Health inspection·November 22, 2024

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, observations and staff interviews it was determined that the facility failed to provide a safe, clean, comfortable, and homelike environment for eight of 12 residents (Resident R3, R5, R70, R73, R76, R93, R113, and R361). Findings include: Review of the facility policy Resident Rights - Quality of Life - Homelike Environment dated August 2024, indicated the facility will provide residents with a safe, clean, comfortable, and homelike environment. Review of Title 42 Code of Federal Regulations §483.10(i) Safe Environment. The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. §483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Review of the admission record indicated Resident R3 was admitted to the facility on [DATE]. Observation on 11/18/24, at 10:30 a.m. of Resident R3's room indicated gouges in the wall behind the head of the bed. Tour and interview with Unit Manager Employee E2 on 11/19/24, at 9:47 a.m. confirmed Resident R3 had gouges in the wall behind the head of the bed. Review of the admission record indicated Resident R5 was admitted to the facility on [DATE]. Observation on 11/18/24, at 11:33 a.m. Resident R5 was seated in a wheelchair at the dining table. The frame and undercarriage of the wheelchair was covered with dust and dried debris. Interview on 11/18/24, at 11:34 a.m. Nurse Aide (NA) Employee E1 confirmed the wheelchair was covered with dust and dried debris. Review of the admission record indicated Resident R70 was admitted to the facility on [DATE]. Observation on 11/18/24, at 11:40 a.m. of Resident R70's room indicated gouges in the wall behind the head of the bed. Tour and interview with Unit Manager Employee E2 on 11/19/24, at 9:47 a.m. confirmed Resident R70 had gouges in the wall behind the head of the bed. Review of the admission record indicated Resident R73 was admitted to the facility on [DATE]. Observation on 11/18/24, at 11:43 a.m. Resident R73 was seated in a wheelchair visiting with family. The frame and undercarriage of the wheelchair was covered with dust and dried debris. Interview on 11/18/24, at 11:44 a.m. Environmental Aide Employee E3 confirmed R73's wheelchair was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395713 If continuation sheet Page 2 of 23 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 11/22/2024 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 0584 covered with dust and dried debris. Level of Harm - Minimal harm or potential for actual harm Review of the admission record indicated Resident R76 was admitted to the facility on [DATE]. Residents Affected - Some Observation on 11/18/24, at 11:44 a.m. of Resident R76's room indicated an uneven surface into the entrance of the bathroom that posed a safety hazard. The transition strip from bedroom to bathroom was missing. Tour and interview with Unit Manager Employee E2 on 11/19/24, at 9:47 a.m. confirmed Resident R76's transition strip from bedroom to bathroom was missing. Review of the admission record indicated Resident R93 was admitted to the facility on [DATE]. Observation on 11/18/24, at 10:39 a.m. Resident R93 was seated in a wheelchair. The frame, wheels, and undercarriage of the wheelchair was covered with dust and dried debris. Interview on 11/18/24, at 10:39 a.m. NA Employee E6 confirmed R93's frame, wheels, and undercarriage of the wheelchair was covered with dust and dried debris. Review of the admission record indicated Resident R113 was admitted to the facility on [DATE]. Observation on 11/18/24, at 10:16 a.m. Resident R113 was seated in a wheelchair with a right lateral support (positioning device) corroded in dried grime and debris. The wheelchair brakes, frame, and undercarriage were grossly corroded in dried grime and debris. Interview on 11/18/24, at 10:16 a.m. NA Employee E6 confirmed R113's right lateral support, wheelchair brakes, frame, and undercarriage were grossly corroded in dried grime and debris. Review of the admission record indicated Resident R361 was admitted to the facility on [DATE]. Observation on 11/18/24, at 9:54 a.m. of Resident R361's room indicated an uneven surface into the entrance of the bathroom that posed a safety hazard. The transition strip from bedroom to bathroom was missing. Tour and interview with Unit Manager Employee E2 on 11/19/24, at 9:47 a.m. confirmed Resident R361's transition strip from bedroom to bathroom was missing. Interview on 11/19/24, at 9:50 a.m. the Unit Manager Employee E2 confirmed that the facility failed to provide a safe, clean, comfortable, and homelike environment for eight of 12 residents (Resident R3, R5, R70, R73, R76, R93, R113, and R361). 28 Pa. Code 201.1(i)Resident rights. 28 Pa Code: 201.14 (a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395713 If continuation sheet Page 3 of 23 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 11/22/2024 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 0625 Level of Harm - Potential for minimal harm Residents Affected - Many Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical record review and staff interviews, it was determined that the facility failed to notify the resident or resident's representative of the facility bed-hold policy (an agreement for the facility to hold a bed for an agreed upon rate during a hospitalization) for three of five residents hospital transfers (Resident R77, R96, R131). Findings include: Review of Resident R131's admission record indicated she was originally admitted on [DATE], with diagnoses that included anxiety disorder, depression and diabetes mellitus. Review of the clinical record indicated Resident R131 was transferred to hospital on 3/23/24 and returned to the facility on 3/28/24. Review of Resident R131's clinical record failed to include documented evidence that the resident or the resident's representative were provided with written information about the facility's bed hold policy at the time of the transfer to the hospital on 3/23/24. Review of Resident R77's admission record indicated she was originally admitted on [DATE], with diagnoses that included heart failure, hyperlipidemia and dysphagia. Review of Resident R77's clinical record revealed that the resident was transferred to the hospital on 7/26/24, and returned to the facility on 7/31/24, also 10/23/24 and returned to the facility 10/28/24. Review of Resident R77's clinical record failed to include documented evidence that the resident or the resident's representative were provided with written information about the facility's bed hold policy at the time of the transfer to the hospital on 7/26/24 and 10/23/24. Review of Resident R96's admission record indicated she was originally admitted on [DATE], with diagnoses that included fracture of right humerus, repeated falls and hyperlipidemia. Review of the clinical record indicated Resident R96 was transferred to hospital on [DATE] and returned to the facility on [DATE]. Review of Resident R96's clinical record failed to include documented evidence that the resident or the resident's representative were provided with written information about the facility's bed hold policy at the time of the transfer to the hospital on [DATE]. During an interview on 11/21/24, at 11:15 a.m. Medical Records Employee E7 confirmed that the facility failed to notify the resident or resident's representative of the facility bed-hold policy for three of five residents hospital transfers as required (Resident R77, R96, R131). 28 Pa. Code 201.29 (a)(c.3)(2) Resident rights FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395713 If continuation sheet Page 4 of 23 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 11/22/2024 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 0638 Assure that each resident’s assessment is updated at least once every 3 months. Level of Harm - Minimal harm or potential for actual harm Based on review of the Resident Assessment Instrument (RAI) Users Manual, clinical record review, and staff interview, it was determined that the facility failed to timely complete a quarterly Minimum Data Set (MDS) assessment for one of nine residents. (Resident 144) Residents Affected - Few Findings include: The Long-Term Care Facility RAI User's Manual, which provides instructions and guidelines for completing required MDS assessments (mandated assessments of a resident's abilities and care needs), revised October 2023, indicates that quarterly assessments must be no more than 92 days after the Assessment Reference Date (ARD) of the most recent assessment, and the assessment was to have a completion date that was no later than the ARD plus 14 calendar days. Clinical record review revealed that Resident 144 had an admission MDS assessment completed on 6/6/24. There was no evidence that any MDS assessment, including a quarterly assessment, had been completed after 6/6/24. Review of Resident R144's clinical record on 11/21/24, indicated a quarterly MDS assessment was to be completed by 9/20/24. It was 62 days overdue. During an interview on 11/21/24, at 9:53 a.m., Registered Nurse Assessment Coordinator, Employee E11 confirmed the facility failed to timely complete a quarterly MDS assessment for one of nine sampled residents. (Resident 144) 28 Pa. Code 211.5(f) Clinical Records. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395713 If continuation sheet Page 5 of 23 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 11/22/2024 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 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 a review of Resident Assessment Instrument (RAI) User's Manual, clinical records, and staff interviews, it was determined that the facility failed to ensure that MDS assessments accurately reflected the resident's status for two of two residents (Resident R36 and R158). Residents Affected - Few Findings include: The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs),dated October 2023, indicated the following instructions: -Observation (Look-Back, Assessment) Period is the time period over which the resident's condition or status is captured by the MDS assessment. Most MDS items themselves require an observation period, such as 7 or 14 days, depending on the item. Since a day begins at 12:00 a.m. and ends at 11:59 p.m., the observation period must also cover this time period. A standard 7-day look-back period counts back from and includes the Assessment Reference Date (ARD+6 previous days). -Section C: Resident interview should be conducted because the resident is at least sometimes understood verbally, in writing, or using another method, and if an interpreter is needed, one is available. Review of Resident R36's admission record indicated she was admitted to the facility on [DATE], with diagnoses of aphasia (a disorder that results from damage to portions of the brain that are responsible for language) and dysphagia (difficulty swallowing). Review of Resident R36's MDS assessment dated [DATE], indicated the diagnoses were current. Section B: Hearing, Speech, and Vision, question B0700 measures the resident's ability to express ideas and wants indicated that Resident R36 is understood. Review of Section C: Cognitive Patterns, Question C0100 indicated that Resident R36 is rarely/never understood, and the BIMS (brief interview for mental status) assessment was not completed. During an attempted interview conducted on 11/18/24, at 10:30 a.m. Resident R36 was unable to be understood. During an interview on 11/20/24, at 11:42 a.m. Licensed Practical Nurse, Employee E13 confirmed Resident R36 does not speak and cannot be understood. Review of Resident R158's admission record indicated he was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses of Parkinson's Disease (a movement disorder of the nervous system that worsens over time), high blood pressure, and anxiety. Review of Resident R158's progress note dated 9/10/24, at 1:49 p.m. indicated the resident was transferred to the hospital due to altered mental status, hypoxia (low oxygen levels), respiratory failure, fever, and high blood pressure. Review of Resident R158's MDS dated [DATE], Section A2105. Discharge Status indicated the resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395713 If continuation sheet Page 6 of 23 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 11/22/2024 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 0641 was discharged to home/community). Level of Harm - Minimal harm or potential for actual harm During an interview on 11/21/24, at 2:56 p.m. the Nursing Home Administrator and DON confirmed the facility failed to ensure that MDS assessments accurately reflected the resident's status for two of two residents (Resident R36 and R158). Residents Affected - Few 28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing Services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395713 If continuation sheet Page 7 of 23 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 11/22/2024 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy, clinical records and staff interview, it was determined that the facility failed to update a care plan for one of two residents (Resident R316) to accurately reflect the current status of the resident. Findings include: Review of facility policy Comprehensive Care Plan dated 8/24 indicates a comprehensive person centered care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and physiological needs is developed for each resident. Review of clinical record indicated Resident R316 was admitted to the facility on [DATE], with diagnoses that included congestive heart failure (serious condition that occurs when the heart can't pump enough blood to meet the body's needs), asthma and atrial fibrillation a heart condition that causes an irregular and often rapid heartbeat in the upper chambers of the heart). Review of Resident R316's Minimum Data Set (MDS-a mandated assessment of a resident's abilities and care needs) assessment, dated 11/9/24, indicated the diagnoses remain current. Review of Resident R316's physician orders dated 11/3/24 indicated 1800 fluid restriction. Review of Resident R316's Resident Care Plan Summary Report (report nurse aides used to know what kind of care to provide) dated 11/13/24, indicated to encourage fluids. During an interview on 11/20/24, at 2:00 p.m. Director of Nursing (DON) confirmed the facility failed to revise care plan for Resident R316. 28 Pa. Code: 211.11(d) Resident Care Plan FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395713 If continuation sheet Page 8 of 23 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 11/22/2024 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 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a resident's interview, clinical record review and review of the facility policy, it was determined that the facility failed to provide the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living, including communication (Resident R36), and eating (Resident R60) for two of seven residents. Residents Affected - Few Finding include: Review of the facility policy titled, Nutritional Assessment and Care Plan last reviewed 8/24, indicated the Dietician will complete a comprehensive nutritional assessment and nutritional care plan for each resident to be individualized to that resident's nutritional problems and/or needs. The information will be documented in the resident's clinical record. Review of Resident R36's admission record indicated she was admitted to the facility on [DATE], with diagnoses of aphasia (a disorder that results from damage to portions of the brain that are responsible for language) and dysphagia (difficulty swallowing). Review of Resident R36's MDS assessment dated [DATE], indicated the diagnoses were current. Review of Resident R36's progress note dated 3/15/24, indicated the resident has expressive aphasia. It was stated the resident's speech is unclear and she has a language barrier. It was indicated the resident is rarely/never makes self understood, however the resident usually understands others. Review of Resident R36's progress note dated 4/8/24, indicated it was difficult to obtain a full review of systems due to much of speech being repetitive and incomprehensible. However, she will answer yes and no to some very simple questions. During an attempted interview conducted on 11/18/24, at 10:30 a.m. Resident R36 was unable to be understood and was incomprehensible. Review of Resident R36's clinical record on 11/20/24, failed to include a care plan to address Resident R36's communication needs. During an interview on 11/20/24, at 11:42 a.m. Licensed Practical Nurse, Employee E13 confirmed Resident R36 does not speak and cannot be understood. It was indicated the resident puts blanket over her head and shakes her head. LPN, Employee E13 confirmed Resident R36 does not have a communication device. During an interview on 11/20/24, at 12:54 p.m. the Director of Nursing confirmed the facility failed to ensure the appropriate treatment and services to maintain or improve Resident R36's ability to carry out the activities of daily living, for communication was provided. Review of Resident R60's admission record indicated she was admitted to the facility on [DATE], readmitted [DATE], with diagnoses of dysphagia (difficulty swallowing), depression, and hemiplegia (paralysis affecting one side of the body). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395713 If continuation sheet Page 9 of 23 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 11/22/2024 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 0676 Review of Resident R60's MDS assessment dated [DATE], indicated the diagnoses were current. Level of Harm - Minimal harm or potential for actual harm Review of Resident R60's active physician order dated 8/1/23, indicated the resident is to be out of bed in a chair every day prior to lunch to help open lung fields and to have her meal out of bed. Residents Affected - Few Review of Resident R60's active physician order dated 8/1/23, indicated the resident is to be out of bed for all meals. Review of Resident R60's care plan dated 8/6/23, indicated the resident has a swallowing problem due to coughing or choking during meals. During an observation and interview on 11/20/24, Resident R60 was observed sitting in bed eating lunch. Resident R60 indicated no one has offered to get her out of bed. She indicated usually on her shower days, staff do not get her out of bed for meals. During an interview on 11/20/24, at 12:13 p.m. LPN, Employee E14 stated they don't take her out of bed on shower days when asked why Resident R60 was not out of bed as ordered for lunch. During an interview on 11/20/24, at 2:48 p.m. the Director of Nursing and Nursing Home Administrator confirmed the facility failed to is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living, including communication (Resident R36), dining and eating (Resident R60). 28 Pa. Code 211.109d) Resident care policies 28 Pa. Code 211.12(c)(d)(1) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395713 If continuation sheet Page 10 of 23 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 11/22/2024 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical record review, observations, and staff interviews, it was determined that the facility failed to ensure vital signs parameters (value ranges) were documented on the medication administration record per physician orders for two of six residents (Resident R24, and R70), and failed to discontinue incisional care once healed for one of six residents (Resident R151). Residents Affected - Few Findings include: Review of facility policy Nursing Documentation of Medication Administration dated August 2024, indicated the facility shall maintain a medication administration record to document all medications administered. Review of the facility policy Nursing - Medication and Treatment Orders dated August 2024, indicated orders for medications and treatments will be consistent with principles of safe and effective order writing. Review of the admission record indicated Resident R24 admitted to the facility on [DATE]. Review of Resident R24's Minimum Data Set (MDS - a periodic assessment of care needs) dated 9/30/24, indicated the diagnosis of high blood pressure, Non-Alzheimer's Dementia (dementia caused by other diseases with symptoms forgetfulness, limited social skills, and impaired thinking abilities that interfere with daily functioning), and depression. Review of Resident R24's physician order dated 11/4/24, indicated losartan (a medication to treat high blood pressure) 25 milligrams (mg) by mouth at bedtime for high blood pressure. Hold medication if blood pressure is less than 110. Review of Resident R24's current care plan indicated the resident will remain free of complications related to high blood pressure through review date. Blood Pressure log as ordered. Review of Resident R24's Medication Administration Record (MAR) dated November 2024, indicated from 11/5/24, through 11/19/24, that Resident R24 received the losartan 25mg at bedtime. The parameter blood pressure at bedtime was not documented on the MAR. Review of Resident R24's Blood Pressure Summary log indicated from 11/4/24, through 11/17/24, blood pressure being recorded on nine occurrences. None of the recorded blood pressures were completed at bedtime, the time of administration of the losartan. Interview on 11/20/24, at 10:10 a.m. Registered Nurse (RN) Employee E8 confirmed the facility did not document the parameter of blood pressure at bedtime as ordered for Resident R24's losartan administration. Review of the admission record indicated Resident R70 admitted to the facility on [DATE]. Review of Resident R70's MDS dated [DATE], indicated the diagnosis of high blood pressure, Non-Alzheimer's Dementia, and anxiety (intense, excessive, and persistent worry and fear about everyday situations). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395713 If continuation sheet Page 11 of 23 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 11/22/2024 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident R70's physician order dated 11/11/24, indicated amlodipine besylate (a medication to treat high blood pressure) 5mg daily. Hold if systolic blood pressure is less than 100. Review of Resident R70's current care plan failed to include high blood pressure. Review of Resident R70's Medication Administration Record (MAR) dated November 2024, indicated from 11/12/24, through 11/19/24, that Resident R70 received the amlodipine besylate on seven occasions. The parameter blood pressure was not documented on the MAR. Review of Resident R70's Blood Pressure Summary log indicated from 11/1/24, through 11/19/24, blood pressure was recorded only one time on 11/1/24, prior to the start of the medication on 11/12/24. Interview on 11/20/24, at 10:10 a.m. RN Employee E8 confirmed the facility did not document the parameter of blood pressure as ordered for Resident R70's amlodipine besylate administration. Review of the admission record indicated Resident R151 was admitted to the facility on [DATE]. Review of Resident R151's MDS dated [DATE], indicated the diagnosis of Non-Alzheimer's Dementia, thyroid disorder, and hip fracture. Review of Resident R151's physician order dated 10/2/24, indicated wound care: cleanse incision to upper back with alcohol and cover with a Primapore dressing (a soft, water resistance, non-adherent wound dressing) one time a day. Review of Resident R151's current care plan indicated skin integrity: spinal (back) incision. Keep skin clean and moisturized. Review of Resident R151's Treatment Administration Record (TAR) dated November 2024, indicated the treatment was administered in the evening from 11/1/24, through 11/17/24. Observation on 11/19/24, at 9:47 a.m. Unit Manager Employee E2 provided privacy to Resident R151 and pulled clothing back to assess spinal incision. There was a healed incision from the base of the neck to lower back. There was not a dressing in place as ordered. Interview on 11/19/24, at 9:48 a.m. Unit Manager Employee E2 indicated They must have forgotten to discontinue the order. The incision is healed. Interview on 11/20/24, at 12:00 p.m. the Director of Nursing confirmed the facility failed to ensure vital signs parameters were documented on the MAR per physician orders for two of six residents (Resident R24, and R70), and failed to discontinue incisional care and treatment once healed for one of six residents (Resident R151). 28 Pa. Code: 211.10(c)(d) Resident care policies. 28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395713 If continuation sheet Page 12 of 23 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 (X3) DATE SURVEY COMPLETED A. Building 11/22/2024 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on review of facility policies, clinical records, facility documents and staff interviews, it was determined that the facility failed to ensure residents were assessed, and provided necessary treatment and services, consistent with professional standards of practice, for a pressure ulcer (PU/PIs- injuries to skin and underlying tissue resulting from prolonged pressure on the skin) for one of three residents (Resident R72). Residents Affected - Few Findings include: Review of facility policy Stage and Treat Pressure Injury, updated in August 2024, indicated the following: 1. Cleanse wound with normal saline before identification and measurement, unless contraindicated. 2. Describe appearance (redness, rash, puffiness, observe edges of wound). 3. Measure length, width, and depth of wound with disposable tape measure. 4. Inspect for drainage and odor. 5. Inspect for presence of eschar in wound bed. 6. Inspect for tunneling. 7. Use Staging Document in Reference options, to identify stage of wound 8. Initiate treatment identified in the Staging Document for the identified stage. Review of facility policy Document Wound and Pressure Injury, updated August 2024, indicated the following: 1. Document size: Measure in centimeters - Length = head to toe direction - Width = hip to hip direction - Depth = Measure deepest part of visible wound bed 2. Document any undermining, tunneling, or sinus tracts, document using the 'clock system' with the head being 12:00 (example: 2cm undermining at 3 o'clock) 3. Describe any exudates (drainage) type, amount, odor 4. Odor: presence or absence of odor 5. Describe characteristics of tissue in wound bed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395713 If continuation sheet Page 13 of 23 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 11/22/2024 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 0686 6. Describe wound edges Level of Harm - Minimal harm or potential for actual harm 7. Describe surrounding tissue: color, edema, firmness, intact, induration, pallor, lesions, texture, scar, rash, moisture Residents Affected - Few 8. Describe indicators of infection 9. Document any pain or indicators of pain associated with wound or treatment 10. Document intervention for healing 11. Document current topical treatment plan, response to treatment, modifications to plan and/or implementation of new orders, reasons for NOT changing plan and any referrals 12. Document Resident Education. Review of facility policy Skilled Nursing - Comprehensive Care Plans, updated 2/7/24, indicated a comprehensive person-centered care plan that includes measurable objectives and timetables to meet resident's medical, nursing, mental and psychological needs is developed for each resident. Review of clinical record indicated that Resident R72 was admitted to facility 10/10/24, with diagnoses of left leg fracture, protein-calorie malnutrition, and diabetes mellitus (a metabolic disorder in which the body has high sugar levels for prolonged periods of time). Review of Resident R72's clinical record Clinical Admission assessment, dated 10/10/24, failed to indicate the resident had any pressure injuries. Review of Resident R72's clinical record Skin Check assessment, dated 10/11/24, indicated a 5 x 5 cm open area on coccyx. The assessment failed to identify type, staging, and description of the open area. Review of Resident R72's active physician order dated 10/11/24, through 10/15/24, indicated to apply a butterfly dressing to the coccyx area. The dressing was ordered to be changed daily and PRN (as needed) for soilage. The facility failed to enter an order to cleanse the resident's stage three pressure ulcer. Review of Resident R72's Minimum Data Set (MDS - a periodic assessment of care needs) dated 11/16/24, indicated diagnoses remain current upon review. Skin Condition - Section M0100 indicated that resident had a pressure ulcer/injury; Section M0210 indicated yes this resident has one or more unhealed pressure/ulcer injuries; Section M0300C. indicated a 1 for the number of Stage 3 (full-thickness skin loss with damage to subcutaneous tissue extending down to (but not including) the underlying fascia) pressure ulcers present on admission. Section V - Care Area Assessment (CAA) Summary, V200, A. CAA Results indicated an X that Pressure Ulcer Care Area triggered, and indicated an X that Care Planning Decision was made. Review of facility provided document Pressure Report, current on 11/18/24, indicated that Resident R72 was admitted to the facility with a stage 3 pressure ulcer. During an interview on 11/20/24, at 9:35 a.m., the Director of Nursing (DON) confirmed that the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395713 If continuation sheet Page 14 of 23 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 11/22/2024 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few facility failed to have a physician order to cleanse the resident's coccyx pressure ulcer from 10/10/24, through 10/15/24. Review of Resident R72's current plan of care on 11/20/24, failed to include a pressure ulcer care plan. During an interview on 11/20/24, at 10:50 a.m., Resident Nurse Assessment Coordinator (RNAC) Employee E11 stated that he failed to care plan goals and interventions for Resident R72's stage 3 coccyx pressure injury. During an interview on 11/20/24, at 12:30 p.m., Wound Care Nurse (WCN) Employee E10 indicated that per her knowledge and best practice, physician orders for wound care should include cleansing, treatment, and dressing instructions. WCN Employee E10 stated that Resident R72 should have had physician orders to cleanse the resident's coccyx wound from 10/11/24, through 10/15/24. During an interview on 11/22/24, at 12:15 p.m., the Nursing Home Administrator (NHA) confirmed that the facility failed to ensure residents were assessed, and provided necessary treatment and services, consistent with professional standards of practice, for a pressure ulcer for one of three residents (Resident R72). 28 Pa. Code 201.18 (b)(1) Management. 28 Pa. Code 211.10 (c)(d) Resident care policies. 28 Pa. Code 211.12 (d)(1)(2)(3)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395713 If continuation sheet Page 15 of 23 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 11/22/2024 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that physician-ordered contracture management interventions were provided as care planned for one of four residents reviewed (Resident R60). Findings include: Review of Resident R60's admission record indicated she was admitted to the facility on [DATE], readmitted [DATE], with diagnoses of dysphagia (difficulty swallowing), depression, and hemiplegia (paralysis affecting one side of the body). Review of Resident R60's MDS assessment dated [DATE], indicated the diagnoses were current. Review of Resident R60's [NAME] (care plan chart or template used by nurses to summarize important information about a patient's needs on 11/19/24, indicated the resident will wear palm guard daily on in the morning and off at dinner time. During an observation and interview on 11/20/24, Resident R60 was observed without a palm guard. Resident R60 indicated no one has offered to apply her palm guard. She indicated usually on her shower days, staff do not apply her palm guard. During an interview on 11/20/24, at 12:13 p.m. LPN, Employee E14 stated Resident R60 is not taken out of bed on her shower days, and that's probably why her palm guard was not put on. During an interview on 11/20/24, at 2:48 p.m. the Director of Nursing and Nursing Home Administrator confirmed the facility failed to ensure that physician-ordered contracture management interventions were provided as care planned for one of four residents reviewed (Resident R60). 28 Pa. Code 211.12(d)(5) Nursing Services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395713 If continuation sheet Page 16 of 23 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 11/22/2024 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review and interview, the facility failed to provide specialized care needs for the provision of respiratory care in accordance with professional standards of practice for four of four residents (Residents R12, R24, R44, and R60). Residents Affected - Some Findings include: Review of facility policy Skilled Nursing-Oxygen Administration dated August 2024, indicated oxygen is administered residents who need it, consistent with professional standards of practice and the care plan. Oxygen is administered under orders of a physician unless in emergency an order can be obtained as soon as the situation is under control. Review of facility policy Skilled Nursing--Cleaning Changing Nasal Cannulas and Masks dated August 2024, indicated all residents who are receiving oxygen therapy shall have masks and nasal cannula tubing changed weekly and/or as needed. Review of admission record indicated Resident R12 was admitted to the facility on [DATE]. Review of Resident R12's Minimum Data Set (MDS - a periodic assessment of care needs) dated 11/14/24, indicated the diagnoses of Non-Alzheimer's Dementia (dementia caused by other diseases with symptoms forgetfulness, limited social skills, and impaired thinking abilities that interfere with daily functioning), anxiety (intense, excessive, and persistent worry and fear about everyday situations), and depression. Review of Resident R12's current physician orders indicated Ipratropium-Albuterol Inhalation Solution (medication to enhance breathing) give by nebulizer (machine turns medication into a mist to breath in) two times a day as needed for wheezing and coughing. Review of Resident R12's current care plan failed to indicate use of or management of Ipratropium-Albuterol Inhalation Solution or use of a nebulizer. Observation on 11/19/24, at 11:43 a.m., Resident R12's dresser had nebulizer tubing and equipment on the dresser. The equipment was not dated and not in a bag. Tour and interview with Unit Manager Employee E2 on 11/19/24, at 11:45 a.m. confirmed Resident R12's nebulizer tubing and equipment on the dresser, and the equipment was not dated and not in a bag as required. Review of the admission record indicated Resident R24 admitted to the facility on [DATE]. Review of Resident R24's MDS dated [DATE], indicated the diagnosis of high blood pressure, Non-Alzheimer's Dementia, and depression. Review of Resident R24's current physician orders failed to include orders for oxygen administration. Review of Resident R24's current care plan failed to indicate oxygen administration or management (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395713 If continuation sheet Page 17 of 23 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 11/22/2024 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 0695 of it. Level of Harm - Minimal harm or potential for actual harm Observation on 11/19/24, at 11:43 a.m. Resident R24's room had an oxygen concentrator (machine that provides oxygen) with humidification and nasal cannula. The humidification did not have a date, and the nasal cannula did not have a date, was on the floor, and not inside a bag. Residents Affected - Some Interview on 11/19/24, at 11:43 a.m. Licensed Practical Nurse (LPN) Employee E9 confirmed the oxygen equipment was on the floor and did not have a date as required. Review of the admission record indicated Resident R44 admitted to the facility on [DATE]. Review of Resident R44's MDS dated [DATE], indicated the diagnosis of asthma, anxiety, and depression. Review of Resident R44's current physician order dated 8/1/23, indicated to administer 1 liter of oxygen via nasal canula every shift, wean as tolerated. Review of Resident R44's current physician order dated 8/4/23, indicated to change humidifier bottle, nasal canula and clean oxygen filter once a week when in use. Review of Resident R44's current physician orders dated 7/26/24, indicated to change oxygen tubing and humidifier every week. Review of Resident R44's current care plan failed to indicate oxygen administration or management of it. Observation on 11/18/24, at 11:18 a.m. Resident R44's room had an oxygen concentrator with humidification and nasal cannula. The humidification did not have a date, and the nasal cannula did not have a date. Observation and interview on 11/19/24, at 11:49 a.m. Resident R44's room had an oxygen concentrator with humidification and nasal cannula. The humidification did not have a date, and the nasal cannula did not have a date. Registered Nurse, Employee E19 confirmed Resident R44's humidification or oxygen was not dated. Interview on 11/20/24, at 10:29 a.m. the Director of Nursing confirmed Resident R44 did not have a care plan for her oxygen use. Review of the admission record indicated Resident R60 admitted to the facility on [DATE], and readmitted [DATE]. Review of Resident R60's MDS dated [DATE], indicated diagnoses of dysphagia (difficulty swallowing), Chronic Obstructive Pulmonary Disease (an ongoing lung condition caused by damage to the lungs), and hemiplegia (paralysis affecting one side of the body). Review of Resident R60's current physician order dated 6/13/24, indicated to administer 1 vial of Ipratropium-Albuterol Solution two times a day. Observation on 11/19/24, at 10:04 a.m. Resident R60's nebulizer tubing was observed hanging off the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395713 If continuation sheet Page 18 of 23 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 11/22/2024 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some resident's counter not inside a bag. LPN, Employee E15 confirmed the facility failed to properly store nebulizer tubing properly when not in use. Interview on 11/22/24, at 1:00 p.m. the Director of Nursing confirmed the facility failed to provide specialized care needs for the provision of respiratory care in accordance with professional standards of practice for four of four residents (Residents R12, R24, R44, and R60). 28 Pa. Code: 211.10(c)(d) Resident care policies. 28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395713 If continuation sheet Page 19 of 23 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 11/22/2024 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 0728 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training. Based on review of facility provided documents, personnel files, and staff interview, it was determined that the facility failed to ensure nurse aides who failed to become certified within four months were not working in the facility for one of five Employees (Nurse Aide Trainee Employee E12). Findings Include: Review of Title 42 Code of Federal Regulations §483.35(d) Requirement for facility hiring and use of nurse aides§483.35(d)(1) General rule. A facility must not use any individual working in the facility as a nurse aide for more than 4 months, on a full-time basis, unless(i) That individual is competent to provide nursing and nursing related services; and (ii)(A) That individual has completed a training and competency evaluation program, or a competency evaluation program approved by the State as meeting the requirements of §483.151 through §483.154. Review of facility provided documentation dated 11/7/24, indicated it was reported to facility administration that Nurse Aide Trainee Employee E12 failed to obtain the certified nurse aide within 120 days of working in a nurse aide training and testing program as required. The Nurse Aide Trainee Employee E12 completed the training program, however, was not able to successfully pass the written exam as required resulting in the non-certified aide providing direct care to residents on 10/21/2024, 10/25/2024, 10/26/2024, 10/27/2024, 10/28/2024, 10/30/2024, 10/31/2024, 11/01/2024, 11/02/2024, 11/03/2024, 11/05/2024, and 11/06/2024. Interview on 11/22/24, at 1:00 p.m. the Nursing Home Administrator confirmed the facility failed to ensure nurse aides who failed to become certified within four months were not working in the facility for one of five Employees (Nurse Aide Trainee Employee E12). 28 Pa Code: 201.14 (a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395713 If continuation sheet Page 20 of 23 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 11/22/2024 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 0744 Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. Level of Harm - Minimal harm or potential for actual harm **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 develop and implement individualized person-centered care plans to address dementia and cognitive loss displayed by one of four residents reviewed (Resident 67). Residents Affected - Few Findings include: Review of Resident R67's clinical record indicated she was admitted to the facility on [DATE], with a diagnosis of dementia (loss of memory, language, problem-solving, and other thinking abilities that interfere with daily life). A review of Resident 67's Minimum Data Set Assessment (MDS, a form completed at specific intervals to determine care needs) dated 4/4/24, indicated that the facility assessed Resident R67 as having a diagnosis of dementia and cognition was moderately impaired. A review of Resident R67's clinical record from 4/17/24, through 9/22/24, failed to indicate that the facility had developed and implemented a person-centered care plan to address the resident's dementia and cognitive loss. Interview on 11/20/24, at 1:56 p.m. with the Registered Nurse Assessment Coordinator, Employee E11 confirmed the facility had no further documentation that the facility developed and implemented individualized person-centered care plans to address Resident R67's dementia and cognitive loss prior to 9/23/24. 28 Pa Code 211.12 (d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395713 If continuation sheet Page 21 of 23 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 11/22/2024 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 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. Based on review of facility policy, review of clinical record, observations and staff and resident interviews, it was determined that the facility failed provide food items consistent with the prescribed diet order for two of five residents observed during dining (Resident R60 and R74). Findings include: Review of facility policy Diet orders and notification of diet changes dated 8/24 indicates the first initial physician dietary order will be prescribed by the Attending physician. Review of physician orders for Resident R60 confirmed a diet order dated 8/1/23 for Regular diet, Pureed texture, Nectar/Mildly Thick consistency. During an observation on 11/19/24, at 10:02 a.m. Resident R60's was observed with a yellow, thin fluid in her cup. Interview with Licensed Practical Nurse (LPN) Employee E15 confirmed Resident R60 was not provided nectar/mildly thick consistency fluids. LPN, Employee E15 stated last week Resident R60 received regular apple juice instead of nectar/mildly thick apple juice. Interview with Director of Nursing (DON) on 11/19/24, at 10:14 a.m. confirmed Resident R60 should have had nectar thick liquids as ordered. Review of physician orders for Resident R74 confirmed a diet order dated 10/15/24 for Regular diet, Mechanical Soft Ground Meat texture, Nectar/Mildly Thick consistency. During observations during dining, on 11/18/24, at 12:15 p.m. revealed Resident R74's meal ticket indicated Nectar Thick Liquids. Observations revealed Resident R74 was served thin iced tea. Interview with Registered Nurse (RN) employee E4 confirmed the above-mentioned findings. Interview with Director of Nursing (DON) on 11/18/24, at 2:00 p.m. confirmed Resident R74 should have had nectar thick liquids as ordered. 28 Pa. Code 211.6(a) Dietary Services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395713 If continuation sheet Page 22 of 23 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 11/22/2024 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 0810 Provide special eating equipment and utensils for residents who need them and appropriate assistance. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy, observations, and staff interview, it was determined that the facility failed to provide adaptive feeding devices for two of five residents (Resident R74). Residents Affected - Few Findings include: Review of facility policy Diet orders and notification of diet changes dated 8/24 indicates the first initial physician dietary order will be prescribed by the Attending physician. Review of clinical record indicated Resident R74 was admitted to the facility on [DATE], with diagnoses of dementia, orthostatic hypotension and acute kidney failure. Review of Resident R74's care plan dated 8/19/24, indicated provide adaptive equipment for feeding as needed: Kennedy cup with meals. During an observation on 11/18/24, at 12:15 p.m. Resident R74 did not have Kennedy cup as care planned with lunch. Interview with Registered Nurse (RN) Employee E4 confirmed the above-mentioned findings. Interview with Director of Nursing (DON) on 11/18/24, ay 2:00 p.m. confirmed Resident R74 should have had a [NAME] cup as care planned. 28 Pa. Code 211.6(a) Dietary Service FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395713 If continuation sheet Page 23 of 23