Health inspection·July 27, 2025

F 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. 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 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.Findings include:1. Record review of a facility face sheet dated 7/30/2025 for Resident #2 indicated that she was a [AGE] year-old female admitted to the facility on [DATE] with hemiplegia and Hemiparesis (muscle weakness or partial paralysis on one side of the body) following non traumatic intracerebral, schizophrenia-bipolar type and major Depressive Disorder.Record review of a quarterly MDS assessment dated [DATE] indicated Resident #2 had a BIMS score of 14, which indicated that she was cognitively intact. She required extensive assistance with ADLs. She was frequently incontinent of bowel and bladder. Record review of a comprehensive care plan for Resident #2 dated 02/27/2025 indicated that he had an ADL self-care performance deficit, and she had the following intervention: . resident requires extensive assist x 1 staff and resident requires extensive assistance by 2 staff for toileting, Encourage the resident to use bell to call for assistance 2. Record review of a facility face sheet dated 7/22/2025 for Resident #1 indicated that he was a [AGE] year-old male admitted to the facility on [DATE] with a urinary tract infection, lack of coordination and metabolic encephalopathy.Record review of a quarterly MDS assessment dated [DATE] indicated Resident #1 had a BIMS score of 14, which indicated that he was cognitively intact. He required partial to moderate assistance with most ADLs. He was frequently incontinent of bowel and bladder. Record review of a comprehensive care plan for Resident #1 dated 6/11/24 indicated that he had an ADL self-care performance deficit, and he had the following intervention: . The resident requires extensive assistance by 1 staff to move between surfaces, Encourage the resident to use bell to call for assistance 3. Record review of a facility face sheet dated 7/27/2025 for Resident #3 indicated that he was an [AGE] year-old male admitted to the facility on [DATE] with acute kidney failure (condition where your kidneys stop working suddenly).Record review of a quarterly MDS assessment dated [DATE] indicated Resident #3 had a BIMS score of 12, which indicated he was moderately cognitively intact. He required partial to moderate assistance with most ADL's. She was always incontinent of bowel and bladder. Record review of a comprehensive care plan for Resident #3 dated 2/17/2025 indicated that he had an ADL self-care performance deficit, and he had the following intervention: .encourage the resident to use bell to call for assistance .4. Record review of a facility face sheet dated 7/30/2025 for Resident #4 indicated that he was a [AGE] year-old female admitted to Residents Affected - Some Page 1 of 6 676439 676439 07/27/2025 Trinity Rehabilitation & Healthcare Center 314 E Caroline St Trinity, TX 75862

F 0919 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the facility on [DATE] with essential hypertension, muscle weakness and lack of coordination.Record review of a quarterly MDS assessment dated [DATE] indicated Resident #4 had a BIMS score of 11, which indicated that she was moderately cognitively intact. She required partial to moderate assistance with most ADLs. She was always incontinent of bowel and bladder. Record review of a comprehensive care plan for Resident #4 dated 10/22//24 indicated that he had an ADL self-care performance deficit, and he had the following intervention: .encourage the resident to use bell to call for assistance .5. Record review of a facility face sheet dated 7/27/2025 for Resident #5 indicated that he was a [AGE] year-old male admitted to the facility on [DATE] with syncope and collapse and hypertensive heart disease with heart failure. Record review of a quarterly MDS assessment dated [DATE] indicated Resident #5 had a BIMS score of 12, which indicated that he was cognitively intact. He required partial to moderate assistance with most ADLs. He was occasionally incontinent of bowel and bladder. Record review of a comprehensive care plan for Resident #5 dated 07/01/2025indicated that he had an ADL self-care performance deficit, and he had the following intervention: .encourage the resident to use bell to call for assistance .6. Record review of a facility face sheet dated 7/30/2025 for Resident #6 indicated that she was an [AGE] year-old female admitted to the facility on [DATE] with muscle wasting and atrophy, and lack of coordination. Record review of a quarterly MDS assessment dated [DATE] indicated Resident #6 had a BIMS score of 15, which indicated that she was cognitively intact. She required partial to moderate assistance with most ADLs. She was occasionally incontinent of bowel and bladder. Record review of a comprehensive care plan for Resident #6 dated 2/13/2025 indicated that she had an ADL self-care performance deficit, and she had the following intervention: .encourage the resident to use bell to call for assistance .7. Record review of a facility face sheet dated 7/27/2025 for Resident #8 indicated that he was a [AGE] year-old male admitted to the facility on [DATE] with muscle wasting atrophy and chronic kidney disease.Record review of a quarterly MDS assessment dated [DATE] indicated Resident #8 had a BIMS score of 04, which indicated that he was cognitively impaired. He required extensive assistance with ADLs. He was always incontinent of bowel and bladder. Record review of a comprehensive care plan for Resident #8 dated 1/8/24 indicated that he had an ADL self-care performance deficit, and he had the following intervention: .encourage the resident to use bell to call for assistance .8. Record review of a facility face sheet dated 7/27/2025 for Resident #7 indicated that he was a [AGE] year-old male admitted to the facility on [DATE] with muscle wasting atrophy, muscle weakness and cognitive communication.Record review of a quarterly MDS assessment dated [DATE] indicated Resident #7 had a BIMS score of 15, which indicated that he was cognitively intact. He required partial to moderate assistance with most ADLs. He was occasionally incontinent of bowel and bladder. Record review of a comprehensive care plan for Resident #7 dated 6/7/2025 indicated that he had an ADL self-care performance deficit, and he had the following intervention: .encourage the resident to use bell to call for assistance .9. Record review of a facility face sheet dated 7/30/2025 for Resident #9 indicated that she was a [AGE] year-old female admitted to the facility on [DATE] with acute respiratory failure with hypoxia, morbid obesity and need for assistance with personal care.Record review of a quarterly MDS assessment dated [DATE] indicated Resident #9 had a BIMS score of 15, which indicated that she was cognitively intact. She required extensive assistance with most ADLs. She was always incontinent of bowel and bladder. Record review of a comprehensive care plan for Resident #9 dated 7/18/2025 indicated that she had an ADL self-care performance deficit, and she had the following intervention: .encourage the resident to use bell to call for assistance .During an observation and interview on 7/26/2025 at 9:50 a.m., the bedroom and bathroom emergency call light was activated by this surveyor in Resident #1's room. The audible alarm did not sound 676439 Page 2 of 6 676439 07/27/2025 Trinity Rehabilitation & Healthcare Center 314 E Caroline St Trinity, TX 75862

F 0919 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some at the Central monitoring station. The call light bulb was not functioning above the doorway of Resident #1's room. Resident #1 said he was fine without the light because he gets up on his own and takes care of himself. He said he did not need to call staff for help with a call light and just yells nurse, nurse and they come check on him. During an observation and interview on 7/26/2025 at 10:00 a.m., the bedroom and bathroom emergency call light was activated by this surveyor in Resident #6's room. The call light did not make a sound to alert staff. The light over the door lit up with no sound. Resident #6 said she does not have a working call light at this time and she's [AGE] years old. She said she needed her call light just in case she has a need to call for staff. She said the aides and nurses check on her often and they provided her a bell to ring today. She said she's a choker and they check on her every few minutes. She said she fears choking or needing staff and cannot call for help. During an interview on 7/26/2025 at 10:12 a.m., the DON said the call light system was struck by lightning about two weeks ago and their maintenance director reset and fixed the call light system twice, but they were struck by lightning again on 7/23/2025 causing the call light system to be even more damaged. She said after the second lightning strike the call light system went out and maintenance was not able to fix the problem. She said they moved the residents within an hour out of the rooms with no working call lights into a room on the same hall with working call lights. She said the second lightning strike caused the even number rooms on 200 hall not to work at all. She said a technician came out on 7/23/2025 and tried to fix the call lights and was not able to get the system to work and caused more damage. She said whatever he did caused all the lights on the 200 hall not to work at all and on the 300 hall it caused the system not to light up above residents doors, beep or relay the call to the nurses station. She said CNAs and/or nursing staff are making rounds every 15 minutes to assure all resident needs are met. She said no other form of communication was provided to the residents to call for assistance. She said she walks the halls herself and wants the call light system fixed as soon as possible due to increase stress and probability for accident and injury to the residents. During an interview and observation on 7/27/2025 at 10:20 a.m., Resident #9 said the call light system was struck by lightning and had been malfunctioning off and on for the past two weeks. She said they have tried to fix the problem but have not been successful. She said not all the call lights on her hall worked after the lightning strike and the residents without working call lights were moved to different rooms that had a working call light. She said a company was working on the call light recently and her whole hall is now without a call light. She said she had no way to call for help and today she was provided a small bell to ring if she need staff to come assist her. She said she can do for herself but if she ever needed staff, she would like to be able to contact them quickly. She said if she puts her call light on, they will know it is an emergency because she rarely calls for help. Call light in the bathroom and bedroom was activated by this surveyor in the by Resident #9 the call light did not light up or make a sound to alert staff. During an observation and interview on 7/26/2025 at 10:35 a.m., the bedroom and bathroom emergency call light was activated by this surveyor in the room occupied by Resident #7. The call light did not make a sound to alert staff. The light over the door did not light up and had no sound. Resident #7 said he does not have a working call light at this time and would like to have one. He said he needs his call light just in case he needs to call for help. Hhe said the aides and nurses check on him often and they provided him a bell to ring today. During an observation and interview on 7/26/2025 at 2:13 p.m., the bedroom and bathroom emergency call light was activated by this surveyor in the room occupied by Resident #3. The audible alarm did not sound at the Central monitoring station. The call light bulb was not functioning above the doorway of Resident #3. Resident #3 said he had been in the hospital 676439 Page 3 of 6 676439 07/27/2025 Trinity Rehabilitation & Healthcare Center 314 E Caroline St Trinity, TX 75862

F 0919 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some and just came back to the facility last Thursday. He said he was glad he has his RP in the next room that comes to his room and sits with and checks on him all throughout the day. He said if he needs help, she will go get the aides or if it's something small she can do it for him. He said he don't like not having the call lights working but he's sure they will get it fixed soon.During an interview on 7/26/2025 at 2:16 p.m., LVN A said she is familiar with the call lights being out for over a week due to lightening striking the phone and internet system. She said staff make rounds to each resident's room every 10 to 15 minutes to check on the residents. She said the maintenance supervisor tried to reset the system, and it worked for a couple of days and kept going out. She said nurses monitor to make sure the aides are making regular rounds, and the nurses will go down the hall about every 30 minutes to make sure the residents are well and have no unmet needs. She said no other method of intervention had been implemented to compensate for the broken call light system until today they got bells for the residents with no call lights. She said she feel her and the staff puts forth continual effort to assure the residents are well care for but having no call lights presents a greater chance for the residents to be injured or not have their needs met timely. During an observation and interview on 7/26/2025 at 2:42 p.m., the bedroom and bathroom emergency call light was activated by this surveyor in the room occupied by Resident #2. The audible alarm sounded at the Central monitoring station and the call light bulb was functioning above the doorway of Resident #2. She said she had an issue with the call light not working for a short period of time when lightning struck the facility. She said she do not like being without her call light. She said she's heavy and in a wheelchair and does need assistance with some of her activities. She said if she was without a call light for as long as her friends on the other halls, she would be a nervous wreck. She said she know things happen, but it is time to get this issue fixed. During an observation and interview on 7/26/2025 at 2:48 p.m., the bedroom and bathroom emergency call light was activated by this surveyor in the room occupied by Resident #4. The audible alarm did not sound at the Central monitoring station. The call light bulb was not functioning above the doorway of Resident #4. Resident #4 said she has been without her call light for about a week. She said she uses a wheelchair to move around and gets in and out of it on her own. She said if she feels or needed help, she will just have to wait until staff come check on her. She said staff make lots of checks on her and the other residents. She said she was provided a bell to ring for help this afternoon. She said she feels the facility could not help what happened to the call light but will be happy when they are repaired. During an interview on 7/26/2025 at 3:03 p.m., RN E said she and the other staff make frequent rounds down hall two and three hundred due to the call light system being out. She said it had not worked properly in approximately two weeks. She said the residents were given call bells today, but no other measures had been put in place for resident to alert staff if they need them for assistance. She said she knows having a working call system is a requirement and increase the risk of harm to the residents if it doesn't work properly.Record review on 7/26/2025 of the facility accident and incident reports. There were no noted accidents and incidents reported on halls 200 and 300 during 7/23/2024 through 7/27/2025. All accidents and incidents reported were prior to the call light system failure. Interview and observation on 7/27/2025 at 1:03 p.m., the bedroom and bathroom emergency call light were activated by this surveyor in Resident #8's room. The audible alarm did not sound at the Central monitoring station. The call light bulb was not functioning above the doorway of Resident #8. Resident #8 said he used the call light system often when it works. He said staff comes into his room more to check on him since the call light is not working. He said he was told its going to be fixed soon and he will be glad, so staff do not have to come in so often and disturb him. He said he was not sure how long the call 676439 Page 4 of 6 676439 07/27/2025 Trinity Rehabilitation & Healthcare Center 314 E Caroline St Trinity, TX 75862

F 0919 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some light has been out, but he knows it have been several days. He said the little bell dings low and he's not sure anyone will hear it if he rings it for help. Observation on 7/27/2025 with Resident #5 at 1:10 p.m., the bedroom and bathroom emergency call light were activated by this surveyor in the room occupied by Resident #5. The audible alarm did not sound at the Central monitoring station. The call light bulb was not functioning above the doorway of Resident #5. Resident #5 was cognitively unable to answer questions asked about the call light and said he does not remember anything about the call lights.During an interview on 7/27/2025 at 1:35 p.m., MA B said she knew of the call light system being down on 200 and 300 halls. She said she knew they started having an aide sit on the halls at all times today and they gave the residents bells on yesterday to ring for help. She said when the lightening first knocked the call lights out maintenance and the administrator thought it was fixed but it was not. She said it is very easy for a resident to have a need, and staff may not recognize it or hear the small bell. She said having no call lights puts residents at a higher risk for harm. Interview on 7/27/2025 at 1:47 p.m., LVN C said she worked PRN but knew the call light system had been out on the 200 and 300 hundred halls. She said staff makes more rounds than they normally do so they can check on the residents frequently to see if they need assistance. She said today is the first time she had seen aides sitting on the hall and bells in the resident's rooms. She said she knows the risk increased for accidents and incidents for the residents, but she had not seen an increase in accident or incidents since the call light system have been out. She said she did not work every day but works 3 to 4 days per week for the past month and the call light system had been out at least two weeks. Interview on 7/27/2025 at1:51 p.m., LVN D said she's aware of the call light system being down. She said the aides must make rounds every 15 minutes and the nurses will help them with rounds if they are busy. She said they are able to manage by teamwork with all staff. She said the administrator and maintenance worker have been working to get the system fixed and all the residents were given bells as of yesterday to ring for assistance.Interview on 7/27/2025 at 2:17 p.m., the DON said she's aware of the call light system being out on the 200 and 300 halls. She said she and the other staff work around the clock making every 15-minute rounds and an aide is sitting on the halls at all times starting today. She said as of yesterday they got bells for every resident without a working call light. She said maintenance had tried to fix the issue but with the second lightning strike she was not able to fix it. She said she and the administrator had in-serviced staff on the importance of frequent rounds and to physically look in every room to make sure the resident is well and does not need assistance. She said when the call lights went out the first time, they moved 2 residents within an hour to another room with working call lights. She said only the even number rooms on hall 200 were not working. She said after the 2nd lightning strike they had to get a technician out to work on the call lights and whatever he done knocked out both halls (200 & 300). She said there is an increased risk for injury or unsafe living environment for the residents due to the call light system not working. She said they have a contractor scheduled to fix the call light system next week. During an interview on 7/27/2025 at 2:25 PM, CNA-F said she sat about halfway down hall 200 to see and hear the residents. She said she and other staff will switch out sitting every hour. She said she and other staff make rounds every 15 minutes to assure all residents needs are met and care is provided. She said the residents were provided bells today to ring for help. She said the call light system has been going in and out for about 2 weeks. She said the nurses will also help them with monitoring the halls.During an interview on 7/272025 at 2:35 PM CNA-G said she is aware that the call light system is out. She said it was struck by lightning. She said they moved some residents from their original rooms due to the call light system not working properly. She said she makes rounds 676439 Page 5 of 6 676439 07/27/2025 Trinity Rehabilitation & Healthcare Center 314 E Caroline St Trinity, TX 75862

F 0919 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some every 15 minutes and an aide always sits mid-way down the hall (halls two and three hundred) so they can see and hear the residents. She said the nurses will also assist with monitoring the halls and checking on the residents. She said the residents were given bells to use when they need to alert staff when they need assistance. She said maintenance and the administrator have been working on the call light system trying to get it fixed but they have not successful at this time. She said the administrator told them that a company would be out on Monday to work on and fix the call light system. During multiple observations on 7/27/2025 from 10 a.m-3 p.m. staff were observed sitting at the nurses' station and one staff sitting mid-way down the hall with view of the 200/300 halls. The staff were making rounds every 10- 15 minutes. Residents on the 200/300 halls were observed having bells in their hands, on their beds or on their bedside tables. Interview on 7/27/2025 at 2:47 p.m., the Administrator said she's aware of the call light system being out. She said lightning struck the building and knocked out the call light system for the even numbered rooms on hall 200 and the internet on 7/12/25. She said maintenance worked on and reset the call lights and they began working within an hour of being notified the call light system was affected by the lightening. She said on 7/13/25 the same lights (even number rooms on the 200 hall) went out again. She said maintenance reset them again and they started back working. She said by the next day on 7/14/25 the same lights on the 200 hall (the even numbered rooms) call lights stopped working again. She said they immediately moved the two (Resident #9, #5) residents that were without call lights to another room with working call lights. She said she had maintenance call a technician that came out on 7/23/25. She said it was worse when he left than when he came. She said the entire call lights for the 200-hall stopped working and the audio portion of the 300-hall stopped working. She said she requested the DON to get with staff and implement nurses and or nurse aides to start making rounds every 15 minutes around the clock for the residents without call lights. When asked if she had tried to implement any other system for the residents to call for help and she said no. She said she looked for bells at local stores and they did not have any. She said she went out of town yesterday and bought bells for all the residents and passed them out and placed a nurse aide to sit on the halls at all times so they can hear as well as see activity down the halls. She said she knows there is an increased risk for a negative outcome such as falls and injury to residents that may need assistance. She said a technician is scheduled to come out on Monday 7/28/2025 to start the repairs on the call light system. She said the repairs are expected to be complete no later than 8/1/2025. Record review of a facility policy 2001 MED-PASS, Inc (Revised February 2020) titled Bathrooms stated . 3. The facility is equipped with call systems which enable residents who cannot use the toilet independently to call caregivers directly for assistance. Calls for assistance from residents are to be answered immediately and responded to as soon feasible.Record review of a facility policy 2001 MED-PASS, Inc (Revised February 2020) titled Bedrooms stated . Policy Statement: All residents are provided with clean, comfortable and safe bedrooms that meet federal and state requirements. Policy Interpretation and Implementation6.All resident rooms are equipped with a resident call system that allows residents to call for staff assistance. Calls are directed to either a staff member or to a centralized work area. 676439 Page 6 of 6