Health inspection·March 20, 2024

F 0800 Level of Harm - Minimal harm or potential for actual harm Observation of meal service in the Dining Room on 3/20/24, at 11:30 a.m. revealed several staff serving meals. An unidentified female resident was seated in the dining room, and NA Employee E1 indicated she's from the other side but she usually eats over here with us. When Survey Agency (SA) asked NA Employee E1 if the female resident's meal ticket was in the stack she was serving from, she stated I'm not sure, I think it's on the other side (middle dining area). Residents Affected - Few Interview on 3/20/24, at 11:31 a.m. NA Employee E2 at the middle dining area indicated the female resident's tray ticket was on the first side. Interview on 3/20/24, at 11:32 a.m. NA Employee E1 at the first dining area indicated she had located the female resident's tray ticket. Observation on 3/20/24, at 11:35 a.m. Resident R1 was observed lying in bed, visiting with family who brought lunch from home for resident. Interview with Resident R1's family on 3/20/24, at 11:35 a.m. indicated the other day, Resident R1 didn't receive a lunch tray and it's happened a few times before. Family also indicated he's supposed to be getting Boost Plus twice a day and he hasn't had it in a while. Observation of lunch tray in room on 3/20/24, at 11:35 a.m. revealed ground Caribbean shrimp, liquefied cauliflower/cheddar soup, potato wedges, ground Italian vegetable blend, Boston crème pie. Two iced teas. The tray ticket also indicated Extra Items of Boost Chocolate and strawberry ice cream. The tray had no Boost Chocolate and the strawberry ice cream was fat free. During the observation in Resident R1's room on 3/20/24, at 11:37 a.m. NA Employee E3 brought another lunch tray in that had a chicken pot pie, mashed potatoes, gravy, two iced teas, and regular strawberry ice cream. There was not a Boost Plus on the tray. When questioned, on 3/20/24, at 11:38 a.m. NA Employee E3 indicated she didn't realize someone had already brought him a tray. They must have brought it from the other side. She confirmed the first tray had fat free strawberry ice cream and that neither tray had Boost Plus on it. Interview on 3/20/24, at 11:42 a.m. NA Employee E4 indicated the other side must have given Resident R1 a tray too and they did not realize there was not a Boost Plus on the tray. Interview on 3/20/24, at 11:43 a.m. NA Employee E2 indicated We haven't had Chocolate Boost Plus in a long time. I just give Resident R1 chocolate milk because he doesn't like vanilla and that's all they can get. Interview on 3/20/24, at 1:01 p.m. Registered Dietitian (RD) Employee E5 indicated We've had supply issues with the Chocolate Boost Plus on and off since the pandemic. Currently we can get Ensure but only in vanilla. RD Employee E5 confirmed the Boost Plus had 360 calories and 14 grams of protein, while the facility's chocolate milk provided only 211 calories and only eight grams of protein per serving, and that it was not an equivalent substitution. Interview on 3/20/24, at 2:00 p.m. the Nursing Home Administrator and Director of Nursing confirmed the facility failed to meet the daily nutritional and special dietary needs for one of six residents (Resident R1), and failed to have a structured meal delivery system to ensure residents received their meals accurately, and timely on a consistent basis. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395713 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 395713 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willows of Presbyterian Senior 1215 Hulton Road Oakmont, PA 15139 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 0800 28 Pa. Code: 201.18(b)(1)(e)(1) Management Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code: 201.12(d)(1)(3)(5) Nursing services 28 Pa. Code: 201.1(i)Resident rights. Residents Affected - Few 28 Pa Code: 211.6(c)(d) Dietary Services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395713 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 395713 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willows of Presbyterian Senior 1215 Hulton Road Oakmont, PA 15139 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to ensure that clinical records were complete and accurate for one of six residents reviewed (Resident R1). Findings include: Review of the facility policy Medical Records-The Medical Record date 12/12/23, indicated that the medical record will contain complete and accurate documentation, which clearly identifies the resident, justifies the diagnoses, condition, treatment, care approaches, and responses to the care provided. Review of Resident R1's admission record indicated the resident was admitted to the facility on [DATE], with the diagnoses of dementia (a general term for loss of memory, language, problem solving and other thinking abilities that are severe enough to interfere with daily life), chronic obstructive pulmonary disease (constricted airways cause difficulty or discomfort in breathing), and congestive heart failure (the heart doesn't pump blood effectively). Review of Resident R1's current physician orders dated 3/20/24, indicated Boost Plus (liquid supplement) two times a day. Review of Resident R1's Medication Administration Record dated March 2024, indicated Boost Plus was administered two times a day from 3/1/24, through 3/19/24. Interview on 3/20/24, at 1:01 p.m. Registered Dietitian (RD) Employee E5 indicated We've had supply issues with the Chocolate Boost Plus on and off since the pandemic. They are supposed to be giving Ensure in place of it. Interview on 3/20/24, at 1:03 p.m. the Director of Nursing confirmed the nurses were documenting twice daily that Boost Plus was being administered, although they did not have Boost Plus in stock, and that the physician's orders should have been updated. Review of Resident R1's current physician orders dated 3/20/24, indicated an order from 2/13/24, for a low air loss mattress (prevents pressure), to be checked by nurse for function every shift. Observation 3/20/24, at 11:35 a.m. Resident R1 had a perimeter mattress on bed. Interview on 3/20/24, at 1:30 p.m. the Director of Nursing confirmed the low air loss mattress was not in place and that the physician order needed updated. Interview on 3/20/24, at 2:00 p.m. the Director of Nursing confirmed the facility failed to ensure that clinical records were complete and accurate for one of six residents reviewed (Resident R1). 28 Pa. Code 211.5(f) Clinical Records 28 Pa. Code 211.12(d)(1)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395713 If continuation sheet Page 4 of 4