Health inspection·January 25, 2023

F 0755 directed by state law. Level of Harm - Minimal harm or potential for actual harm Record review of 22 TAC §303.1 Destruction of Dispensed Drugs accessed online 01/24/2023 at https://texreg.sos.state.tx.us/ indicated; Residents Affected - Some (a) Drugs dispensed to patients in health care facilities or institutions. (1) Destruction by the consultant pharmacist. The consultant pharmacist, if in good standing with the Texas State Board of Pharmacy, is authorized to destroy dangerous drugs dispensed to patients in health care facilities or institutions. A consultant pharmacist may destroy controlled substances as allowed to do so by federal laws or rules of the Drug Enforcement Administration. Dangerous drugs may be destroyed provided the following conditions are met. (A) A written agreement exists between the facility and the consultant pharmacist. (B) The drugs are inventoried, and such inventory is verified by the consultant pharmacist. The following information shall be included on this inventory: (i) name and address of the facility or institution. (ii) name and pharmacist license number of the consultant pharmacist. (iii) date of drug destruction. (iv) date the prescription was dispensed; (v) unique identification number assigned to the prescription by the pharmacy; (vi) name of dispensing pharmacy; (vii) name, strength, and quantity of drug; (viii) signature of consultant pharmacist destroying drugs; (ix) signature of the witness(es); and (x) method of destruction. C) The signature of the consultant pharmacist and witness(es) to the destruction and the method of destruction specified in subparagraph (B) of this paragraph may be on a cover sheet attached to the inventory and not on each individual inventory sheet, provided the cover sheet contains a statement indicating the number of inventory pages that are attached and each of the attached pages are initialed by the consultant pharmacist and witness(es). v) any two individuals working in the following capacities at the facility: (I) facility administrator; (II) director of nursing; (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675900 If continuation sheet Page 2 of 8 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 675900 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River Pointe of Trinity Healthcare and Rehabilitat 808 S Robb Trinity, TX 75862 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)

F 0755 (III) acting director of nursing; or Level of Harm - Minimal harm or potential for actual harm (IV) licensed nurse. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675900 If continuation sheet Page 3 of 8 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 675900 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River Pointe of Trinity Healthcare and Rehabilitat 808 S Robb Trinity, TX 75862 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)

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and distributed under sanitary conditions in 1of 1 kitchen reviewed for kitchen sanitation. Residents Affected - Some The facility failed to ensure food items in the beverage center and dry storage room were labeled and stored in accordance with the professional standards for food service. These failures could place residents at risk for food-borne illness and cross contamination. Findings Included: During an observation of the dry storage area and interview with the DM on 01/23/23 at 10:30 a.m. a zip lock bag with tortilla chips with no open date and a Zip lock bag of animal crackers with no open date were on the shelf. The dietary manager said those should be dated when they were opened but they did not have a date on the bag. During an observation of the beverage center and interview with the DM on 01/23/23 at 2:30 p.m., three boxed containers of concentrated juice (apple, orange, and cranberry) with no open date were spiked connected to the automatic drink dispenser. Interview with dietary manager, hire date 2/9/22, stated she was not aware of the date of expiration for the juices once opened but she would call the regional consultant and find out. She said she was not aware she should date the juices when they were opened, because they were changed out frequently. She said if the juices were used beyond the expiration date it could possibly cause a food borne illness. During an interview on 01/23/23 at 5:00 p.m. the administrator said she expected the dietary staff to label all items when opened in the kitchen as required by policy and using items past the expiration date or recommended use date could result in food borne illness. During an interview on 01/24/23 on 12:00 p.m. the DM said the concentrated juice boxes were good for 6 months once opened (DM had confirmed with the manufacturer). The DM said she and her staff members had received training to date all perishable items when opened. The DM said she had completed training on dating items when opened with her staff members on 1/24/23. She said she had failed to date the three juice boxes that were attached to the dispenser. She said she had removed the three juice boxes and had discarded them, then replaced with new juices and dated the boxes on 1/24/23. Review of the facility's Policy and Procedure dated 11/20222: Dietary Services Policy *: . number 2 D meals and food. Procedure: . 7. Food is obtained from our contracted vendor. All laws relating to food and food labeling are upheld by the contracted vendor. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675900 If continuation sheet Page 4 of 8 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 675900 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River Pointe of Trinity Healthcare and Rehabilitat 808 S Robb Trinity, TX 75862 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)

F 0812 8. Food purchased, stored, and served in this facility is labeled and dated according to all food service regulations. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675900 If continuation sheet Page 5 of 8 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 675900 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River Pointe of Trinity Healthcare and Rehabilitat 808 S Robb Trinity, TX 75862 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)

F 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to maintain and ensure safe and sanitary storage of resident's food items for 2 of 7 resident personal refrigerators reviewed for food safety (Residents #29 and #260). Residents Affected - Few The refrigerator for Resident #29 had a container of cottage cheese and a jar of nut n butter with orange chunks inside that was expired on 6/4/2021. The refrigerator for Resident #260 had 2 small cups of Jell-O that was expired on 11/13/2022 and 12/302022. These failures could place the residents at risk for food borne illnesses. The findings included: During an observation and interview on 1/23/2023 at 10:56 AM, Resident #29 said she had been at the facility for 3 years. Her personal refrigerator had a container of cottage cheese with an expiration date of 11/7/2022 and a jar of nut n butter with orange chunks inside dated 6/4/21. She said the oranges were placed in the jar and were frozen. When asked if staff checked her refrigerator she said they checked it every morning and would remove expired food items when needed. During an observation of Resident #260's personal refrigerator there was 1 small cup of sugar free Jell-O with an expiration date of 12/30/2022 and 1 small cup of sugar free Jell-O with an expiration date of 11/13/2022. During an interview on 1/25/2023 at 9:28 AM, the HSK said she worked halls 100 and 300. She said she would talk to Resident #29, and she was very particular about her food items and Resident #29 would not let her know if foods were expired and if it was ok with her to throw foods away. The HSK said she was not sure how often they were supposed to check the personal refrigerators for expired foods. She said daily the housekeeping staff would look inside of them to see if they were dirty or if anything had spilled. She said Saturdays and Sundays the housekeeping staff would look at the temperatures inside the fridges and wrote it down on the logs. She said if a resident ate something that was out of date, it could make them sick. She said with Resident #260's refrigerator she would not have to go through everything with her and could throw away foods that were out of date. She said she was not aware that Resident #260 had expired food items in her refrigerator. During an interview on 1/25/2023 at 11:15 AM, the HSK supervisor said housekeeping staff and all of management were responsible for checking the personal refrigerators daily. She said management were to check the personal refrigerators and notify housekeeping if food items needed to be removed. She said management conducted angel rounds daily and were assigned rooms on each hall. She said she was not aware that Resident #260 or Resident #29 had expired foods in their personal refrigerators. During an interview on 1/25/2023 at 11:20 AM, MDS nurse said she had been employed at the facility since November 2022. She said management were assigned rooms that they were responsible for during angel rounds. She said angel rounds was how management staff would check on each of the assigned residents for satisfaction along with checking their personal refrigerators. She said she was assigned to Resident #260 and Resident #29's room but Resident #29 would not allow her to check her personal refrigerator. She said management checked the refrigerators for any food allergies that someone may (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675900 If continuation sheet Page 6 of 8 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 675900 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River Pointe of Trinity Healthcare and Rehabilitat 808 S Robb Trinity, TX 75862 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)

F 0813 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few have brought to the resident, temperatures inside the refrigerators along with expired foods. She said the rounds were to be done daily but on Monday 1/23/2023 she did not get a chance to check their room because state entered the facility. She said if a resident ate foods that were expired and had grown bacteria it could make them sick. During an interview on 1/25/2023 at 1:25 PM, the Administrator said the housekeeping supervisor was responsible for the personal refrigerators and going forward she was going to start providing oversight during the angel rounds to ensure staff were noticing things that may be wrong in each room. Record review of a care plan for Resident #29 dated 7/15/2022 did not include her refusal to allow access to her personal refrigerator or disposing of expired foods. A facility policy titled Resident/Personal Food Storage with a revised date of 11/2022 indicated, .Food or beverage brought in from outside sources for storage in facility pantries, refrigeration units, or personal/resident room refrigeration units will be monitored by designated facility staff for food safety . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675900 If continuation sheet Page 7 of 8 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 675900 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River Pointe of Trinity Healthcare and Rehabilitat 808 S Robb Trinity, TX 75862 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)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based 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 in 1 of 15 resident rooms reviewed for infection control. (Resident #260's room) Residents Affected - Few CNA A left a dirty brief on Resident #260's over bed table. This failure could place residents at risk of exposure to communicable diseases and infections. Findings included: During an observation on 1/23/2023 at 10:56 AM in Resident # 260's room a dirty blue brief was wrapped up sitting on the over bed table with a suction machine and a water pitcher on top of the over bed table on Resident #260's side. During an observation on 1/23/2023 at 11:39 AM in Resident #260's Room the dirty brief was still sitting on the over bed table. During an observation on 1/23/2023 at 12:10 PM in Resident #260's Room the dirty brief was still sitting on the over bed table. During an observation on 1/23/2023 at 12:45 PM in Resident #260's room the dirty brief was still sitting on the over bed table. During an observation and interview on 1/23/2023 at 12:50 PM, CNA A who was an agency CNA said she had been in Resident #260's room earlier that morning around 8:30 AM assisting Resident #260 and another CNA. She said she was changed by the other CNA but did not know her name and Resident #260 was getting changed before she was taken to the shower room. CNA A pointed to the dirty brief on the table and said it should not be there. She put on gloves and removed the brief from the room and placed in in the trash. She said the staff should be mindful and pick up everything before they leave the room. She said she did not know that the dirty brief was left on the table, and it should not have been placed there. During an interview on 1/24/2023 at 10:41 AM, DON said they notified her about the dirty brief that was left on Resident #260's over bed table yesterday and said she did an in-service with all staff yesterday on placing dirty briefs in the trash when incontinent care was completed. She said there was a risk of infection associated with leaving dirty briefs or items on the over bed tables in the rooms. A facility policy titled Perineal Care with a revised date of October 2010 indicated, .The purpose of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. 10. Discard disposable items into designated containers. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675900 If continuation sheet Page 8 of 8