Health inspection·July 29, 2025

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few eval.Record review of a signed witness statement, dated 6/21/2025, by CNA A, indicated, it was time to get [Resident #2] up and we went to her room, and I checked her and placed the Hoyer pad underneath her. I then brought the Hoyer over her and hooked her onto it and then lifted her up. Once I was done lifting her up, I moved the Hoyer and Resident #2 fell. We checked on her.Record review of a signed witness statement, dated 6/21/2025, by Hospitality aide B, indicated, we went to get Resident #2 up when she got her up, I got up and went to help move her and she fell out the pad.Record review of a counseling/disciplinary notice for CNA A, dated 6/21/2025, indicated her date of hire was 11/25/2024 and the notice was a suspension for incorrect use of Hoyer lift causing injury and did not use spotter during transfer. Corrective action was suspension pending investigation. Sent home by LVN O. Signed by CNA A and the DON.Record review of a counseling/disciplinary notice for CNA A, dated 6/25/2025, indicated a discharge with last day worked 6/21/2025. Corrective action was termination. Signed by CNA A and the DON.Record review of a counseling/disciplinary notice for Hospitality aide B, dated 6/21/2025, indicated her date of hire was 2/6/2025 and the notice was a suspension for improper use of Hoyer lift, on the phone at time of incident. Corrective action was in-service and suspension. Signed by Hospitality aide B and the DON.Record review of a counseling/disciplinary notice for Hospitality aide B, dated 6/25/2025, indicated a discharge with last day worked 6/21/2025. Corrective action was termination. Signed by the DON. Hospitality aide B was contacted by phone because she did not have a babysitter.Record review of an x-ray report for Resident #2, dated 6/29/2025, indicated an x-ray of her right hip reflected: bones were osteoporotic with an acute femoral neck fracture.During an observation of video evidence in the room of Resident #2, dated 6/21/2025, from 11:58 AM to 12:00 PM, revealed: 1 staff (Hospitality aide B) was sitting in a recliner talking on a cell phone not looking in the direction of the other staff (CNA A) who was at the bed of Resident #2 with a mechanical lift. CNA A attached the four straps to the lift and one of the straps came off. She proceeded to lift Resident #2 out of her bed without any assistance from Hospitality aide B. When CNA A moved the lift away from the bed, Resident #2 fell out of the lift to the floor. Hospitality aide B immediately stood up and walked toward the lift and looked at the sling that was only attached by three straps and she was still talking on the phone and was heard saying let me call you right back. CNA A said she was going to get the nurse. Hospitality aide B looked at Resident #2 on the floor and then went back to the recliner to get a cell phone and she placed it in her pocket; then went back to the lift and looked at the sling that was attached. Hospitality aide B then bent down and could be heard talking to Resident #2 but was not able to hear what was being said. During an observation on 7/28/2025 at 9:55 AM, revealed Resident #2 was in bed resting with her eyes closed with her bed in the lowest position and a fall mat was on the floor by her bed. She was lying on an air mattress with a scoop mattress and her call light was in reach. There was a sign on the wall above the head of bed which read 2 person assist, no twisting or bending of right hip/leg, log roll only. Camera in room on wall pointed at bed. Recliner in the room.During an interview on 7/28/2025 at 9:05 AM, the Administrator and DON were both present. Both said the incident on 6/21/2025 with Resident #2 involved 2 staff members, 1 was in a chair (Hospitality aide B) who was noncertified, and the other staff (CNA A) transferred Resident #2 by herself and the resident fell out of the mechanical lift because one of the straps came off before she lifted her. Both said the two staff were immediately suspended and after watching video evidence that was provided by family, the two staff were terminated. Both said they did 100% in-service with staff on lift transfers and in-service on abuse/neglect. The DON said she was conducting spot checks on use of the mechanical lifts weekly with random audits. The DON said the staff had check offs on lifts with return demonstration and the DOR helped with the training. (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 07/29/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few The Administrator said they discussed the incident and had a QA meeting and continued to have weekly IDT meetings and the incident was discussed weekly. The Administrator said Resident #2 was not sent out to the hospital after the fall because her family did not want to send her out. The Administrator said Resident #2 was alert and at her baseline following the fall without any change, but she did sustain a bump to the back of her head. The Administrator said she talked with the family along with hospice and they were informed of the risks and the family declined to have Resident #2 sent out to the ER. The DON said about 5 days after the incident, Resident #2 started having some swelling to her right leg and they had mobile x-ray come out as the family did not want to send her to the hospital and it revealed a displaced fracture to her right femur. The DON said the family was adamant they wanted the two staff involved to lose their certifications. The Administrator said they talked to the family and informed them the resident would have to stay in bed until her fracture healed and they agreed.During an interview on 7/28/2025 at 11:51 AM, the DOR said she had been employed at the facility for 3 years. She said the incident with Resident #2, she went to the facility and took staff and a Hoyer lift to the therapy room and showed them how to properly transfer a resident and did check offs for all staff. She said it took about a week to get everyone trained and she did not train kitchen, housekeeping, or laundry staff, but did discuss with them if they were needed to assist to place a hand over the resident and not operating the lift. She said she had the staff do return demonstrations with the mechanical lift. She said two people should always operate the Hoyer lift and expressed to staff to always have hands on the resident. She said the nursing staff were continuing to provide oversight and checked staff daily to ensure they used the lift appropriately. She said she stressed to the staff that both staff must be hands on during the procedure. She said if staff did not use the lift appropriately it could result in serious injury to a resident.During a phone interview on 7/28/2025 at 3:04 PM, CNA A said she worked at the facility from December 2024 until 06/21/2025. She said she worked with Resident #2 on the day she fell from the Hoyer lift. She said Resident #2 was a two person assist and she checked the resident that day and she was wet. She said she placed the lift sling underneath Resident #2 and was doing it by herself. She said the other staff in the room was sitting down (Hospitality aide B) talking on a phone. She said she placed the sling underneath Resident #2 and hooked the straps, and she guessed one of the straps was not placed on it right. She said when she raised the lift, once she moved away from the bed, Resident #2 fell to the floor. She said the lift sling disconnected from one side, and Resident #2 was on the floor lying on her back. She said she went down and checked on her along with Hospitality aide B and made sure Resident #2 was okay, and then she left the room to get the nurse. She said she told LVN O the resident had fallen out of the Hoyer, and he went into the room with her. She said when they entered the room, Hospitality aide B had her hand on the back of the resident's head because she was bleeding. She said LVN O looked at Resident #2 and the other nurse on shift took her and Hospitality aide B's statements and told them to write it down. She said she was trained on how to use a Hoyer prior to that incident. She was taught two people were to use the lift and she just went ahead and did it without Hospitality aide B. She said Hospitality aide B was a student who was about to take her test to become certified. She said most of the time Hospitality aide B would help her but was not sure why she did not on that day. She said the DOR instructed her on how to use the Hoyer lift with return demonstration that day after the incident. She said after LVN O assessed Resident #2 they got her up and placed her wheelchair. She said Resident #2 did not go out of the facility to the ER. She said a nurse told her later that day, she had to leave the facility. She said she had a meeting with the facility about a week later and was told she was terminated because they (her and the Hospitality aide B) did (continued on next page) 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 07/29/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few not use the Hoyer lift correctly. She said death or injuries could happen if staff did not use two people during transfers with a Hoyer. She said the resident's head was bleeding. She said she had not used the Hoyer lift by herself before the incident and was trained on how to properly use it. During a phone interview on 7/28/2025 at 3:29 PM, Hospitality aide B said she worked at the facility from February 2025 to June 2025 and worked PRN. She said the facility let her go because a resident (Resident #2) fell out of a Hoyer lift. She said she was in the room of Resident #2 on the day she fell and was sitting in a chair because that was not her assigned hall that day. She said CNA A asked her to help with a Hoyer transfer with Resident #2. She said she was trained to not to use the Hoyer by yourself and there were supposed to be two people in the room but was not told about two people always helping when she started work at the facility. She said that was the reason she was in the room and only sat in the chair that day. She said at the time CNA A was putting the lift sling on Resident #2, she was checking her phone. She said she normally would not help the staff and was just there to make sure the residents did not fall. She said she always made sure the other staff had the lift on right but was distracted that day and was exhausted and had a message from her babysitter. She said CNA A lifted Resident #2 and the resident fell, hit the back of her head. She said she stayed in the room with the resident while CNA A went and notified the nurse. She said LVN O, and another nurse came in the room. She said the incident happened around lunch time and the nurses looked at the resident. She said she and CNA A left out of the room and passed lunch trays to the other residents. She said the nurses picked the resident up and her family member came a little while later. She said after they finished passing the trays on the hall, someone came and relieved both of their duties. She said they had to write witness statements and was sent home suspended. She said about a week later she heard from the facility that she was terminated. She said she had a Hoyer skills check off on hire and was told two people had to always be in the room. She said she would not ever do a transfer with a Hoyer by herself and would have someone else in the room. She said if it was her family, she would have been upset. She said she felt bad about the incident and was shaken up.During an interview on 7/29/2025 at 9:48 AM, LVN O said he worked at the facility since February 2017 on the 6 am-6 pm shift. He said he was working on the day with Resident #2 on and a staff member told him they had dropped Resident #2 on the floor. He said he went to the room of Resident #2 who was lying on the ground, the Hoyer lift was raised high, and the resident had some bleeding to the back of her head. He said CNA A and Hospitality aide B were in the room and told him the strap came off the lift when they got Resident #2 up. He said he checked Resident #2's vital signs and did neuro checks and she did not seem to be in pain. He said the resident was contracted but did not have any swelling in her extremities. He tried to get her head to stop bleeding and assisted her up in a wheelchair. He said she was awake the entire time and never seemed like she was in pain. He said he notified the DON, Administrator, and the resident's family member. The two staff involved were in-serviced on the use of Hoyer lifts. He said the family member came and told him Hospitality aide B was sitting in a chair when she looked at the video footage, and he wrote her up and sent her home. He said the DON arrived at the facility and reviewed the video and CNA A was sent home also. He said the DOR came into the facility and all staff had to do an in-service on Hoyer lifts with return demonstration. He said two people were required for hands on assisting with the lift to prevent injury. During an interview on 7/29/2025 at 10:23 AM, LVN P said she had been employed at the facility for about 8-9 months and worked the 6 am-6 pm shift. She said she was working on the day Resident #2 fell from a Hoyer lift. She said one of the staff involved came and told her Resident #2 had fallen out of the sling and hit the floor. She said she went in the room and examined Resident #2's head because it was bleeding. (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 07/29/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few She said the staff told her Resident #2 fell out of the lift and found out later one staff was not helping with the transfer (Hospitality aide B). She said following the incident she had both staff involved write witness statements. She said an educational in-service was provided by the DON about Hoyer lifts. She said two people were required to use the lift and staff were not to be on their phones in resident rooms or care areas. During an observation and interview on 7/29/2025 at 1:33 PM, in the room of Resident #2 was the RP. The RP said Resident #2 was on hospice services and they declined to send her out to the hospital immediately after the fall on 6/21/2025. She said they had a camera in the room and when they were contacted about Resident #2 falling, she immediately looked at video footage to see what happened. She said they contacted the Administrator and sent them the video so they could see exactly what happened. She said about 5-7 days later a family member was visiting and noticed her right leg and hip was swollen and the facility ordered a mobile x-ray, and she had a fractured right hip. The RP voiced they were upset at the staff involved in the incident and hoped something would happen to them so they could not work in a place with the elderly anymore. During an interview on 7/29/2025 at 2:03 PM, the DON said she was notified by LVN O about Resident #2 falling while being transferred in a lift by CNA A and Hospitality aide B. She said she interviewed both staff involved, and both were suspended pending investigation. She said after she observed the video both staff were terminated. She said both staff had skills check offs prior to the incident on Hoyer lift transfers. She said both staff were supposed to provide hands on assist with lift transfers. She said the incident was preventable with Resident #2. She said she expected for Hoyer lift transfers to have two people assisting, one person operating and the other person always guiding with hands on the resident. She said when a check off was done correctly when using a lift, she expected the staff to perform it correctly every time. During an interview on 7/29/2025 at 3:04 PM, the Administrator said she expected her staff to follow policy and procedures when using a mechanical lift with two people assisting. She said after the incident with Resident #2 they have continued to do random checks on staff to ensure they are operating the lifts correctly. She said if staff did not use the lifts correctly it could result in major injuries to the residents. Record review of a Hoyer lift transfer competency skills checklist, dated 1/2/2025, for CNA A indicated she met the requirements.Record review of a Hoyer lift transfer competency skills checklist, dated 4/24/2025, for Hospitality aide B indicated she met the requirements.On 7/28/2025-7/29/2025, the surveyor confirmed the facility implemented appropriate measures: Observation of staff (CNA C and CNA E) with a mechanical lift transfer of Resident #3 on 7/28/2025 at 10:02 AM indicated no concerns with transfer using a mechanical lift.Observation of staff (CNA C and CNA D) with a mechanical lift transfer of Resident #4 on 7/28/2025 at 11:22 AM indicated no concerns with transfer using a mechanical lift.During interviews on 7/28/2025 at 10:19 AM to 7/29/2025 until 3:04 PM, CNA C (day shift), CNA D (day shift), DON, Staffing Coordinator, SW, CNA E (day shift), DOR, MA F (day shift), CNA G (day shift), LVN H (day shift), LVN K (day shift), CNA L (day shift), CNA M (night shift), LVN N (night shift), LVN O (day shift), LVN P (day shift), CNA Q (day shift), ADON, Treatment Nurse, CNA R (day shift), Maintenance Supervisor and CNA S (day shift): were all able to verbalize the proper procedure and technique when operating a mechanical lift, what to check and inspect before using (lift and lift sling), verbalized the transfer required 2 people who were to provide hands on assistance, all verbalized having in-service training on abuse/neglect, no cell phone use in resident rooms or care areas, all had return demonstrations on proper technique when using the mechanical lift. The scheduled shifts were for 12 hours and they either worked 6 am-6 pm or 6 pm- 6 am.Record review of a QA meeting held on 7/15/2025 with IDT team members reflected the Medical Director was in attendance.Record review of a counseling/disciplinary (continued on next page) 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 07/29/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete notice for CNA A, dated 6/25/2025, indicated a discharge date with the last day worked 6/21/2025. Corrective action was termination. Signed by CNA A and the DON.Record review of a counseling/disciplinary notice for Hospitality aide B, dated 6/25/2025, indicated a discharge date with the last day worked 6/21/2025. Corrective action was termination. Signed by the DON. Hospitality aide B was contacted by phone because she did not have a babysitter.Record review of a facility inservice on patient lift safety guide was conducted on 6/21/2025 to 34 staff that instructed them on proper procedure and technique when operating a mechanical lift.Record review of a facility inservice on mechanical lift timeout was conducted on 6/21/2025 to 30 staff that instructed them to make sure the lift was properly secured before lifting a resident.Record review of a facility inservice on abuse/neglect, fall trauma, and cell phone usage during working hours in resident rooms and care areas was instructed to 32 staff.Record review of a facility in-service on proper use of a Hoyer lift was conducted on 6/21/2025 to CNA A and Hospitality B that instructed them on proper procedure of using a mechanical lift.Record review of quizzes provided by the facility to 45 staff that tested their knowledge on how many people were required for a Hoyer lift transfer, not to use torn or frayed slings and how many hooks to use. No concerns were noted.Record review of knowledge checks on mechanical lift proficiencies were provided to 32 staff with no concerns noted.Record review a facility inservice on 6/21/2025 to 43 staff by the DOR instructed them on Hoyer transfers with return demonstration. No concerns were noted.Record review of a QIT was held on 6/21/2025 for mechanical lift transfers and identified an issue with Resident #2 and staff using a mechanical lift. Record review of the facility's policy titled Mechanical Lift, dated 10/2022, indicated, .To help ensure the physical safety of our employees and our residents. 5. Ensure the sling is applied correctly, securely. 11. Always use a minimum of two healthcare personnel during patient transfers with a mechanical lift, with one operating the lift and one assisting.The noncompliance was identified as PNC. The IJ began on 6/21/2025 and ended on 6/30/2025. The facility had corrected the noncompliance before the survey began. 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 07/29/2025 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.Findings include: Record review of an admission Record for Resident #4, dated 7/28/2025, indicated a [AGE] year-old male who was admitted to the facility on [DATE]. Record review of active physician orders for Resident #4, dated 7/28/2025, indicated he had diagnoses which included pneumonia (lung infection), emphysema (chronic lung disease that leads to shortness of breath and difficulty breathing) and Huntington's Disease (an inherited condition that causes the nerve cells in the brain to die). He had an order for enhanced barrier precautions and PPE was required for high resident contact care activities, wounds every shift that started on 5/29/2025.Record review of a Quarterly MDS Assessment for Resident #4, dated 6/4/2025, indicated he was rarely/never understood and had a BIMS score was not calculated. He was dependent on staff for all ADL's. He was always incontinent of bowel and bladder. He had one or more unhealed pressure ulcers.Record review of a care plan for Resident #4, dated 5/22/2025, indicated he had a pressure ulcer related to adult failure to thrive (weight loss from poor nutrition) and impaired mobility. Interventions included to use enhanced barrier precautions.During an observation on 7/28/2025 at 11:22 AM, revealed Resident #4's door had PPE hanging on the door which consisted of gowns and gloves on the wall in the room. Resident #4 was sitting in a wheelchair and CNA C and CNA D were in the room to transfer him using a mechanical lift. Both staff sanitized their hands and donned (put on) gloves. Resident #4 was transferred from his wheelchair to his bed by CNA C and CNA D using a mechanical lift. CNA C removed her gloves, placed them in the trash, washed her hands in the bathroom and exited the room. CNA D remained in the room and performed incontinent care and did not perform hand hygiene or change her gloves. CNA D opened Resident #4's brief and used wipes to clean his penis and placed the wipes in the trash. CNA D rolled Resident #4 onto his right side, removed the brief, placed it in the trash and she cleaned Resident #4's rectal area with wipes and placed them in the trash. CNA D placed a clean brief underneath Resident #4's buttocks and rolled him onto his back and secured it. CNA D removed her gloves and placed them in the trash and washed her hands in the bathroom. During an interview on 7/28/2205 at 1:51 PM, CNA D said she had been at the facility since around the middle of June 2025 and worked 12-hour shifts from 6 am to 6 pm. She said she rotated halls when she worked and did not have an assigned hall. She said the PPE on the door for Resident #4 was to be worn when wound care was provided only. She said she was not assigned to the hall with Resident #4 all the time. She said she did not change her gloves when she changed him and was not sure why she did not and should have changed her gloves after the transfer and when she changed from removing dirty items to clean items. She said she sanitized her hands before care was started but she did not touch anything else. She said she would normally have extra gloves with her because the door was locked to get gloves from the supply closet. She said residents could be at risk for infections and bacteria from not changing gloves. She said she received training on infection control and enhanced barrier precautions. During an interview on 7/29/2025 at 10:57 AM, CNA C said on 7/28/2025, when she assisted with Residents Affected - Few (continued on next page) 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 07/29/2025 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete putting Resident #4 in bed, she should have put on a gown. She said the resident had a wound and was on EBP. She said she forgot and was not thinking she needed to put on a gown. She said the resident's door had PPE present for the staff which included gowns and gloves. She said she had training on EBP a while ago. She said residents could be at risk for infections if they did not follow proper procedures when residents were on EBP.During an interview on 7/29/2025 at 11:31 AM, the Staffing Coordinator said she was responsible for skills check offs with nurse aides and did a round with them during orientation and checked them annually and as needed. She said all staff were trained on EBP a while ago by the previous ADON, but new hires and all staff were trained on EBP. She said Resident #4 was on EBP and if direct patient care was provided to him then the staff needed to wear a gown and gloves while care was performed. She said he had a wound and was on EBP. She said hand hygiene should be performed before care, after going from dirty to clean, at the end of care and gloves should be changed and not worn during the entire procedure. She said residents were at risk for infections if staff did not perform hand hygiene, change gloves, or wear appropriate PPE for residents on EBP which included a gown and gloves.During an interview on 7/29/2025 at 2:03 PM, the DON said when staff had their competency evaluations for skills, and it was done correctly at that time she expected the staff to correctly perform every time. She said she was the IP for the facility and staff were trained on handwashing monthly. She said incontinent care was done on an annual basis along with random checks. She said Resident #4 was on EBP for a wound and staff should wear a gown and gloves when patient care was provided. She said hand hygiene should be performed before and after care, when changing from dirty to clean and gloves should be changed before starting incontinent care or changing tasks. She said residents could be at risk for infections if staff did not follow infection control procedures. During an interview on 7/29/2025 at 3:04 PM, the Administrator said the DON was the IP for the facility and was responsible for ensuring all staff followed infection control practices. She said at least three times a year the staff were trained on infection control, and it was an ongoing training. She said residents could be at risk for infections if staff did not follow infection control measures which included hand hygiene and wearing the appropriate PPE.Record review of a training certificate for CNA D, dated 6/20/2025, indicated she was trained on infection control and enhanced barrier precautions. Record review of a training certificate for CNA C, dated 3/25/2025, indicated she was trained on enhanced barrier precautions.Record review of the facility's policy titled Infection Control, revised 4/2025, indicated, .It is the policy of this facility to implement infection control measures to prevent the spread of communicable diseases and conditions. 3. Enhanced Barrier Precaution (EBP): used in conjunction with standard precautions and expand the use of PPE through the use of gown and gloves during high-contact resident care activities. A. PPE: the use of gown and gloves for high-contact resident care activities. C. Examples of high-contact resident care activities requiring gown and gloves include: iii. Transferring, iv. Providing hygiene. Record review of the facility's policy titled Hand Hygiene, revised 10/2022, indicated, .It is the policy of this facility to provide the necessary supplies, education, and oversight to ensure healthcare workers perform hand hygiene based on accepted standards. 2. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap and water for the following situations: h. before moving from a contaminated body site to a clean body site during resident care; l. after contact with objects (e.g., medical equipment) in the immediate vicinity of the resident. Event ID: Facility ID: 675900 If continuation sheet Page 8 of 8