Inspection·September 5, 2025

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide adequate pharmaceutical services, including accurate dispensing, and administering of all drugs, to meet the needs of each resident for two of three Residents (Residents 1 and 8) when Diclofenac Sodium (generic name) External Gel 1% / Voltaren (brand name) External Gel 1% (Topical gel containing an active ingredient of non-steroidal anti-inflammatory drug NSAID for pain relief) was ordered, dispensed, and administered without appropriate order details including the dosage quantity as required by professional standards. This failure had the potential to endanger the health and safety of residents being administered medication without the appropriate order details including dosage amount to be dispensed.During a review of the facility's policy and procedure titled, Medication and Treatment Orders, SNF (Skilled Nursing Facility) Pharmacy, dated 7/3/25, the policy indicated, Orders for medication and treatments will be consistent with principles of safe and effective order writing.All drug orders shall.(include) The name, quantity or specific duration of therapy, dosage, and time or frequency of administration.During a review of the facility's policy and procedure titled, Administering Medications, SNF Pharmacy, undated, the policy indicated, Medication shall be administered in a safe.manner.If a dosage is believed to be inappropriate.the person preparing or administering the medication shall contact the resident's attending provider or the facility's Medical Director.The individual administering the medication must check the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method of administration before giving the medication.A review of Resident1's medical record indicated that Resident 1 was admitted on [DATE] with diagnoses that included Other Specified Arthritis (a group of conditions that cause inflammation and pain in the joints), Fibromyalgia (condition characterized by muscle pain and other symptoms such as fatigue, sleep disturbance, and cognitive difficulties), and Diabetes Mellitus.A review of Resident 1's medical record indicated that the Minimum Data Set (MDS, Tool for evaluating and implementing a standardized assessment) Brief Interview for Mental Status (BIMS, Section C assessing cognitive function) score dated 6/18/25, demonstrated Resident 1 scored 15/15, which equates to being cognitively intact. Resident 1 is their own representative (RP) and makes all their own medical decisions. During a concurrent observation, interview, and record review on 9/4/25 at 8:45 am, with Licensed Nurse (LN) A at the medication cart, Resident 1's medication orders are reviewed during medication pass prior to administration. Resident 1 has a medication order, dated 5/13/25, for Diclofenac Sodium External (topical) Gel 1%, Apply to Left (L) Shoulder, L Hip, topically one time a day for mild pain related to Other Specified Arthritis, Unspecified Site and low back per resident's directions. LN A is observed using the manufacturer's recommended dosing card enclosed in the medication box to measure an amount to administer for Resident 1. LN A states I have never seen an order from the medical provider for Diclofenac Topical Gel/ Voltaren External Gel with the precise dosage provided, so I use the manufacturer's recommended dose guide and make sure there is enough to cover the affected areas since some resident's areas are larger than other resident's areas.A review of Resident 8's medical record indicated that Resident 8 was admitted on [DATE] with diagnoses that included Adult Failure to Thrive (FTT, condition in older adults marked by physical and mental decline), Chronic Lymphocytic Leukemia of B Cell Type (CLL, slow progression type of cancer of the blood and bone marrow), Anemia (Abnormally low number of red blood cells or hemoglobin in the blood). A review of Resident 8's medical record indicated that the MDS BIMS score dated 5/16/25, demonstrated that Resident 8 scored 14/15, which equates to being cognitively intact. Resident 8 is their own RP and makes all their own medical (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555907 If continuation sheet Page 2 of 4 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 09/05/2025 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete decisions.A review of Resident 8's medical record titled, Order Details, for Voltaren External Gel 1%, Apply to general application topically every 6 hours as needed for mild to severe pain of 1/10 to 10/10 pain. During a concurrent interview and record review on 9/4/25 at 2:00 pm, with the Director of Staff Development (DSD) in the DSD staff office, Resident 1 and 8's medical records titled, Order Details regarding medication orders of Diclofenac Sodium External Gel 1%/ Voltaren External Gel 1% were reviewed. DSD confirms none of the provider's orders have dosages included as is expected per professional standards.During a concurrent interview and record review on 9/4/25 at 2:30 pm, with the Pharmacist (PD) in the conference room, Resident 1and 8's medical records titled, Order Details for Diclofenac Sodium External Gel 1%/ Voltaren External Gel 1% were reviewed. PD confirms the orders have no dosage. PD states this has been an issue since the medication became available over the counter (OTC, not requiring a prescription for at home use). PD confirms the professional standard dictates orders are not complete without a dosage, and there should be at least a maximum dosage in grams (a unit of measure) provided in order to administer the medication at the facility. Event ID: Facility ID: 555907 If continuation sheet Page 3 of 4 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 09/05/2025 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 - Many FORM CMS-2567 (02/99) Previous Versions Obsolete 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 maintain professional standards of practice to ensure food service safety for the residents of the facility when: 1. During the initial tour food preparation equipment was not sanitary. 2. Dietary staff failed to maintain clean, sanitary floors. 3. Dietary staff failed to keep foods stored away from unsanitary surfaces in the walk-in refrigerator. These failures had the potential for risk of cross contamination, to cause infection control issues, and lead to food borne illness for residents consuming food in the facility. A review of a facility document titled, Infection Control, Dietary, with an expiration date of 11/07/2025, indicated, .services are provided in a manner that minimizes the risk of hospital acquired infections to patients, staff, and visitors. The document continues, Keep work areas, surfaces.clean and orderly. and Observe safe practices in storing and serving foods. A review of a facility document titled, Cleaning List- AM Cooks, undated, indicated, the cleaning of the steam table (a table with slots to hold food containers which are kept hot by steam or hot water circulating beneath them) and under the steam table is to be done on Tuesdays and Saturdays. A review of a facility document titled, Night Aide: Cleaning Duties, undated, indicated, the kitchen floors were to be swept and mopped daily. 1. During an interview and observation on 9/2/25 at 12:56 pm, the steam table had a build-up of rust and dark burnt food around its body, on 3 sides. The attached stainless steel shelf below had rust, white food particles, dirt, and drops of dried paint . Sitting on the shelf were two shallow serving dishes and one deep serving dish with a lid, all with white food particles on them. The edges of the shelf had dried food drip marks. The legs had dried liquid streak drip marks and mineral streak drip marks. The long plastic cutting board attached to the steam table was stained yellow, with darker yellow/brown spots. Cut marks and cracks were stained a dark color. The Dietary Manger (DM) confirmed that the condition of the steam table and cutting board could cause infection control issues.2. During an interview and observation on 9/2/25 at 12:56 pm, the floor around the steam table had a heavy build-up of hard dirt and grime, dried food particles, and heavy build-up of rust around the legs and underneath the steam table. The DM confirmed that the dirt, grime and rust could cause infection control issues.3. During an interview and observation on 9/2/25 at 1:05 pm, the supporting structure for the condenser (cooling system) in the walk-in refrigerator had a build-up of dirt and grime. The left bracket of the supporting structure of the condenser had an off-white/light yellow, dirt and dark grime coating. There was also small areas with dark centers with a radiating light brown color encompassing the dark centers in an irregular pattern. The right bracket of the supporting structure for the condenser had peeling white paint, along with an off-white, dirt and grime coating. The DM confirmed that the dirt and grime coating and the small areas of varied discoloration could be an infection control issue.During an interview on 9/2/25 at 2:02 pm, the DM confirmed that the steam stable, the floors, and the brackets on the condenser in the walk-in refrigerator were unsanitary and could cause cross-contamination and infection control issues. The DM stated that these conditions could attract pests, rodents, and unknown organisms, which could be harmful to the residents.During an interview on 9/5/25 at 9:01 am, Maintenance (MN) confirmed that the dirt and grime build-up and peeling paint on the brackets of the condenser in the walk-in refrigerator could be a cause for cross contamination and infection control issues. MN stated that the kitchen floors would be back on the schedule for regular maintenance. Event ID: Facility ID: 555907 If continuation sheet Page 4 of 4