Health inspection·December 17, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.The findings included:Record review of an admission Record for Resident #1 dated 12/17/2025 indicated she was admitted to the facility on [DATE] and was [AGE] years old with diagnoses of UTI (infection in the urinary tract), type 2 diabetes, vascular dementia (decreased blood flow to areas of the brain), hypertension, and hemiplegia (paralyzed on one side of the body). Record review of active physician orders for Resident #1 dated 12/17/2025 indicated an order to change PICC/Midline dressing using sterile technique every 7 days and or prn when the dressing becomes wet or soiled that started on 11/27/2025.Record review of a care plan for Resident #1 dated 12/8/2025 indicated she was on antibiotic therapy related to a UTI and sacrum wound infection. Interventions included administering antibiotic medications as ordered by the physician. The care plan did not include Resident #1's PICC line, dressing changes, or interventions for the maintenance of the PICC line.Record review of a PPS/5 Day MDS Assessment for Resident #1 dated 12/1/2025 indicated she had moderate impairment in thinking with a BIMS score of 12. Special Treatments, Procedures, and Programs indicated during the 14 day look back period the resident received IV medications while a resident in the facility.During an observation and interview on 12/17/2025 at 9:50 AM, Resident #1 was in her room sitting in a wheelchair. She was alert to person and place with some confusion noted. She said she had been at the facility for a while but had been in and out of the hospital a lot. She had a PICC line to her right upper arm with the dressing dated 12/7/2025. She said she did not remember when the dressing was last changed but she was not getting antibiotics at this time. During an interview on 12/17/2025 at 2:29 PM, the MDS Coordinator said she was responsible for updating the care plans. She said during the morning meetings they discussed changes in resident care, and the care plans were updated as needed. She said Resident #1's care plan did have the IV medications she received but it did not have her PICC line. She said she did not know why the care plan did not have the PICC line with interventions. She said she would get the care plan updated. She said if care plans were not updated to reflect accurate information for the residents, residents might not get the care that was needed.During an interview on 12/17/2025 at 2:34 PM, the Director of Clinical Operations said the DON was out of the facility sick with the flu. She said care plans should be updated every 3 months or as needed when there was an acute change. She said a resident that had IV access should be included in their care plan. She said the MDS Coordinator was responsible for ensuring the care plans were updated. She said if the care plans were Page 1 of 4 676439 676439 12/17/2025 Trinity Rehabilitation & Healthcare Center 314 E Caroline St Trinity, TX 75862

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few not updated, there was a risk that everyone might not know what was going on with the residents. During an interview on 12/17/2025 at 2:43 PM, the Administrator said the MDS Coordinator was responsible for updating the care plans and should be updated as needed along with the quarterly assessments. She said PICC lines, and IV access should be included in the care plan. She said there could be a risk for the residents not to receive care. Record review of a facility policy titled Care Plans, Comprehensive Person-Centered revised December 2016 indicated, .A comprehensive, person-centered care plan that includes measurable objectives, and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 8. The comprehensive, person-centered care plan will: a. include measurable objectives and timeframes; c. describe services that would otherwise be provided for the above; 13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. 676439 Page 2 of 4 676439 12/17/2025 Trinity Rehabilitation & Healthcare Center 314 E Caroline St Trinity, TX 75862

F 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed. 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 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.Findings included:Record review of an admission Record for Resident #1 dated 12/17/2025 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of UTI (infection in the urinary tract), type 2 diabetes, vascular dementia (decreased blood flow to areas of the brain), hypertension, and hemiplegia (paralyzed on one side of the body). Record review of active physician orders for Resident #1 dated 12/17/2025 indicated an order to change PICC/Midline dressing using sterile technique every 7 days and or prn when the dressing becomes wet or soiled that started on 11/27/2025.Record review of a care plan for Resident #1 dated 12/8/2025 indicated she was on antibiotic therapy related to a UTI and sacrum wound infection. Interventions included administering antibiotic medications as ordered by the physician.Record review of a PPS/5 Day MDS Assessment for Resident #1 dated 12/1/2025 indicated he had moderate impairment in thinking with a BIMS score of 12. Special Treatments, Procedures, and Programs indicated during the 14 day look back period the resident received IV medications while a resident in the facility.During an observation and interview on 12/17/2025 at 9:50 AM, Resident #1 was in her room sitting in a wheelchair. She was alert to person and place with some confusion noted. She said she had been at the facility for a while but had been in and out of the hospital a lot. She had a PICC line to her right upper arm with the dressing dated 12/7/2025. She said she did not remember when the dressing was changed last but was not getting antibiotics at this time. During an interview on 12/17/2025 at 12:54 PM, LVN A said Resident #1's PICC line was supposed to be discontinued but they were waiting until her wound cultures results are back. She said an RN was the only staff that could perform a PICC line dressing change but was aware that the dressings were to be changed every 7 days. During an observation and interview on 12/17/2025 at 1:01 PM, LVN A went into the room of Resident #1 and looked at her PICC line dressing and said the dressing was dated 12/7/2025. She said the dressing should have been changed Sunday 12/14/2025. She said residents could be at risk for infections if the dressings were not changed in a timely manner and per physician orders.During an interview on 12/17/2025 at 1:10 PM, the ADON said an RN that worked in the facility would be the only staff allowed to change PICC line dressings. She said the PICC line dressings should be changed every 7 days. She said Resident #1 still had a PICC line. She said she was not aware that Resident #1 had not had a dressing change in 7 days from the last time it was changed. She said residents could be at risk of infections if the dressings were not changed every 7 days as ordered by the physician.During an interview on 12/17/2025 at 1:22 PM, the Director of Clinical Operations said the DON was out of the facility sick with the flu. She said PICC line dressings should be changed every 7 days. She said she was not aware that Resident #1 did not get a dressing change every 7 days as ordered. She said she would change the dressing that day (12/17/2025). She said the PICC line dressings were a sterile technique and only an RN could change the dressings. She said residents could be at risk of infections if they were not changed as ordered.During an interview on 12/17/2025 at 2:43 PM, the Administrator said an RN was the only staff in the facility that could change PICC line dressings, and they should be changed once a week. He said if the dressings were not changed per order, then a resident could be at risk for infections. He said he expected the Residents Affected - Few 676439 Page 3 of 4 676439 12/17/2025 Trinity Rehabilitation & Healthcare Center 314 E Caroline St Trinity, TX 75862

F 0694 Level of Harm - Minimal harm or potential for actual harm staff to change the dressings every 7 days as ordered and would educate the staff on dressing changes. Record review of a facility policy titled Central Venous Catheter Dressing Changes revised April 2016 indicated, .The purpose of this procedure is to prevent catheter-related infections that are associated with contaminated, loosened, soiled, or wet dressings. 5. Change transparent semi-permeable membrane (TSM) dressings at least every 5-7 days and prn (when wet, soiled, or not intact). Residents Affected - Few 676439 Page 4 of 4