Cycle 1
Health 2025-04-30 · Fire 2025-04-30
5 health deficiencies
Top issue: Infection Control (2 deficiencies)
3 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Trinity, TX
River Pointe Of Trinity Healthcare And Rehabilitat
3-star overall rating with 4-star inspections with $27,748 in total fines with 5 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
808 S Robb, Trinity, TX
(936) 336-7400
Overall
3 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
104
Certified beds
Average residents
66
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
2001-12-20
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
329 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.26
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.88
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
2.04
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.19
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.14
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.60
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.14
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.26
CMS adjusted RN staffing hours
Adjusted total hours
3.21
CMS adjusted total nurse staffing hours
Case-mix index
1.36
Higher values indicate more complex resident acuity
RN turnover
40%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
54%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,767
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
10.61
Composite VBP score used to determine payment impact.
Payment multiplier
0.9809
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Performance 23.39% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
2.03
Baseline 6.26% · Performance 7.23% · Measure score 2.03 · Achievement 2.03 · Improvement 0
Total nurse turnover
1.67
Baseline 55.36% · Performance 56.86% · Measure score 1.67 · Achievement 1.67 · Improvement 0
Adjusted total nurse staffing
0.55
Baseline 4.21 hours · Performance 3.23 hours · Measure score 0.55 · Achievement 0.55 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.4% |
10.72%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 46 · Observed rate 15.22% · Lower 95% interval 7.51% |
| Discharge to community | 42.06% |
50.57%
8.5 pts worse
|
No Different than the National Rate · Eligible stays 31 · Observed rate 32.26% · Lower 95% interval 26.9% |
| Medicare spending per beneficiary | 1.07 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 97.83% |
95.27%
2.6 pts better
|
Numerator 45 · Denominator 46 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 46 |
| Discharge self-care score | 51.72% |
53.69%
2 pts worse
|
Numerator 15 · Denominator 29 |
| Discharge mobility score | 48.28% |
50.94%
2.7 pts worse
|
Numerator 14 · Denominator 29 |
| Pressure ulcers or injuries, new or worsened | 13.04% |
2.29%
10.8 pts worse
|
Numerator 6 · Denominator 46 · Adjusted rate 10.36% |
| Healthcare-associated infections requiring hospitalization | 7.23% |
7.12%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 39 · Observed rate 7.69% · Lower 95% interval 4.23% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 94 |
| Staff flu vaccination coverage | 28.09% |
42%
13.9 pts worse
|
Numerator 25 · Denominator 89 |
| Discharge function score | 62.07% |
56.45%
5.6 pts better
|
Numerator 18 · Denominator 29 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 4.76% |
25.2%
20.4 pts worse
|
Numerator 1 · Denominator 21 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.9 |
2.1
0.2 pts better
|
1.9
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.7 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.3 |
2.1
0.8 pts better
|
1.8
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.3 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
97.1%
2.9 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
97.9%
2.1 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.3% |
3.3%
About the same
|
3.3%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 3.6% · Q3 2.0% · Q4 3.7% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
2.7%
2.7 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 4.2% |
3.3%
0.9 pts worse
|
5.4%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 7.3% · Q3 2.6% · Q4 7.1% · 4Q avg 4.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 10.7% |
18.9%
8.2 pts better
|
19.6%
8.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.9% · Q2 9.8% · Q3 10.5% · Q4 11.6% · 4Q avg 10.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 3.8% |
10.8%
7 pts better
|
16.7%
12.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 2.9% · Q3 3.4% · Q4 3.2% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 10.0% |
15.4%
5.4 pts better
|
16.3%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 10.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 29.1% |
16.1%
13 pts worse
|
14.9%
14.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.8% · Q2 25.0% · Q3 17.1% · Q4 42.1% · 4Q avg 29.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.5%
0.5 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
0.8%
0.8 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 20.3% |
15.0%
5.3 pts worse
|
19.8%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.7% · Q2 24.5% · Q3 16.2% · Q4 19.4% · 4Q avg 20.3% |
| Percentage of long-stay residents with pressure ulcers | 3.1% |
4.2%
1.1 pts better
|
5.1%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 4.0% · Q3 2.3% · Q4 2.2% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.4% |
89.7%
9.7 pts better
|
81.7%
17.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 98.9% · Q4 98.9% · 4Q avg 99.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 2.7% |
12.0%
9.3 pts better
|
12.0%
9.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 2.7% · Observed 3.0% · Expected 12.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
88.0%
12 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.6% |
25.9%
3.3 pts better
|
23.9%
1.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.6% · Observed 24.2% · Expected 25.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-20 · Fire 2024-03-20
7 health deficiencies
Top issue: Resident Rights (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cycle 3
Health 2023-01-25 · Fire 2023-01-25
4 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-04-30
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-05-15
E · Potential for more than minimal harm
2025-04-30
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-05-15
E · Potential for more than minimal harm
2025-04-30
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-05-15
E · Potential for more than minimal harm
2024-03-20
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-04-03
Inspection history
Recent health citations
J · Immediate jeopardy
2025-07-29
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-06-30
D · Potential for more than minimal harm
2025-07-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-08-05
E · Potential for more than minimal harm
2025-04-30
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-05-15
D · Potential for more than minimal harm
2025-04-30
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2025-05-15
D · Potential for more than minimal harm
2025-04-30
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-15
G · Actual harm
2024-05-13
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-05-14
F · Potential for more than minimal harm
2024-05-13
F837 · Administration Deficiencies
Health
Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.
Corrected 2024-05-14
D · Potential for more than minimal harm
2024-05-13
F557 · Resident Rights Deficiencies
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2024-05-14
D · Potential for more than minimal harm
2024-05-13
F622 · Resident Rights Deficiencies
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2024-05-14
F · Potential for more than minimal harm
2024-03-20
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-04-13
D · Potential for more than minimal harm
2024-03-20
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-04-13
D · Potential for more than minimal harm
2024-03-20
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-04-13
E · Potential for more than minimal harm
2023-01-25
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-02-17
E · Potential for more than minimal harm
2023-01-25
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-02-17
D · Potential for more than minimal harm
2023-01-25
F813 · Nutrition and Dietary Deficiencies
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2023-02-17
D · Potential for more than minimal harm
2023-01-25
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-02-17
Penalties and ownership
What sits behind the stars
$22,925
2025-07-29
Fine
Fine · fine $22,925
Fine
$4,823
2024-05-13
Fine
Fine · fine $4,823
Fine
Ownership
Liberty County Hospital District No. 1
5% Or Greater Direct Ownership Interest · Organization
Burnam, Soon
Corporate Officer · Individual
Jafri, Syed
Operational/Managerial Control · Individual
Keetch, Chad
Corporate Officer · Individual
Pedro, Agatha
Operational/Managerial Control · Individual
Stratton, Charles
Corporate Officer · Individual
Whispering Pines Healthcare, Inc.
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Trinity Rehabilitation & Healthcare Center
Trinity, TX
1-star overall rating with 1-star inspections with Special Focus status with $274,314 in total fines with 33 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Groveton Nursing Home
Groveton, TX
5-star overall rating with 5-star inspections with $86,735 in total fines with 3 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Huntsville Health Care Center
Huntsville, TX
4-star overall rating with 4-star inspections with $21,645 in total fines with 8 recent health deficiencies
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