with a summary of the baseline care plan for 1 of 4 residents (Resident #58) reviewed for the base line care plans. The facility did not provide a summary of the Baseline Care Plan to Resident #58 or their Responsible Party (RP). This failure could place newly admitted residents at risk of not receiving continuity of care and communication among nursing home staff.
Inspectors wroteBased on interview and record review, the facility failed to make sure a comprehensive care plan was prepared by an interdisciplinary team, that included but not limited to the participation of the resident and the resident representative for 1 of 4 residents (Resident #16) reviewed for care plans. The facility failed to ensure Resident #16 has care plan conferences at least every 3 months, and her representative, were invited to the resident care plan conferences. This failure could place residents at risk of not being able to provide input on their care, and receiving the care and services to meet their needs.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assures accurate acquiring, receiving, dispensing, and administering of medications for 1 of 6 residents (Resident #16) reviewed for pharmacy services. The facility did not ensure LVN A watched Resident #16 take administered medications, and they were not left in her room on 4/14/2026. This failure could place residents at risk for the unsafe administration of medications.
Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to serve food that was palatable for 1 of 1 meal reviewed for food palatability. (noon meal 4/14/26). The facility did not provide palatable and appetizing food for the residents receiving pureed food for the 10/28/2025 noon meal. This failure could place residents who received food from the kitchen at risk for diminished meal satisfaction and potential weight loss due to poor meal intake.
Inspectors wroteBased on interviews and record reviews, the facility failed to ensure professional licensed, certified, or registered in accordance with applicable State laws standards of quality for 1 of 6 licensed staff (LVN B) reviewed for administration. The facility failed to ensure LVN B's nurse license did not expire as of [DATE]. This failure could place residents at risk for not receiving nursing services from a licensed nurseThe
Inspectors wroteBased on observation, interview, 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 #16) reviewed for infection control. The facility failed to ensure CNA C and CNA D washed or sanitized their hands during incontinent care provided to Resident #16 on 4/14/2026. This failure could place residents at risk of exposure to infectious diseases due to improper infection control practices.
Inspectors wroteBased on interviews and record review, the facility failed to develop, implement, and maintain an effective training program for 2 of 17 employees (Dietary Manager and the Activity Director) new and existing staff reviewed for training requirements. The facility failed to ensure the Activity Director was trained in effective communication, HIV, dementia, infection control and restraint reduction on hire. The facility failed to ensure the Dietary Manager was trained in falls, dementia, infection control and behavioral health on hire This failure could place residents at risk of not receiving care to attain or maintain their highest practicable physical, mental, and psychosocial well-being due to lack of staff training.
Inspectors wroteBased on interview and record review, the facility failed to provide the required education on the rights of the residents and the responsibilities of a facility to properly care for its residents for 1 of 17 employees (CNA E) reviewed for training requirements, in that:The facility failed to ensure that annually required education was provided on the rights of the residents and responsibilities of a facility to properly care for its residents were conducted with CNA E.This failure could affect residents and place them at risk of being uninformed due to lack of staff training.
Inspectors wroteBased on interviews and record review, the facility failed to ensure employees received the required training on Abuse, Neglect, and Exploitation and dementia management training for 1 of 17 (CNA E) reviewed for required training. The facility did not ensure Abuse, Neglect, and Exploitation and dementia management training was completed by the CNA E during annual training for 2025. This failure could place residents with dementia at risk of abuse, neglect, and exploitation and poor quality of care by staff with inadequate training when caring for dementia residents.
Inspectors wroteBased on interviews and record review, the facility failed to ensure the required minimum 12 hours annual in-service education was provided for 1 of 5 CNAs (CNA E) reviewed for training requirements. The facility did not provide the required 12 hours of annual in-service education to CNA F. This failure could place residents with dementia at risk of abuse, neglect, exploitation and poor quality of care by staff with inadequate training when caring for residents.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain personal hygiene for 1 of 4 residents reviewed for ADL care. (Resident #10)The facility failed to ensure Resident #10 received timely incontinent care on 03/04/2026 which caused redness to inner thighs and excoriation to buttocks. This failure could place residents at risk of embarrassment, discomfort, and skin breakdown.
Inspectors wroteBased on observation, interview, and record review the facility failed to, based on the comprehensive assessment of a resident, ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 5 residents (Resident #1) reviewed for quality of care. The facility failed to ensure Resident #1's skin was appropriately assessed and treated resulting in skin breakdown. This failure could place all residents at risk of skin breakdown, infection, and hospitalization.
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 1 of 6 residents reviewed for quality of care. (Resident # 4)The facility failed to ensure CNA A and CNA B properly and safely transferred Resident #4 while using a mechanical lift on 3/3/2026. This failure could result in a loss of quality of life due to injuries.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to have sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable, physical, mental, and psychosocial well-being for 1 of 5 staff (CNA B) reviewed for nursing services. The facility failed to ensure CNA B properly and safely transferred Resident #4 while using a mechanical lift on 3/3/2026. This deficient practice could place residents at risk for injury and harm.
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 5 residents (Resident #5) reviewed for infection control. The facility failed to ensure CNA A followed enhanced barrier precautions when she provided personal care that included dressing of Resident #5 on 3/3/2026. This failure could place residents at risk of exposure to infectious diseases due to improper infection control practices.
Inspectors wroteBased on interviews and record reviews review the facility failed to ensure the resident received adequate supervision and assistive devices to prevent accidents for one (CR #1) of eleven residents reviewed for falls in that: The facility failed to provide adequate supervision and develop and implement interventions to reduce the risk of falls or injury for CR#1. This failure could affect residents who were a fall risk which could result in injury and contribute to avoidable accidents.
Inspectors wroteThe resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes, but is not limited to, seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Based on interviews and record review, the facility failed to ensure the resident was free from abuse for 1 (CR #1) of 11 residents reviewed. The facility failed to ensure that all staff were trained and knowledgeable in how to react and respond appropriately to resident behavior. The facility failed to protect the resident from physical abuse when staff used physical force during care that resulted in injury. This failure could place residents at risk for abuse, neglect, and exploitation and compromise their right to be free from harm. [...]
Inspectors wroteBased on the interviews and record review, the facility failed to ensure that all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegation was made, to the facility administrator and to other officials, including the State Survey Agency, as required by State law and established facility procedures. Federal and state regulations require all staff to recognize, report, and document any incident or allegation of abuse, regardless of intent or injury, to ensure timely investigation and protection for one (CR #1) of eleven residents reviewed related to abuse and neglect. The facility failed to report an incident on 09/01/2025 involving CR #1, in which a Certified Nurse Aide (CNA) admitted to physically grabbing the resident's arm during care, resulting in a 5 x 2.5 cm skin tear to the left forearm. [...]
Inspectors wroteBased on interviews and record review, the facility failed to revise and implement a comprehensive, person-centered care plan to address the resident's known and ongoing medical and nursing needs for 1 (CR #1) of 11 residents reviewed. The facility failed to identify and incorporate care plan interventions related to changes in condition and emergency response, including the use of Naloxone (Narcan), despite known risk factors. This failure resulted in staff responding to ongoing fall risk, behavioral escalation, and changes in condition without clear, individualized guidance. This failure could place residents at risk for unmet medical and nursing needs, delayed response to changes in condition, and inconsistent care. [...]
Inspectors wroteBased on interview and record review, the facility failed to ensure that pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) were provided to meet the needs of each resident for 1 of 11 residents reviewed for pharmacy services (CR#1). The facility failed to administer Naloxone (Narcan), as ordered for suspected opioid overdose, to CR #1 on 09/09/2025. Despite staff suspicion of possible drug use and the resident presenting with unresponsiveness, facility nursing staff did not provide the emergency medication before EMS arrival. This failure could place residents at risk for delayed emergency intervention, exacerbation of life-threatening conditions, and increased potential for physical harm.
Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, which includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental needs, for 1 of 6 (Resident #1) residents reviewed. The facility failed to include Resident #1's PICC line (intravenous access to deliver medications into the blood stream) on her care plan. This failure could affect residents by placing them at risk of not receiving appropriate interventions to meet their current needs.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure residents received parenteral fluids administered consistent with professional standards of practice and in accordance with physician orders for 1 of 1 resident (Resident #1) reviewed for parenteral fluids. The facility failed to manage Resident #1's PICC line (intravenous access to deliver medications into the blood stream) dressing per professional standards and per the physician's order. This failure placed residents at risk of developing an infection.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received necessary services to maintain grooming and personal hygiene for 1 of 5 residents (Resident #1) reviewed for ADLS. The facility failed to provide hair care to Resident #1 which resulted in a large hair mat at the back of her head that had to be cut out on 11/11/25. The facility failed to provide showers or baths to Resident #1 in compliance with their shower/bath schedule. This failure could place residents at risk of a decline in hygiene, at risk of skin breakdown, level of satisfaction with life, and feelings of self-worth.
Inspectors wroteBased on observation, interview and record review, the facility failed to maintain clinical records on each resident in accordance with accepted professional standards and practices that were complete and accurately documented for 1 of 5 residents (Resident #1) reviewed for accuracy of clinical records. Facility staff failed to document Resident #1's ADL for baths or showers and hair care or refusals. This failure could place residents at risk of not receiving care and services to meet their needs. [...]
Inspectors wroteBased on observation, interviews, and record review, the facility failed to consult with the physician when the resident experienced a change in condition for 3 of 4 residents (Resident's #11, #12, and #13) reviewed for a change of condition.1. The facility failed to notify the wound care physician to obtain and implement wound care orders for Resident #11 until 10/20/25, 2 days after identifying unstageable pressure injury (a full-thickness tissue loss where the base of the ulcer is covered by slough or eschar, making it impossible to determine the depth of the wound) to right heel on 10/18/25. The facility failed to contact surgeon or wound care physician to obtain wound care orders for Resident #11 on 11/3/25 after debridement of pressure ulcer (the medical process of removing necrotic (dead) tissue from a wound) in surgeon's office on 11/3/25. 2. [...]
Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the necessary treatment and services, in accordance with comprehensive assessment and professional standards of practice, to prevent development of pressure injuries was provided for 4 of 4 Residents (Resident's #11, #12, #13, and #16) reviewed for pressure injuries.1. The facility failed to complete weekly skin assessments after 10/18/25 for Resident #11 who admitted on [DATE] after ORIF (Open Reduction Internal Fixation) for fracture to right foot. She was admitted with no pressure ulcers and developed an unstageable pressure injury to Right heel on 10/18/25. The facility failed to obtain and implement wound care orders for Resident #11 for 2 days after identifying unstageable pressure injury to right heel on 10/18/25. [...]
Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure residents were free of any significant medication errors for 2 of 11 residents reviewed for medications. (Resident #4 and Resident #2)1. The facility failed to administer Metoprolol (a medication to treat high blood pressure) and Entresto (a medication to treat high blood pressure and treat heart failure) to Resident #2 on 10/6/25 at 9:00 pm as ordered.2. The facility failed to ensure Entresto 24/26 mg 1 tablet by mouth twice a day was ordered for Resident #4 when she was admitted to the facility from the hospital on 9/18/2025. 3. [...]
Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that residents received care and services in accordance with professional standards of practice for 4 of 11 residents (Resident #1, # 7, #14, and #15) reviewed for quality of care.1. The facility failed to ensure RN A assessed, provided care, conducted and documented a neuro assessment, and notify the physician and family when Resident #1 fell and hit her head on 10/30/2025. 2. The facility failed to ensure a head-to-toe skin assessment was completed by a nurse after CNA G identified possible ant bites to Resident #15 on 10/9/25, and Residents #7 and #14 on 10/10/25. These failures could place residents at risk for not receiving appropriate care and treatment and or decline in their health.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services to ensure the accurate administration of medications for 1 (Resident #2) of 16 residents reviewed for pharmacy services. The facility failed to administer ordered medications for Resident #2 on 9/3/25, 9/6/25, 9/9/25, 9/17/25, 9/30/25, 10/6/25, 10/7/25, 10/13/25, 10/14/25, 10/29/25, 10/30/25, and 11/1/25. This failure could place the residents at risk of a decline in health, and decreased quality of life.
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 3 of 10 residents (Resident #2, Resident #17, and Resident #13) and 3 of 5 staff (CNA H, LVN F, and MDS Coordinator) reviewed for infection control. The facility failed to ensure CNA H changed her gloves and washed/sanitized her hands during incontinent care provided to Resident #2 on 11/4/2025. The facility failed to ensure LVN F changed her gloves when she changed from dirty to clean during wound care provided to Resident #17 on 11/4/2025. [...]
Inspectors wroteBased on interview and record review the facility failed to make sure a comprehensive care plan was prepared by an interdisciplinary team, that included but not limited to the participation of the resident and the resident representative for 1 of 10 residents (Resident #2) reviewed for care plans. The facility failed to ensure Resident #2, and her representative were invited and attended the resident care plan conferences. This failure could place residents at risk of not receiving the care and services to meet their needs.
Inspectors wroteBased on observations, interviews, and record reviews the facility failed to be adequately equipped to allow residents to call for staff through a communication system which relayed the call directly to a staff member or to a centralized staff work area from bedside and toileting and bathing facilities for 2 (Hall 200 and 300) of 4 hallways and 9 of 9 (Residents #1, #2, #3, #4, #5, #6, #7, #8, and #9) residents reviewed for call light response. The facility failed to ensure Hall 200 and 300's call lights were visible and audible to staff and failed to provide an alternate method for residents (Residents #1, #2, #3, #4, #5, #6, #7, #8, and #9) to call for assistance. This failure could place residents at risk of injury, pain, hospitalization, and a diminished quality of life.
Inspectors wroteBased on observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food under sanitary conditions in 1 of 1 kitchen. The facility failed to ensure the temperature for the dish machine was at the appropriate temperature of 120 degrees according to the manufacturer's guidelines on 2/24/2025. The facility failed to remove 9 cups of yogurt from the refrigerator that were dated 2/23/2025 on 2/24/2025. The facility failed to ensure a box of white onions, a box of cucumbers and tomatoes were removed from the refrigerator when they had white, hairy, and black substances present on 2/24/2025. These failures could place residents who eat from the kitchen at risk of foodborne illnesses.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain an effective pest control program and ensure it was free of pests for 1 of 1 Kitchen reviewed for pest control. The facility failed to ensure an effective pest control program was in place to keep roaches out of the kitchen from 2/24/2025-2/25/2025. This failure could place residents at risk for injury due to an ineffective pest control program at the facility.
Inspectors wroteBased on interview and record review, the facility failed to ensure the baseline care plan that included the instructions for resident care needed to provide effective and person-centered care was completed for 3 of 6 residents reviewed for new admissions (Resident #167, #174, and #175). The facility failed to complete baseline care plans within 48 hours of admission for Residents #167, #174, and #175. This failure could place residents at risk of not receiving care and services to meet their needs.
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 3 of 6 residents (Resident #9, Resident #117, and Resident #175) and 3 of 5 staff (CNA A, CNA D, and LVN G) reviewed for infection control. The facility failed to ensure CNA D washed or sanitized her hands when passing out meal trays to residents on Hall 100 on 2/24/2025. CNA A did not wear appropriate PPE for enhanced barrier precautions when care was provided to Resident #117 on 2/24/2025. The facility failed to implement contact isolation per physician orders for Resident #175 from 2/13/25 until 2/25/25. [...]
Inspectors wroteBased on interviews and record review, the facility failed to ensure employees received the required training effective communications for 6 of 15 new employees (LVN M, LVN N, SW, CNA O, CNA P, CNA Q) reviewed for training. The facility did not ensure an effective communication training was completed on hire for LVN M, LVN N, SW, CNA O, CNA P, CNA Q. This failure could place residents at risk of miscommunication and social isolation due to lack of staff training.
Inspectors wroteBased on interview and record review, the facility failed to provide the mandatory training on standards, policies, and procedures for an infection prevention and control program for 5 of 15 staff (LVN N, SW, CNA O, CNA P, CNA Q) reviewed for training. The facility failed to ensure infection prevention and control training was provided to LVN N, SW, CNA O, CNA P, CNA Q on hire. This failure could place residents at risk of the spread of illness due to lack of staff training.
Inspectors wroteBased on interviews and record review, the facility failed to ensure CNAs completed Abuse, Neglect, and Exploitation (ANE) and dementia management trainings for 3 of 5 CNAs (CNA O, CNA P, and CNA Q) reviewed for training. The facility did not ensure ANE, and dementia management trainings were completed by CNA O, CNA P, and CNA Q during orientation. This failure could place residents with dementia at risk of abuse, neglect, and exploitation and a poor quality of care by staff with inadequate training when caring for dementia residents.
Inspectors wroteBased on interviews and record review, the facility failed to provide mandatory effective behavioral health training for 6 of 15 employees (LVN M, LVN N, SW, CNA O, CNA P, CNA Q) reviewed for training. The facility failed to ensure effective behavioral health training was provided to LVN M, LVN N, SW, CNA O, CNA P, CNA Q S on hire. This failure could place residents with behaviors at risk of not receiving care to attain or maintain their highest practicable physical, mental, and psychosocial well-being due to lack of staff training.
Inspectors wroteBased on observation, interview, and record review the facility failed to provide a safe, clean, and comfortable environment for residents for 1 of 24 residents (Resident #29) observed for resident environment. The facility failed to ensure the privacy curtain and a wheelchair in the room of Resident #29 was clean and without odors on 2/24/2025. This failure could place residents at risk for an unsanitary environment.
Inspectors wroteBased on interview and record review, the facility failed to ensure the right to be free from misappropriation of property was provided for 1 of 3 residents reviewed for misappropriation of property. (Resident #17) The facility failed to prevent a diversion (misappropriation) of Resident #17's Hydrocodone-Acetaminophen 10-325mg tablets (a combined hydrocodone/acetaminophen narcotic pain reliever) on December 31, 2024. This failure could place residents at risk for decreased quality of life, unrelieved pain, misappropriation of property, and dignity.
Inspectors wroteBased on interviews and record review, the facility failed to refer all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change of condition for 1 of 6 Residents (Resident #4) reviewed for PASARR (Preadmission Screening and Resident Review Services). The facility failed to ensure Resident #4 had a new level 1 PASARR completed with a new diagnosis of major depressive disorder added on 10/28/2024. These failures could place residents at risk of not receiving the needed PASARR services to meet their individual needs and could result in a decreased quality of life.
Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain grooming, and personal and oral hygiene were provided for 2 of 6 residents (Resident #1 and #173) reviewed for ADL care. The facility failed to follow care plan for Resident #1 and assist her with showers on 2/17/25, 2/21/25, and 2/25/25. The facility failed to ensure Resident #173 had clean and trimmed nails on 2/24/25 and 2/25/25. This failure could place residents at risk of not receiving care/services, decreased quality of life, and loss of dignity.
Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure each resident received adequate supervision with smoking materials to prevent accidents for 1 of 8 residents (Resident #27) reviewed for accidents and hazards. The facility failed to ensure Resident #27 returned his lighter and cigarettes to the staff when returning from smoking. This failure could place residents at risk of harm or injury and contribute to avoidable accidents.
Inspectors wroteBased on interview and record review the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation and follow a policy to provide pharmacy services for 2 of 12 months (January 2025 and February 2025) reviewed for pharmacy services. The facility failed to document the required number of 2 witness signatures for drug destruction on 1/28/2025 and 2/20/2025. This failure could put residents at risk for misappropriation and drug diversion.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure drugs and biologicals used in the facility were stored in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for 1 of 26 residents (Resident #5) reviewed for medication storage. The facility did not ensure Nystatin powder was not stored at the bedside for Resident #5 on 2/24/25. This failure could place all residents at risk of misuse of medication and decreased quality of life.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 1 kitchen reviewed for essential equipment. The facility did not ensure the gas stove was in safe operating condition with the pilot light staying lit and allowing gas to leak on 2/24/2025. This failure could place the residents at risk of a fire and not receiving their meals in a timely manner.
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. The facility failed to ensure the DM and [NAME] wore a hairnet effectively to cover all of their hair on 8/27/2024. The failure could place residents at risk of foodborne illness and food contamination.
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 #6) and 1 of 8 staff (CNA A) reviewed for infection control. CNA A did not sanitize or wash her hands between glove changes when providing incontinent care to Resident #6 on 8/27/2024. The failure could place residents at risk of exposure to infectious diseases due to improper infection control practices.
Inspectors wroteBased on interview and record review, the facility failed to have sufficient nursing staff to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, for one of four quarters for 2023 (Quarter 2) reviewed for sufficient nursing staff. The facility did not have sufficient staff on weekends according to the PBJ report for Quarter 2 2023 (January 1 through March 31). This failure could place residents at risk of diminished quality of life and quality of care.
Inspectors wroteBased on interview and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 12 of 12 months (October 2022 through October 2023) and failed to ensure a registered nurse served as DON on a full-time basis for 3 of 3 months (November 2023 through January 2024) reviewed for RN coverage. The facility did not have the required eight consecutive hours of RN coverage for 15 days in October 2022, 25 days in November 2022, 7 days in December 2022, 13 days in January 2023, 6 days in February 2023, 8 days in March 2023, 8 days in April 2023, 8 days in May 2023, 6 days in June 2023, 2 days in July 2023, 7 days in August 2023, and 5 days in September 2023. The facility did not have an RN serving as full-time DON in November 2023, December 2023, and January 2024. [...]
Inspectors wroteBased on interview and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs for 1 of 14 residents whose medications were reviewed. (Resident #25) Resident #25 received Humalog insulin when the resident's blood glucose was outside parameters set by the physician. This failure could place the residents who were prescribed insulin to lower blood glucose which included parameters at risk of adverse side effects from medications.
Inspectors wroteBased on observation, interview, 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 2 of 14 residents reviewed for infection control. (Resident #'s 5 and 25) LVN A did not don appropriate PPE before entering Resident #5's COVID-19 (a disease caused by a virus named SARS-COV-2 causing respiratory symptoms, which is very contagious and spreads quickly) isolation room. The facility did not ensure proper infection control procedures for the sanitizing the bed when Resident #25 was removed from isolation. These failures could place the residents at risk of contracting an infectious disease and a decline in health.
Inspectors wroteBased on interview and record review, the facility failed to provide services as outlined by the comprehensive care plan, to meet professional standards of quality for consultation with the resident's physician when there was a significant change in the resident's condition or a need to alter treatment significantly for one (Resident #25) of 14 residents reviewed for following physician's orders. The facility failed to implement Resident #25's care plan for when her blood glucose was above 450 for 5 days and did not notify her physician in December 2023. (12/07/23, 12/11/23, 12/12/23, 12/17/23 and 12/20/23). The failure placed residents, who required blood glucose monitoring, at risk for diabetic complications due to delayed physician intervention.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident who was unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for 1 of 14 residents reviewed for ADL care. (Resident #8) The facility did not ensure Resident #8's fingernails were trimmed. This failure could place the residents at risk of not receiving the appropriate care and services to maintain their highest level of well-being.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was fed by enteral means received the appropriate treatment and services to prevent complications from enteral feeding for 1 (Resident #12) of 1 resident reviewed for enteral feeds. The facility failed to ensure Resident #12's enteral feed was properly labeled with the type of formula, date and time it was hung, and the rate of administration. This failure could place residents at risk of not receiving the proper nutritional requirements prescribed by the physician.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 2 of 14 residents reviewed for respiratory care. (Resident #'s 1 and 6) The facility did not ensure Resident #1's and #6's oxygen filters were clean and free of dust and debris. This failure could place residents who required respiratory care at risk of not receiving proper care and treatment and decreased quality of life.
Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure residents were free from physical restraints for 1 (Resident #1) of 31 residents reviewed for physical restraints. The facility failed to inform Resident #1 or their representative of the risks associated with use of assist bars, care plan for risks associated with assist bars/bed rails, obtain consent for the use of assist bars, obtain physician orders for use of assist bars, and implement interventions following an incident of entrapment with the assist bar. Resident #1 was found by LVN A on the floor in his room with his left arm caught between the assist bar and air mattress on 09/24/2023 and had no interventions to address risk of entrapment following incident. [...]
Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to implement policies and procedures that prohibit and prevent physical restraints of residents for 1 (Resident #1) of 31 residents reviewed for physical restraints. The facility failed to inform Resident #1 or their representative of the risks associated with use of assist bars, care plan for risks associated with assist bars, obtain consent for the use of assist bars, and obtain physician orders for use of assist bars, and implement interventions following identified entrapment incident from assist bars. Resident #1 was found by LVN A on the floor in his room with his left arm caught between the assist bar and air mattress on 09/24/2023 and had no interventions to address risk of entrapment following incident. [...]
Inspectors wroteBased on observation, interview and record review the facility failed to ensure bedrails were assessed for the risk of entrapment of residents prior to installation, and review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation for 9 of 31 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, and Resident #9) reviewed for bed rails. 1. The facility failed to inform Resident #1, Resident#2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, and Resident #9 or their representative of the risks associated with the use of assist bars. 2. The facility failed to care plan for risks associated with assist bars, obtain consent for the use of assist bars, and obtain physician orders for use of assist bars. 3. [...]
7 fire safety citations on file: 1 on April 15, 2026, 5 on February 27, 2025, 1 on January 10, 2024.
| Date | Penalty | Amount or length |
|---|---|---|
| January 28, 2026 | Fine | $12,425 |
| January 28, 2026 | Fine | $12,425 |
| January 28, 2026 | Payment Denial | 8 days from April 2, 2026 |
| November 12, 2025 | Fine | $68,640 |
| November 12, 2025 | Payment Denial | 4 days from December 11, 2025 |
| November 5, 2023 | Fine | $168,714 |
A payment denial means Medicare and Medicaid stopped paying for new admissions for that period.
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | Texas | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | not reported | 3.39 | 3.86 |
| Registered nurses | not reported | 0.43 | 0.69 |
| All nursing staff on weekends | not reported | 2.98 | 3.42 |
| Nurse aides | not reported | ||
| Licensed practical nurses | not reported | ||
| Nursing staff turnover (share who left in a year) | not reported | 55.3% | 45.8% |
| Registered nurse turnover | not reported | 54.6% | 42.9% |
| Administrators who left | not reported |
CMS note on this home's staffing data: This facility did not submit staffing data.
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In October to December 2025, nursing staff hours per resident were 3.35 on weekdays and 2.87 on weekends, 14% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 0.0% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 2.96 in April to June 2025 to 3.22 in October to December 2025.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Oct to Dec 2025 | 3.22 | 0.23 | 3.35 | 2.87 | 0.0% | 2 of 92 | 58 |
| Jul to Sep 2025 | 3.41 | 0.38 | 3.59 | 2.95 | 0.0% | 0 of 92 | 61 |
| Apr to Jun 2025 | 2.96 | 0.30 | 3.12 | 2.56 | 0.0% | 0 of 91 | 63 |
| United States, Oct to Dec 2025 | 3.76 | 0.62 | 3.93 | 3.34 | 5.3% | 0.5% of days | |
| Texas, Oct to Dec 2025 | 3.34 | 0.40 | 3.49 | 2.95 | 2.1% | 0.8% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Staff pay reports
No staff pay figure for this home has passed review yet. A figure appears only after at least 5 reports from at least 3 different people, sent over at least 60 days, have passed review.
| Job | Median | Middle half | Employed |
|---|---|---|---|
| Texas, all employers | |||
| CNAs (nursing assistants) | $18.03 | $16.97 to $20.71 | 88,680 |
| LPNs and LVNs | $29.92 | $27.46 to $32.89 | 57,560 |
| Registered nurses | $46.14 | $38.06 to $50.53 | 271,380 |
| United States, nursing care facilities | |||
| CNAs (nursing assistants) | $20.67 | $17.91 to $22.55 | 534,270 |
| LPNs and LVNs | $33.86 | $30.05 to $37.40 | 188,210 |
| Registered nurses | $41.11 | $37.85 to $47.68 | 142,270 |
Hourly wages; the middle half runs from the 25th to the 75th percentile. Source: U.S. Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2025. BLS has no separate estimate for medication aides. These are survey estimates for whole occupations, not figures for any one home.
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | Texas | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 8.0 | 15.8 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 0.0 | 0.3 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 0.0 | 0.8 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 6.2 | 3.3 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 3.4 | 1.5 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 8.3 | 14.0 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 6.8 | 3.8 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 6.9 | 9.6 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 43.4 | 25.7 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 34.0 | 12.3 | 12.0 |
| Number of hospitalizations per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 3.7 | 2.2 | 1.9 |
| Number of outpatient emergency department visits per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 5.2 | 2.1 | 1.8 |
For a stay to recover after a hospital visit, these are the results CMS publishes for Trinity Rehabilitation & Healthcare Center's Medicare short-stay residents. On returning residents home or to the community, CMS rates it no different from the national rate (45.6% of residents, after adjusting for how sick they were). How to read these, and what Medicare pays for.
45.6% this home
No different from the national rate
US median of homes 51.5% · Texas: 116 better, 50 worse
Rate of successful return to home or community from a SNF (risk-standardized discharge to community rate). Higher is better. October 2022 to September 2024. 50 eligible stays.
11.1% this home
No different from the national rate
US median of homes 10.7% · Texas: 0 better, 9 worse
Rate of potentially preventable hospital readmissions 30 days after discharge from a SNF (risk-standardized rate). Lower is better. October 2022 to September 2024. 52 eligible stays.
7.4% this home
No different from the national rate
US median of homes 7.1% · Texas: 4 better, 11 worse
Percentage of infections residents got during their SNF stay that resulted in hospitalization (risk-standardized rate). Lower is better. October 2023 to September 2024. 33 eligible stays.
Not reported
CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Median of homes: Texas57.3% · US 56.6%
Percentage of residents who are at or above an expected ability to care for themselves and move around at discharge. Higher is better. October 2024 to September 2025. 13 residents counted.
0.0% this home
Median of homes: Texas0.0% · US 0.0%
Percentage of SNF residents who experience one or more falls with major injury during their SNF stay. Lower is better. October 2024 to September 2025. 26 residents counted.
4.1% this home
Median of homes: Texas1.3% · US 1.7%
Percentage of residents with pressure ulcers or pressure injuries that are new or worsened (adjusted rate). Lower is better. October 2024 to September 2025. 26 residents counted.
Not reported
CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Median of homes: Texas98.5% · US 98.7%
Percentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge. Higher is better. October 2024 to September 2025. 4 residents counted.
Source: CMS Skilled Nursing Facility Quality Reporting Program - Provider Data, released 2026-09-30. Better, no different and worse are CMS's own comparisons with the national rate, after adjusting for how sick residents were. Medians of homes and the state counts are worked out by us from the same file.
Legal business name: CHAMBERS COUNTY PUBLIC HOSPITAL DISTRICT NO. 1.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Cooper, Kimberly | Corporate director | Individual | 01/29/2024 | |
| Newton, Elizabeth | Corporate director | Individual | 02/22/2024 | |
| Trinity Rhc LLC | Operational/managerial control | Organization | 05/01/2021 | |
| Whatley, Darcy | Operational/managerial control | Individual | 05/01/2021 | |
| Trinity Rhc LLC | Adp of the SNF | Organization | 05/08/2025 | |
| Sciarrini, Joseph | Adp of the SNF | Individual | 05/01/2021 | |
| Smith, Michael | Adp of the SNF | Individual | 05/01/2021 | |
| Squyres, Hulen | Adp of the SNF | Individual | 05/01/2021 |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Chosen from this home's own inspection record.
These are the official offices in Texas. NursingHomeClear cannot take or act on complaints.