TRINITY REHABILITATION & HEALTHCARE CENTER
314 E CAROLINE ST, TRINITY, TX 75862 · CCN 676439
SFF Candidate
Ratings
- Overall
- ★☆☆☆☆ 1
- Health inspection
- ★☆☆☆☆ 1
- Quality measures
- ★★☆☆☆ 2
- Staffing
- ★★☆☆☆ 2
Facility
- Ownership type
- Government - Hospital district
- Certified beds
- 76
- Avg residents/day
- 60.9
- Phone
- 9367441300
Inspection history vs Texas & national averages
Cycle 1 is the most recent standard health inspection. Lower total deficiency counts are better.
| Cycle | Inspection date | This facility | Texas avg | National avg | vs state |
|---|---|---|---|---|---|
| 1 | 2025-02-27 | 33 | 9.1 | 9.5 | +23.9 worse |
| 2 | 2024-01-10 | 10 | 9.4 | 9.8 | +0.6 worse |
| 3 | 2022-11-30 | 11 | 8.1 | 9.3 | +2.9 worse |
Cycle 1 deficiencies by category
| Category | Deficiencies |
|---|---|
| Abuse, neglect, exploitation | 3 |
| Quality of life and care | 7 |
| Resident assessment and care planning | 6 |
| Nursing and physician services | 1 |
| Resident rights | 2 |
| Nutrition and dietary | 1 |
| Pharmacy service | 5 |
| Environmental | 3 |
| Administration | 2 |
| Infection control | 3 |
Staffing (hours per resident per day)
| Metric | This facility | Turnover |
|---|---|---|
| Total nurse staffing (reported) | 3.41 | 66.7% |
| RN staffing (reported) | 0.38 | 33.3% |
| Total nurse staffing (adjusted) | 3.74 | — |
Fines & penalties
- Total fines
- $274,314
- Number of fines
- 2
- Number of penalties
- 2
- Payment denials
- 0
Inspection citations (54)6 immediate jeopardy1 actual harm
- DF0600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.2026-01-28 · Health
Potential for more than minimal harm
- DF0609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.2026-01-28 · Health
Potential for more than minimal harm
- DF0656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.2026-01-28 · Health
Potential for more than minimal harm
- EF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2026-01-28 · Health
Potential for more than minimal harm
- DF0760Ensure that residents are free from significant medication errors.2026-01-28 · Health
Potential for more than minimal harm
- DF0656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.2025-12-17 · Health · corrected 2025-12-18
Potential for more than minimal harm
- DF0694Provide for the safe, appropriate administration of IV fluids for a resident when needed.2025-12-17 · Health · corrected 2025-12-18
Potential for more than minimal harm
- EF0677Provide care and assistance to perform activities of daily living for any resident who is unable.2025-11-26 · Health · corrected 2025-12-15
Potential for more than minimal harm
- EF0842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.2025-11-26 · Health · corrected 2025-12-15
Potential for more than minimal harm
- KF0580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.2025-11-12 · Health · corrected 2025-11-20
Immediate jeopardy
- DF0657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.2025-11-12 · Health · corrected 2025-12-08
Potential for more than minimal harm
- HF0684Provide appropriate treatment and care according to orders, resident’s preferences and goals.2025-11-12 · Health · corrected 2025-12-05
Actual harm
- KF0686Provide appropriate pressure ulcer care and prevent new ulcers from developing.2025-11-12 · Health · corrected 2025-11-20
Immediate jeopardy
- EF0755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.2025-11-12 · Health · corrected 2025-12-08
Potential for more than minimal harm
- KF0760Ensure that residents are free from significant medication errors.2025-11-12 · Health · corrected 2025-11-20
Immediate jeopardy
- EF0880Provide and implement an infection prevention and control program.2025-11-12 · Health · corrected 2025-12-08
Potential for more than minimal harm
- EF0919Make sure that a working call system is available in each resident's bathroom and bathing area.2025-07-27 · Health · corrected 2025-08-12
Potential for more than minimal harm
- DF0584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.2025-02-27 · Health · corrected 2025-02-28
Potential for more than minimal harm
- DF0602Protect each resident from the wrongful use of the resident's belongings or money.2025-02-27 · Health · corrected 2025-02-28
Potential for more than minimal harm
- DF0644Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.2025-02-27 · Health · corrected 2025-03-13
Potential for more than minimal harm
- EF0655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted2025-02-27 · Health · corrected 2025-02-28
Potential for more than minimal harm
- DF0677Provide care and assistance to perform activities of daily living for any resident who is unable.2025-02-27 · Health · corrected 2025-03-14
Potential for more than minimal harm
- DF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2025-02-27 · Health · corrected 2025-03-14
Potential for more than minimal harm
- DF0755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.2025-02-27 · Health · corrected 2025-02-28
Potential for more than minimal harm
- DF0761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.2025-02-27 · Health · corrected 2025-02-28
Potential for more than minimal harm
- FF0812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.2025-02-27 · Health · corrected 2025-02-28
Potential for more than minimal harm
- EF0880Provide and implement an infection prevention and control program.2025-02-27 · Health · corrected 2025-03-14
Potential for more than minimal harm
- DF0908Keep all essential equipment working safely.2025-02-27 · Health · corrected 2025-03-13
Potential for more than minimal harm
- FF0925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.2025-02-27 · Health · corrected 2025-02-28
Potential for more than minimal harm
- EF0941Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.2025-02-27 · Health · corrected 2025-03-24
Potential for more than minimal harm
- EF0945Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.2025-02-27 · Health · corrected 2025-03-24
Potential for more than minimal harm
- EF0947Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.2025-02-27 · Health · corrected 2025-03-24
Potential for more than minimal harm
- EF0949Provide behavior health training consistent with the requirements and as determined by a facility assessment.2025-02-27 · Health · corrected 2025-03-24
Potential for more than minimal harm
- FF0812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.2024-08-28 · Health · corrected 2024-09-24
Potential for more than minimal harm
- DF0880Provide and implement an infection prevention and control program.2024-08-28 · Health · corrected 2024-09-24
Potential for more than minimal harm
- DF0658Ensure services provided by the nursing facility meet professional standards of quality.2024-01-10 · Health · corrected 2024-02-01
Potential for more than minimal harm
- DF0677Provide care and assistance to perform activities of daily living for any resident who is unable.2024-01-10 · Health · corrected 2024-02-01
Potential for more than minimal harm
- DF0693Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.2024-01-10 · Health · corrected 2024-02-01
Potential for more than minimal harm
- DF0695Provide safe and appropriate respiratory care for a resident when needed.2024-01-10 · Health · corrected 2024-02-01
Potential for more than minimal harm
- FF0725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.2024-01-10 · Health · corrected 2024-02-01
Potential for more than minimal harm
- FF0727Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.2024-01-10 · Health · corrected 2024-02-01
Potential for more than minimal harm
- EF0757Ensure each resident’s drug regimen must be free from unnecessary drugs.2024-01-10 · Health · corrected 2024-02-01
Potential for more than minimal harm
- EF0880Provide and implement an infection prevention and control program.2024-01-10 · Health · corrected 2024-02-01
Potential for more than minimal harm
- KF0604Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.2023-11-05 · Health · corrected 2023-11-06
Immediate jeopardy
- KF0607Develop and implement policies and procedures to prevent abuse, neglect, and theft.2023-11-05 · Health · corrected 2023-11-06
Immediate jeopardy
- KF0700Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.2023-11-05 · Health · corrected 2023-11-06
Immediate jeopardy
- DF0636Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.2022-11-30 · Health · corrected 2022-12-23
Potential for more than minimal harm
- DF0638Assure that each resident’s assessment is updated at least once every 3 months.2022-11-30 · Health · corrected 2022-12-23
Potential for more than minimal harm
- DF0641Ensure each resident receives an accurate assessment.2022-11-30 · Health · corrected 2022-12-23
Potential for more than minimal harm
- EF0655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted2022-11-30 · Health · corrected 2022-12-29
Potential for more than minimal harm
- DF0695Provide safe and appropriate respiratory care for a resident when needed.2022-11-30 · Health · corrected 2022-12-20
Potential for more than minimal harm
- FF0727Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.2022-11-30 · Health · corrected 2022-12-06
Potential for more than minimal harm
- EF0805Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.2022-11-30 · Health · corrected 2022-12-01
Potential for more than minimal harm
- DF0842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.2022-11-30 · Health · corrected 2022-12-28
Potential for more than minimal harm
Ownership
| Owner | Type | Role | Percent | Since |
|---|---|---|---|---|
| CHAMBERS COUNTY PUBLIC HOSPITAL DISTRICT NO. 1 | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | 2021-05-01 |
| TRINITY RHC LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | 2021-05-01 |
| WHATLEY, DARCY | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | 2021-05-01 |
| COOPER, KIMBERLY | Individual | CORPORATE DIRECTOR | — | 2024-01-29 |
| NEWTON, ELIZABETH | Individual | CORPORATE DIRECTOR | — | 2024-02-22 |
Other facilities in TRINITY
| Name | Overall | Beds |
|---|---|---|
| RIVER POINTE OF TRINITY HEALTHCARE AND REHABILITAT | ★★★☆☆ | 104 |
Source: CMS Provider Data Catalog, Nursing Home Care Compare files (processed 2026-03-01). Citations show the 3 most recent inspection cycles.