Inspection·July 21, 2023

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that Minimum Data Set (MDS, a standardized assessment tool that described resident health and functional status) assessments were completed accurately for eight out of nine sampled residents, (Residents 1, 2, 3, 4, 6, 7, 8 and 9) when the MDS's incorrectly indicated that these residents were using restraints (a device that limits a resident's movement). Residents Affected - Many This failure had the potential for an inaccurate picture of the resident's status. Findings: A review of the document titled, Centers for Medicare and Medicaid Services (CMS) Long-Term Care (LTC) Facility Resident Assessment Instrument 3.0 User's Manual, dated 10/1/19, located on the CMS website: MDS 3.0 RAI Manual v1.17.1_October 2019 (cms.gov), page 20 indicated: Medicare and Medicaid participating LTC facilities are required to conduct comprehensive, accurate, standardized and reproducible assessments of each resident's functional capacity and health status. During a review of Resident 1's Quarterly MDS, (assessment performed every three months), dated 5/18/23, the assessment indicated Resident 1 was admitted to the facility on [DATE], and bedrails were used as a restraint daily. During a review of Resident 2's Quarterly MDS, dated [DATE], the assessment indicated Resident 2 was admitted to the facility on [DATE], and bedrails were used as a restraint daily. During a review of Resident 3's Annual MDS Assessment (performed yearly), dated 6/29/23, the assessment indicated Resident 3 was admitted to the facility on [DATE], and bedrails were used as a restraint daily. During a review of Resident 4's Quarterly MDS, dated [DATE], the assessment indicated Resident 4 was admitted to the facility on [DATE], and bedrails were used as a restraint daily. During a review of the Resident 6's Quarterly MDS, dated , 5/17/23, the assessment indicated Resident 6 was admitted to the facility on [DATE], and bedrails were used as a restraint daily. During a review of Resident 7's admission MDS Assessment (completed upon admission to the facility), dated 4/24/23, the assessment indicated Resident 7 was admitted to the facility on [DATE], and bedrails were used as a restraint daily. During a review of Resident 8's Quarterly MDS, dated [DATE], the assessment indicated Resident 8 was admitted to the facility on [DATE], and bedrails were used as a restraint less than daily. During a review of Resident 9's Quarterly MDS, dated [DATE], the assessment indicated Resident 9 was admitted to the facility on [DATE], and bedrails were used as a restraint daily. During an interview on 7/20/23 at 10:13 am, the MDS nurse (MDS) C confirmed that the MDS assessment, Section P (the portion of the MDS assessment that included use of restraints) had been incorrectly coded for Residents 1, 2, 3, 4, 6, 7, 8 and 9. MDS C stated that bedrails were being used for mobility, not as a restraint. MDS C stated there was fine print at the top of MDS Section P that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555907 If continuation sheet Page 2 of 21 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 555907 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Trinity Hospital Skilled Nursing Facility 60 Easter Ave Weaverville, CA 96093 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 0641 described what a restraint was and she had not read it, prior to completing the assessment. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555907 If continuation sheet Page 3 of 21 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 555907 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Trinity Hospital Skilled Nursing Facility 60 Easter Ave Weaverville, CA 96093 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide one out of nine sampled residents (Resident 4) with treatment and services that were consistent with the facility's policies and procedures (P&P), when Resident 4 developed a stage two pressure ulcer (a shallow open area of the skin with a red or pink woundbed), and a physician ordered treatment was not obtained, his responsible party was not notified, nursing had not documented on his change in condition, and he was not turned and/or repositioned every two hours. Residents Affected - Few This failure had the potential for Resident 4's pressure ulcer (PU) to worsen resulting in a negative health outcome. Findings: A review of the facility's undated P&P titled, Pressure Ulcer Management, SNF indicated when a resident developed a pressure ulcer the physician would be notified no later than 24 hours after discovery of the pressure ulcer and staff would obtain an order for treatment. The P&P indicated nursing interventions that would be included in the resident's Care Plan included hygiene measures, pressure relieving devices, nutrition, and wound healing measures. The P&P indicated the RP would be notified; dietary would be contacted to request a nutritional assessment with recommendations that supported wound healing. The P&P indicated an incident report would be completed and the resident would be placed on alert charting. A review of the facility's undated P&P titled, Change in a Resident's Condition or Status, SNF, defined a significant change of condition as a major decline in resident status that would not resolve itself without staff intervention. The P&P indicated staff would utilize the Interact SBAR Communication Form prior to notifying the provider of the residents change of condition. A review of the facility's undated P&P titled, Care Plans, Comprehensive Person-Centered, SNF, indicated the Care Plan would be person-centered, describe the services that were provided to the resident, and the IDT must review and update the care plan when there has been a significant change in the resident's condition. A review of Resident 4's records indicated admission to the facility on [DATE] with the diagnoses of dementia (memory loss), chronic pain, and polyneuropathy (a condition that affect nerves that could cause symptoms of numbness, difficulty using arms or legs, and changes to the skin). The records indicated Resident 4 was admitted to the facility with no PU's, was incontinent of bowel and bladder, required extensive assistance of two staff members to use the toilet and to move from side-to-side in bed. Resident 4 was totally dependent upon staff for bathing, and was on a turning and repositioning program. Resident 4 had poor cognition (ability to think, reason, or remember), was not his own responsible party (RP), and relied on his RP to make all his decisions. During an interview on at 7/19/23 at 3:07 pm, Resident 4's RP, stated the facility usually called if there was a change of condition with Resident 4 and they had not received any phone calls recently with updates. RP stated the facility had not called to notify that Resident 4 had developed a new PU. During an observation on 07/21/23 at 8:00 am, Resident 4 was observed in bed with eyes closed. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555907 If continuation sheet Page 4 of 21 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 555907 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Trinity Hospital Skilled Nursing Facility 60 Easter Ave Weaverville, CA 96093 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 0686 Level of Harm - Minimal harm or potential for actual harm head of the bed (HOB) was raised to approximately 35 degrees and Resident 4 was lying in a supine position (laying on the back). During an observation on 07/21/23, at 10:07 am, Resident 4 was observed in bed with eyes closed. The HOB was raised to approximately 35 degrees and Resident 4 was lying in a supine position. Residents Affected - Few During a concurrent interview and record review on 7/21/23, at 10:23 am, with Licensed Nurse (LN) A, Resident 4's Progress Note, dated 7/18/23, was reviewed. LN A stated the Progress Note indicated Resident 4 had developed a stage 2 PU on the sacrum (lower back area just above the buttocks), A&D ointment (a skin protectant) was placed over the PU, and LN would report the PU to the morning LN. LN A reviewed Progress Notes, dated 7/18/23 through 7/20/23, and stated the Progress Notes did not include expected information such as: notifying or alerting the facility's physician that Resident 4 had a change of condition (development of PU), Resident 4's RP had not been notified, and there did not appear to be any alert charting (a Progress Note that described the wound and was written by the LN during each shift). LN A stated the facility's Registered Dietician (RD) should be notified and confirmed the Progress Notes did not indicate the RD had been alerted that Resident 4 had developed a stage two PU. LN A stated the Interdisciplinary Team (IDT, team members share resident information, updates, and collaborate with each other to develop patient centered care plans) should have met and discussed a plan for the treatment of Resident 4's PU, and confirmed there was no documentation in the Progress Notes that indicated an IDT meeting had been held. During an observation on 7/21/23 at 11:18 am, Resident 4 was observed lying in a supine position with the HOB flat. During a review of Resident 4's record titled, Care Plan (a written plan that provided an individualized plan of care the resident required) Skin Integrity, updated on 1/11/23, the Care Plan indicated the intervention (action to prevent or treat a medical condition) to turn every two hours was to be provided to Resident 4. During a concurrent interview and record review on 7/21/23, at 11:47 am, with Certified Nursing Assistant (CNA) F, Resident 4's POC charting (section of electronic medical records for CNA documentation), was reviewed. CNA F stated Resident 4 was not at high risk for developing PU and that he had, good skin. CNA F stated the turn every two-hour section had not been initiated in the POC section indicating Resident 4 did not require this and he was not repositioned every two hours. CNA F confirmed Resident 4 had developed a new PU and stated Resident 4 was now being repositioned every two hours. During a concurrent observation and interview on 7/21/23, at 12:05 am, with CNA G, Resident 4 was observed laying in a supine position with the HOB flat. CNA G stated Resident 4 had been repositioned about one and a half hours ago (approximately 10:30 am) when CNA G had assisted Resident 4 with getting dressed. Lying underneath Resident 4 was a Hoyer sling (a thick and heavy sling that wrapped around the resident who required use of a Hoyer machine to get out of bed, and would require repositioning the resident to place the sling underneath the resident). CNA G stated the Hoyer sling had been placed underneath Resident 4 at approximately 11:30 am. CNA G was asked to clarify when Resident 4 had last been repositioned due to different times being provided (10:30 am and 11:30 am). CNA G was not able to verbalize an answer. During a concurrent interview and record review on 7/21/23, at 12:21 pm, with Chief Nursing Officer (CNO), Resident 4's medical records were reviewed. CNO reviewed the record titled, Progress Notes, dated 7/18/23 through 7/20/23, and stated when a resident developed a new PU the facility's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555907 If continuation sheet Page 5 of 21 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 555907 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Trinity Hospital Skilled Nursing Facility 60 Easter Ave Weaverville, CA 96093 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few physician would be notified of the change of condition, new orders to treat the new PU would be obtained, LN would place the resident on alert charting, the care plan would be updated with interventions that were personalized, an incident report would be completed and the RP would be notified. CNO stated an IDT meeting would not be held for the development of a new PU and that the severity of the wound and how the wound was healing would indicate if an IDT meeting would be held. CNO confirmed the Progress Notes did not indicate the physician or resident's RP was notified, an incident report had not been completed, and Resident 4 was not placed on alert charting. CNO reviewed Resident 4's Open Wound Care Plan , dated 7/19/23, and stated the care plan indicated Resident 4 had three interventions that included to monitor the wound, turn every two hours, and provide frequent brief changes. CNO confirmed Resident 4's wound care plan had not included personalized treatment interventions and should have. CNO reviewed Resident 4's Orders, with multiple dates and stated there was an order for A&D ointment to be applied with each brief change and confirmed the order for A&D ointment was written prior to the PU development and there was not a new treatment order that outlined PU treatment that should be provided to Resident 4. During a concurrent observation and interview on 7/21/23, at 4:18 pm, with CNO, CNA F, and CNA G, Resident 4 was observed laying in his bed, supine, with the HOB flat. The Hoyer sling was underneath Resident 4 (four hours after initial observation). CNA F and CNA G stated Resident 4's PU looked better and assisted with rolling over Resident 4 for an observation of the PU. Resident 4 was observed to have a stage 2 PU to the sacrum. The PU wound bed was red in color and the redness extended approximately one and half inches outward, encircling the entire wound bed. When asked if the Hoyer Sling had been left under Resident 4 all day, no answer was provided by CNA F or CNA G. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555907 If continuation sheet Page 6 of 21 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 555907 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Trinity Hospital Skilled Nursing Facility 60 Easter Ave Weaverville, CA 96093 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 - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that one of one sampled residents (Resident 10) was reassessed for safe smoking, supervised during smoking, and that his plan of care was followed. This had the potential to result in physical and psychosocial harm for Resident 10. Findings: A review of the facility's policy titled, Smoking Policy-Residents, SNF dated 3/29/22, indicated, smoking is not allowed inside the facility, this includes electronic cigarettes. The resident will be evaluated on admission to determine if he or she is a smoker. The evaluation will include the current level of tobacco consumption, method, and the desire to quit smoking. Resident 10 was admitted to the facility on [DATE] with diagnoses that included cognitive decline (difficulty with recall, and thinking), diabetes, high blood pressure, and need for assistance with personal care. During a record review of Resident 10's, Active Orders dated 5/24/23, the orders indicated Resident 10 did not have the capacity to make healthcare decisions and sign consents. During a record review of Resident 10's, Smoking and Safety assessment, dated 5/24/23, Resident 10 used tobacco products and could follow the facility's policy on location and time of smoking. There was no documentation that indicated Resident 10 was being monitored for safety while smoking. During a record review of Resident 10's, Elopement Evaluation dated 5/24/23, Resident 10 was identified to wander throughout the facility. A review of Resident 10's Minimum Data Set, (MDS, a resident assessment tool), dated 6/6/23, indicated for functional ability Resident 10 needed supervision with one person assistance for locomotion off the unit, (how the resident moves to and from off-unit locations) to leave the unit. The designated smoking area was observed to be located outside, off the unit, in the back of the facility. The MDS further indicated that Resident 10 had a severe cognitive impairments (unable to think, reason, and make decisions), with a Brief Interview Mental Status (BIMS) score of 6 out of 15. Section J, health conditions, indicated Resident 10 had one fall within the last month and one fall within the last two to six months. A review of Resident 10's, Tobacco Use care plan, revised 6/12/23, indicated Resident 10's problem was Tobacco Use. The interventions were to conduct smoking safety evaluations on admission and as needed, staff to extinguish cigarettes, and to utilize a cigarette holder. During an observation on 7/18/23 at 12:40 pm, Resident 10 was ambulating with a cane to the dining room from the designated smoking area with no assistance. During an interview on 7/18/23 at 12:42 pm, Resident 10 stated, Yes, I smoke. I just smoked before lunch; they are not always with us. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555907 If continuation sheet Page 7 of 21 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 555907 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Trinity Hospital Skilled Nursing Facility 60 Easter Ave Weaverville, CA 96093 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 - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 7/18/23 at 1:49 pm, Certified Nursing Assistant, (CNA) D stated, I go with [Resident 10] to smoke, at least to light his cigarette. I think he needs someone all the time because he gets confused. I try to always stay with him. During an observation on 7/19/23 at 9:54 am, the designated smoking area had a table with two chairs and a standing ashtray. There was no call light or alert system to call for staff, no fire extinguisher, and no smoking blanket or smoking aprons were present. During an interview on 7/19/23 at 10:02 am, CNA E stated, [Resident 10] is confused, I always stay with him. I think he needs someone every time he smokes. During an interview on 7/19/23 at 10:47 am, CNA C stated, There was an order for [Resident 10] to have supervision while smoking for the first two weeks after admission, and then it stopped. During a record review of Resident 10's medical chart, the facility had not conducted any reassessments to determine if Resident 10 was safe while smoking. During an interview on 7/19/23 at 11:47 am, Chief Nursing Officer (CNO) confirmed Resident 10 did not have current or ongoing assessments to determine the level of monitoring he should have for safety while smoking. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555907 If continuation sheet Page 8 of 21 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 555907 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Trinity Hospital Skilled Nursing Facility 60 Easter Ave Weaverville, CA 96093 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 0711 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** During an interview on 7/21/23 at 12:13 pm, with Chief Executive Officer (CEO), he stated that he was not aware that AP was not signing monthly Active Orders or documenting monthy visits and resident conditions in his Progress Notes. The CEO indicated that Active Orders and Physician Progress Notes should be signed and completed by the AP, for each resident at the beginning of every month. During an interview on 7/21/23 at 2:10 pm, with AP, he stated that he was in the facility every other week on the second and fourth Thursday and he signed orders and performed other duties typically on the second Thursday. AP indicated that it was the staff's responsibility to have documentation that required his signature available and ready for him to sign when he comes in. AP stated he was not aware of the time frames for signing Active Orders or making Progress Notes, as specified in the facility's policy. Based on interview and record review, the facility failed to ensure that the attending Physician (AP), took an active role in the supervision of the care for 7 of 9 sampled residents (Resident 1, 3, 6, 7, 8, 9 and 10), when; 1. AP did not acknowledge, sign and date the current Active Orders (the physician's orders give the facility the legal authority to provide specific care and services to residents), for the months of June and July, 2023. 2. AP did not document a Progress Note (a note describing the Resident's current status at the time when the physician visited), in each Resident's medical record after he saw them each month. These failures had the potential for residents to not receive the appropriate level of care and services and negatively impact their ability to attain or maintain their highest practicable level of emotional and physical well-being. Findings: A review of the facility's policy titled, Attending Physician Responsibilities, SNF dated 3/29/22, indicated, The provider will verify the accuracy of verbal orders when they are given and will authenticate, co-sign, and date them in a timely manner no later than the next visit to the resident. A review of the facility's policy titled, Medical Staff Delinquent Chart Suspension, Administration dated 1/25/22, indicated, This policy was to ensure timely completion of charts by physicians. Orders for SNF Recap Orders will be completed within five days, after the first of the month. 1. A review of Resident 1's records indicated admission to the facility on [DATE], with the diagnoses of type 2 diabetes mellitus with diabetic nephropathy (diabetes that could include nerve dysfunction) and depressive episodes (depression, a sad mood). A review of Resident 1's, Order Summary Report, dated 6/30/23, indicated AP had not reviewed or signed all Active Orders for Resident 1. A review of Resident 3's record indicated admission was on 11/26/2020, with diagnoses of Dementia, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555907 If continuation sheet Page 9 of 21 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 555907 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Trinity Hospital Skilled Nursing Facility 60 Easter Ave Weaverville, CA 96093 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 0711 Level of Harm - Minimal harm or potential for actual harm Adult Failure to Thrive (a state of decline), Chronic Obstructive Pulmonary Disease (COPD, chronic inflammatory lung disease), and Diabetes. During a record review of Resident 3's, Active Orders, AP had not signed Resident 3's Active Orders in June and July, 2023. Residents Affected - Many A review of Resident 6's record indicated admission was on 11/08/2022, with diagnoses of Dementia, Hypertension (high blood pressure), Heart Failure, and an unruptured Cerebral Aneurysm (blood clot in the brain. During a record review of Resident 6's, Active Orders, AP had not signed Resident 6's Active Orders in June or July, 2023. Resident 7 was admitted to the facility on [DATE] with diagnoses that included high blood pressure, dementia, anxiety (feelings of fear, dread, and uneasiness), and a left below the knee amputation. During a record review of Resident 7's, Active Orders the AP had not signed Resident 7's Active Orders in June or July, 2023. Resident 8 was admitted to the facility on [DATE] with diagnoses that included heart disease, dementia unspecified severity, without behavioral disturbance, psychotic disturbance (hallucinations, paranoia and delusions), mood disturbance and anxiety, and leukemia (a type of blood cancer). During a record review of Resident 8's, Active Orders the AP had not signed Resident 8's Active Orders for June and July, 2023. A review of Resident 9's record indicated admission was on 12/09/2022, with diagnoses of Dementia, Adult Failure to Thrive, Parkinson's Disease (progressive neurological disorder that affects the nerves and the parts of the body controlled by the nerves), and Atrial Fibrillation (irregular and often very rapid heart rate). During a record review of Resident 9's, Active Orders, AP had not signed Resident 9's Active Orders in June or July, 2023. Resident 10 was admitted to the facility on [DATE] with diagnoses that included cognitive decline, diabetes, high blood pressure, and need for assistance with personal care. During a record review of Resident 10's, Active Orders the AP had not signed Resident 10's Active Orders for June and July, 2023. During an interview on 7/21/23 at 11:24 am, Licensed Nurse (LN) A, confirmed that the AP had not signed the Active Orders for June and July, 2023 for Residents 7, 8 and 10. During an interview on 7/21/23 at 11:45 am, the Chief Nursing Officer (CNO), confirmed that the physician had not signed the Active Orders for Resident's 3, 6, 7, 8, 9 and 10, in June and July 2023, and should have within the first 5 days of each month. A review of the facility's policy titled, Attending Physician Responsibilities, SNF dated 3/29/22, indicated, The attending physicians shall be the primary practitioner's responsibility for providing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555907 If continuation sheet Page 10 of 21 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 555907 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Trinity Hospital Skilled Nursing Facility 60 Easter Ave Weaverville, CA 96093 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 0711 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many medical services and coordinating the healthcare of each resident. The facility's policy indicated making periodic, pertinent patient visits in the facility and providing appropriate, timely, and pertinent documentation. At each visit, the attending physician will provide a progress note (written, typed, or electronic) in a timely manner for placement in the medical record. 2. A review of Resident 3's record indicated admission was on 11/26/2020, with diagnoses of Dementia, Adult Failure to Thrive, Chronic Obstructive Pulmonary Disease, and Diabetes Mellitus. During a record review of Resident 3's, Physician Progress Notes AP had not documented that he visited or evaluated Resident 3's condition in June and July, 2023. Resident 7 was admitted to the facility on [DATE] with diagnoses that included high blood pressure, dementia, anxiety and a left leg below the knee amputation. During a record review of Resident 7's, Physician Progress Notes AP had not documented that he visited or reviewed Resident 7's condition in June or July, 2023. Resident 8 was admitted to the facility on [DATE] with diagnoses that included heart disease, dementia unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, and leukemia. During a record review of Resident 8's, Physician Progress Notes AP had not documented that he visited or reviewed Resident 8's condition in July, 2023. A review of Resident 6's record indicated admission was on 11/08/2022, with diagnoses of dementia, Hypertension, Heart Failure, and unruptured Cerebral Aneurysm. During a record review of Resident 6's, Physician Progress Notes AP had not documented that he visited or evaluated Resident 6's condition in June or July, 2023. A review of Resident 9's record indicated admission was on 12/09/2022, with diagnoses of dementia, Adult Failure to Thrive, Parkinson's Disease, and Atrial Fibrillation. Resident 9's MDS dated [DATE], assessed Resident 6's cognition 07/15, (severe impairment). During a record review of Resident 9's, Physician Progress Notes AP had not documented that he visited or evaluated Resident 9's condition in June and July, 2023. Resident 10 was admitted to the facility on [DATE] with diagnoses that included cognitive decline, diabetes, high blood pressure, and need for assistance with personal care. During a record review of Resident 10's, Physician Progress Notes AP had not documented that he visited or reviewed Resident 10's condition in June or July, 2023. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555907 If continuation sheet Page 11 of 21 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 555907 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Trinity Hospital Skilled Nursing Facility 60 Easter Ave Weaverville, CA 96093 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 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Have 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. Based on interview and nursing schedule review, the facility failed to provide a Registered Nurse (RN) for eight consecutive hours a day, seven days a week, and have a Director of Nursing (DON) on site for 40 hours per week, to supervise the care of all of the residents. This had the potential to adversely affect all of the residents' quality of life and quality of care. Findings: A review of the Payroll Based Journal (PBJ, an electronic system for facilities to submit staffing information) for Fiscal Year Quarter 1 for 2023, (10/1/22-12/31/22), indicated the facility had no RN on duty for; 10/1/22, 10/2/22, 10/08/22, 10/09/22, 10/15/22, 10/16/22, 10/23/22, 11/12/22, 11/13/22, 11/20/22, 11/26/22, 11/27/22, 12/01/22, 12/03/22, 12/04/22, 12/09/22, 12/10/22, 12/11/22, 12/16/22, 12/18/22, 12/22/22, 12/23/22, 12/24/22, 12/25/22, 12/26/22, 12/27/22, 12/28/22, 12/29/22, and 12/31/22. A review of the PBJ for Fiscal Year Quarter 2 for 2023, (1/1/23-3/31/23) indicated the facility had no RN on duty for; 1/6/23, 1/7/23, 1/12/23, 1/14/23, 1/15/23, 1/16/23, 1/22/23, 1/27/23, 1/29/23, 2/3/23, 2/4/23, 2/5/23, 2/10/23, 2/11/23, 2/17/23, 2/18/23, 2/19/23, 2/23/23, 2/24/23, 2/25/23, 2/26/23, 3/1/23, 3/2/23, 3/3/23, 3/4/23, 3/10/23 3/17/23, 3/18/23, 3/24/23, 3/26/23, and 3/31/23. During an interview on 7/19/23 at 11:52 am, Chief Nursing Officer (CNO) confirmed there was not an RN dedicated to oversee resident care for eight-hours a day, 7 days a week. The CNO stated that she was providing the duties of the DON temporarily, but only spent about an hour per day overseeing the care of the residents who resided in the skilled nursing facility. The CNO added, We are trying to find and keep more RNs. During an interview on 7/20/23 at 10:01 am, the Director of Staff Development (DSD, an RN), confirmed the facility did not have an RN eight hours a day, 7 days a week. She stated, They do call me in occasionally for RN coverage. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555907 If continuation sheet Page 12 of 21 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 555907 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Trinity Hospital Skilled Nursing Facility 60 Easter Ave Weaverville, CA 96093 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** During a concurrent interview and record review on 7/20/23 at 11:15 am, Licensed Nurse (LN) A reviewed Resident 3, 6 and 9's MRRs, dated 6/2/23 and 7/7/23 by PC, confirmed that there were no acknowledgements or responses to the PC recommendations by the AP. During a concurrent interview and record review on 7/21/23 at 12:00 pm, Chief Nursing Officer (CNO), reviewed Resident 3, 6 and 9's MRRs, dated 6/2/23 and 7/7/23 by PC, and confirmed that there were no acknowledgements or responses to the PC recommendations by the AP. During an interview on 7/21/23 at 11:00 am, PC indicated that many of the MRR recommendation that were made go unresponded to for long periods of time. PC confirmed that he had not communicated this with the AP, but instead continues to write the recommendations again and waits for the AP to respond. During an interview on 7/21/23 at 12:13 pm, the Administrator (Admin), indicated there was a pharmaceutical meeting every quarter and medications were discussed with AP, and he does not know who follows up. During an interview on 7/21/23 at 2:10 pm, AP indicated that he does follow up on recommendations at the quarterly pharmaceutical meetings. AP confirmed that he has seen the MRRs in the resident's charts, but did not always write a response. During in interview on 7/20/23 at 11:30 am, PC stated the AP was required to enter a statement of risk versus benefits when using medications with potential adverse interactions or side effects along with the reason why medication recommendations would not be not followed. The PC added that the AP was required to sign the MRR, and that they were not being addressed or signed by the AP. Based on interview and record review, the facility failed to ensure that the Pharmacy Consultant's (PC) Medication Regimen Review (MRR), recommendations were acted upon (responded to), by the attending physician (AP), for eight of nine sampled residents (Resident's 1, 2, 3, 6, 7, 8, 9 and 10), when: 1. AP did not respond to MRR recommendations for Resident 1 in April, 2023. 2. AP did not respond to MRR recommendations for Resident 2 in March and April, 2023. 3. AP did not respond to MRR recommendations for Resident 2 in May, 2023. 4. AP did not respond to MRR recommendations for Resident 6 in June and July, 2023. 5. AP did not respond to MRR recommendation for Resident 7 in July, 2023. 6. AP did not respond to MRR recommendations for Resident 8 in May, 2023. 7. AP did not respond to MRR recommendations for Resident 9 in June, 2023. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555907 If continuation sheet Page 13 of 21 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 555907 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Trinity Hospital Skilled Nursing Facility 60 Easter Ave Weaverville, CA 96093 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 0756 8. AP did not respond to MRR recommendations for Resident 10 in June, 2023. Level of Harm - Minimal harm or potential for actual harm These failures had the potential for the residents to have negative clinical outcomes and subject the residents to unwanted and adverse medication side effects and/or harmful interactions. Residents Affected - Many Findings: During a review of a the facility's policy titled, Medication Regimen Reviews, Skilled Nursing Facility (SNF) Pharmacy not dated, indicated, The Consultant Pharmacist shall review the medication regimen of each resident at least monthly. The Consultant Pharmacist will document his/her findings and recommendations on the monthly drug/medication regimen review report. The Consultant will provide a written report to the providers for each resident with an identified irregularity. The Consultant Pharmacist will provide the Director of Nursing Services and Medical Director with a written, signed, and dated copy of the report. Copies of drug/medication review reports, including physician responses, will be maintained as part of the permanent medical record. 1. A review of the records indicated Resident 1 was admitted to the facility on [DATE] with the diagnoses of depressive episodes (a sad mood), acquired absence of right leg below knee (lower leg amputation), and hypertension (high blood pressure). During a review of Resident 1's MRR, dated 4/1/2023, the PC alerted the AP that three of the medications Resident 1 was taking had possible major medication interactions (an adverse or unwanted reaction between two or more medications), Trazodone (an antidepressant), Cyclobenzaprine (a muscle relaxant), and Duloxetine (an antidepressant). The PC further indicated that Trazodone and Duloxetine were SSRI's (a type of antidepressant that can cause Serotonin Syndrome- muscle rigidity, fever or seizures). The AP had not responded to this recommendation to review Resident 1's medications. 2. A review of Resident 2's record indicated that he was admitted on [DATE], with the diagnoses of multiple sclerosis (a disease that involved damage to the nerves that could result in numbness, difficulty with speech, and inability to walk), paraplegia (inability to voluntarily move the lower parts of the body), and muscle spasms (involuntary muscle contractions). During a review of Resident 2's, MRR, dated 3/1/2023, the PC recommended the AP review Resident 2's medications for possible adverse interactions. The PC indicated that Baclofen (a muscle relaxant), Norco (an opiate pain medication), Diazepam (a muscle relaxant and antianxiety medication), Amitriptyline (an antidepressant), and ondansetron (medication used to prevent nausea or vomiting), when used together increased Resident 2's risk for sedation, falls and injuries. The AP had responded to the recommendation, but according to the PC he could not read the AP's writing, and had not followed up to get clarification. During a review of Resident 2's MRR, dated 4/1/23, the PC alerted the AP once again of potential adverse effects of using the following medications together, Norco, Gabapentin (a medication that was used to treat nerve pain), Diazepam, Baclofen, Amitriptyline, and ondansetron, and added that these medications put Resident 2 at a high risk for Central Nervous System (CNS) which could cause the brain to slow down creating feelings of confusion and sleepiness and serotonin syndrome. The AP had not responded to the PC's recommendations. 3. During a review of Resident 3's record indicated that Resident 3 was admitted on [DATE]. Resident 3's diagnoses included Dementia, Adult Failure to Thrive (not eating, giving up), Chronic (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555907 If continuation sheet Page 14 of 21 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 555907 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Trinity Hospital Skilled Nursing Facility 60 Easter Ave Weaverville, CA 96093 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 0756 Obstructive Pulmonary Disease (lung problems), and Diabetes. Level of Harm - Minimal harm or potential for actual harm During a review of Resident 3's MRR, dated 5/30/23, the PC recommended the AP review Resident 3's high AIC (blood test that monitors blood sugar levels and is used to manage diabetes) level (7.5%, less than 7 is ideal). AP had not responded to this recommendation. Residents Affected - Many 4. A review of Resident 6's record indicated that Resident 6 was admitted on [DATE] with diagnoses that included, Dementia, High blood pressure, Heart Failure, and an Unruptured Cerebral Aneurysm (blood clot in the brain). During a review of Resident 6's MRR, dated 6/2/23, the PC recommended the AP review Resident 6's high blood pressure readings for possible medication adjustments, Resident had 21 Systolic Blood Pressure (SBP) readings greater than 140 mmHg (measurement to record blood pressure). Goal is never to go over 140/90 mmHg, according to American Hospital Association (AHA) guide, given age and comorbidities. The AP did not respond to the PC's recommendation. During a review of Resident 6's MRR, dated 7/7/23, the PC again recommended that AP review Resident 6's continued high blood pressures, Seventeen SBP readings were greater than 140 mmHg. The PC also recommended that AP address a potential medication interaction between Valsartan (a blood pressure medication) and potassium (K+), a supplement. AP did not respond to these recommendations. 5. Resident 7 was admitted to the facility on [DATE] for diagnoses that included high blood pressure, dementia, anxiety (feelings of fear, dread, and uneasiness), and a left leg below the knee amputation. During a record review of Resident 7's, MRR, dated 7/7/23, the PC recommended that the AP review Resident 7's Lisinopril (a blood pressure medication) 15 milligrams (mg, a unit of measure) due to Resident 7's, Majority of blood pressure readings are greater than 140 mmHg (millimeters of mercury), (normal blood pressure systolic readings are 120 mmHg or less), which indicated that the dose may need to be changed. The MRR was not addressed by the AP. 6. Resident 8 was admitted to the facility on [DATE] for diagnoses that included heart disease, dementia, psychotic disturbance (hallucinations, paranoia or delusions), mood disturbance and anxiety, and leukemia, (a type of blood cancer). During a review of Resident 8's MRR, dated 5/12/23, the PC recommended that the AP review her use of Seroquel (an antipsychotic medication) 12.5 mg, for possible discontinuance. The AP did not respond to the recommendation. 7. A review of Resident 9's record indicated that she was admitted on [DATE], with diagnoses that included Dementia, Adult Failure to Thrive, Parkinson's Disease, and Atrial Fibrillation. During a review of Resident 9's MRR, dated 6/2/23, the PC recommended that AP review Resident 9's high blood pressure recordings where 34 Systolic Blood Pressures (SBP) were greater than 140 mmHg and that Resident 9 was taking both Megestrol (an appetite stimulant), and Marinol (an appetite stimulant) which was duplicate therapy and added that, If resident is not increasing weight appropriately, consider discontinuing. A recommendation was also made to review a major medication interaction between Valsartan (a blood pressure medication and Potassium (a supplement). AP did not responded to the PC's recommendations. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555907 If continuation sheet Page 15 of 21 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 555907 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Trinity Hospital Skilled Nursing Facility 60 Easter Ave Weaverville, CA 96093 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete 8. Resident 10 was admitted to the facility on [DATE] for diagnoses that included cognitive decline, diabetes, high blood pressure, and need for assistance with personal care. During a record review of Resident 10's MRR, dated 6/21/23, the PC recommended that the AP include in Resident 10's orders, Recommend orders regarding what to do in the case of hypoglycemia. The AP did not respond to the recommendation. Event ID: Facility ID: 555907 If continuation sheet Page 16 of 21 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 555907 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Trinity Hospital Skilled Nursing Facility 60 Easter Ave Weaverville, CA 96093 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide safe storage and labeling of resident medications and medical supplies when: 1. Over the Counter (OTC) medications were not labeled with an open date in one out of one medication cart (used to store resident medication). 2. Expired wound care supplies were stored in the treatment cart. 3. The treatment cart, located in the hallway across from the nurse's station, was left unlocked and unattended. 4. Expired laboratory supplies were stored in one of two storage rooms. 5. The medication disposal box (where discontinued medication is kept awaiting destruction), located in the nurse's station was not secure and could be easily accessed and the medications removed. These failures had the potential for unsafe medication use, and the use of medical tests and supplies which would no longer be effective, which could lead to negative clinical outcomes for the residents. Findings: 1. During a concurrent observation and interview on [DATE] at 9:07 am, with Licensed Nurse (LN) A, a bottle labeled Diabetic Tussin (an OTC cough syrup), a container labeled Cerovite Senior (an OTC multi-vitamin), and a container labeled Natures Truth D3 (an OTC viatmin supplement), were observed in the medication cart. LN A stated that they were expected to write the date on the containers of OTC medications, when they first opened the bottles and confirmed that the above OTC medications contained no date of when they had been opened. 2. During a concurrent observation of the treatment cart and interview on [DATE] at 9:07 am, with LN A, four packages of Optifoam Gentle wound care dressings had expired on [DATE]. LN A confirmed that the Optifoam Gentle dressings were expired and should have been taken out of the treatment cart. 3. During a concurrent observation and interview on [DATE] at 9:07 am, with LN A, an unattended treatment cart was observed to be unlocked. LN A confirmed the treatment cart was unlocked and should not have been when the cart is unattended by a nurse. 4. During a concurrent observation and interview on [DATE] at 9:07 am, with LN A, expired laboratory supplies were observed in the nurse's station storage area. Six blood specimen collection tubes that included, three yellow topped tubes had an expiration date of [DATE], one red and grey topped tube had an expiration date of [DATE], one lavender topped tube had an expiration date of [DATE], and one blue topped tube had an expiration date of [DATE], were in a drawer and available for use. LN A stated the facility staff did not normally collect blood samples, but if there was an emergency the LN A would utilize the blood specimen collection tubes that were stored in the nurse's station (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555907 If continuation sheet Page 17 of 21 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 555907 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Trinity Hospital Skilled Nursing Facility 60 Easter Ave Weaverville, CA 96093 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few storage area. LN A confirmed the six tubes were expired and should not be available for use. Two Hemoccult tests (a screening test that determined if there was blood in the stool), were observed with an expiration date of [DATE]. LN A confirmed the Hemoccult tests were expired and should not have been available for use. 5. During a concurrent observation and interview on [DATE] at 9:07 am, with LN A, a medication disposal box was observed to be sitting on top of the counter in the nurse's station. On the top left side of the medication disposal box was an opening that could be easily accessed and not prevent the retrieval of the medications. Upon observation, the opening contained more than five loose medications they were easy to remove. LN A confirmed there were more than five loose medications that were not secure in the disposal box and anyone could easily take the medications. LN A stated that nurses were expected to use a white paddle-like device to push the medications into the disposal box, rendering them inaccessible. During an interview on [DATE] at 11:30 am, the Pharmacy Consultant (PC) was asked if LNs were expected to write the opened date onto the bottles of OTC medication. PC was not able to provide an answer. During a review of the facility's undated policy and procedure (P&P) titled, Administering Medications, SNF Pharmacy, the P&P indicated when a multi-dose container was opened, the open date would be recorded on the container. The P&P indicated medication carts were to be locked when out of sight of a LN. During a review of the facility's undated P&P titled, Storage of Medications, SNF Pharmacy, the P&P indicated all nursing staff would be responsible for maintaining medication storage areas in a safe manner. During a review of the facility's undated P&P titled, Discarding and Destroying Medications, SNF Pharmacy, the P&P indicated medication would be destroyed in accordance with federal, state, and local regulations governing management of non-hazardous pharmaceuticals, hazardous waste, and controlled substances. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555907 If continuation sheet Page 18 of 21 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 555907 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Trinity Hospital Skilled Nursing Facility 60 Easter Ave Weaverville, CA 96093 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 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review, the facility failed to ensure food safety and sanitation guidelines were followed when: Residents Affected - Few 1. The deep freezer had a collapsed interior lid and ice buildup, where frozen food was stored. 2. Chipped paint with exposed rust or corrosion was on white wire shelves in the three-door reach in refrigerator, where food was stored. 3. The ventilation fans in the walk-in refrigerator, and the fans by the upper windows within the kitchen, had black debris and dust buildup. 4. The pipes under the food preparation sink next to the stove and dishwashing area, were covered with black debris and cumulative dust. 5. An open, unlabed, and undated ice cream cup was in the kitchenette designated for resident snacks. 6. Multiple areas of tile and floor covering was missing from the kitchen floor and there was dirt and debris in the corners of the floor. 7. A large area in the kitchen ceiling had an open hole, exposing the wood rafters near the dishwashing area at the exit door. These failures had the potential for the resident's to consume unsanitary food that had been prepared in a dirty kitchen, exposed to freezer burn, bacteria, mold, dirt and dust and cause them serious food borne illnesses. Findings: During a review of the facility's policy titled, Sanitation dated 2018, the policy indicated that all equipment shall be maintained as necessary and kept in working order.Counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seam, cracks, and chipped areas. The kitchen staff is responsible for all the cleaning except for ceiling vents, light fixtures, and the hood over the stove to maintain a clean kitchen. Additionally, the maintenance department will assist kitchen staff as necessary maintaining equipment and performing janitorial duties that the kitchen staff cannot do. 1. During a concurrent observation and interview on 7/18/23 at 10:00 am, the lid on the large deep freezer was collapsed and the inside of the lid was torn away from the outside of the lid and sagging therefore, unable to seal properly. Ice build-up was observed within the collapsed lid and within the body of the freezer. The Dietary Manager (DM) confirmed that the lid was broken, and it was possibly not sealing correctly, noting the ice buildup within. She stated that employees sit on the lid, and a new one needed to be ordered. In an interview on 7/21/23 at 8:45 am, Dietary [NAME] (DC) 3 confirmed that the freezer lid was broken and that a new one needed to be ordered. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555907 If continuation sheet Page 19 of 21 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 555907 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Trinity Hospital Skilled Nursing Facility 60 Easter Ave Weaverville, CA 96093 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few According to the USDA Food Code 2022 Section 4-501.11, Equipment shall be maintained in a state of repair and condition that meets requirements specified .equipment components such as doors, seals, hinges, fasteners, and kick plates shall be kept intact, tight and adjusted in accordance with manufacturers' specifications. 2. During a concurrent observation and interview on 7/18/23 at 10:00 am, the three-door reach-in refrigerators had chipped paint with rust or corrosion noted on the white wire shelves where residents' food was stored. The DM confirmed that the shelving was chipped with possible corrosion and agreed that cross contamination could potentially occur and could cause food-borne illness. According to the USDA Food Code 2022 Section 4-202.11 Multiuse food contact- surfaces shall be: Smooth, Free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections. 3. During a concurrent observation and interview on 7/18/23 at 10:00 am, the ventilation fans within the walk-in refrigerator and the fans in the kitchen near the upper-level windows had black debris and dust accumulation. DC 1 stated that the ventilator fans in the walk-in refrigerator and fans around the kitchen were, definitely dirty and that Maintenance was responsible for the cleaning the fans. The DM confirmed that the dirty vents/fans could cross contaminate food and cause food-borne illness. According to the USDA Food Code 2022 Section 4-601.11 (C) Nonfood- contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue and other debris .The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of pathogenic organisms, moisture, and debris tht deters the attraction of rodents and insects. 4. During a concurrent observation and interview on 7/18/23 at 10:00 am, the water pipes under the sink areas and overhead along walls within the kitchen had black debris and dust accumulation on them, some had noted corrosion. The DM confirmed the pipes were dirty, some rusty or corroded, all required cleaning, and dirty and corroded pipes in the kitchen could cause cross contamination and food borne illness. 5. During a concurrent observation and interview on 7/18/23 at 1:00 pm, a single, undated, unlabeled open ice cream cup was in the freezer in the kitchenette where resident snack food was kept. Certified Nursing Assistant (CNA) E confirmed the ice cream cup was open, undated, and unlabeled and indicated that it should not have been left that way. CNA E added that the ice cream had been brought in for a special ice cream day, and needed to be thrown away. During an interview on 7/19/23 at 8:30 am, the DM confirmed that an open container of any food item, should either be properly sealed, dated, and labeled, or thrown out. The DM stated that the evening Dietary Aide was responsible for checking the resident food items in the kitchenette. During a record review of the facility's policy titled, Foods brought by family/visitors, Med/Surg, SNF, Swing Bed dated 12/31/2019, indicated that perishable foods (once open), must be stored in resealable containers, labeled and dated, and discarded on the third day. 6. In a concurrent observation and interview on 7/18/23 at 10:00 am, the flooring in the kitchen was observed to be incomplete and unsightly with portions of floor missing, with debris and dirt noted in the corners. DM confirmed that all of the floor tiles had been removed because the floor was in the process of being replaced. DM confirmed that the condition of the flooring made it difficult to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555907 If continuation sheet Page 20 of 21 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 555907 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Trinity Hospital Skilled Nursing Facility 60 Easter Ave Weaverville, CA 96093 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few clean thoroughly and that there was debris and dirt which could be a source of cross contamination and food borne illness. According to the USDA Food Code 2022 Section 6-201.13 (A) Regarding floor cleaning in which cleaning methods other than water flushing are used for cleaning floors, the floor and wall junctures shall be covered and closed. 7. In a concurrent observation and interview on 7/18/23 at 10:00 am, there was a large gaping open area in the ceiling with exposed wood rafters at the back of the kitchen in the dishwashing area above the exit door. The DM confirmed that the hole was a result of water damage and was scheduled to be fixed by maintenance. DM confirmed that the hole in the kitchen ceiling could be a source of cross contamination and food-borne illness. According to the USDA Food Code 2022 Section 6-201.18 (Ceiling wood) Studs, joists, and rafters may not be exposed in areas subject to moisture. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555907 If continuation sheet Page 21 of 21