Health inspection·October 15, 2025

F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Level of Harm - Actual harm Residents Affected - Some **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, facility submitted documents, clinical records and staff interviews, it was determined that the facility failed to make certain each resident was free from neglect by not ensuring adequate supervision and assistance for transfers, which resulted in actual harm of a head contusion (bruise) for one of four residents (Resident R28), and actual harm of a skin tear for two of four residents (Residents R117 and R134), and failed to ensure that residents were free from neglect for an unknown skin condition injury for one of four residents reviewed (Resident R134).Findings include:Review of facility policy Skilled Nursing - Abuse dated August 2025, indicated neglect is defined as the failure of the community, its employees or services providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.Review of facility policy Skilled Nursing - Lifting and Transferring Residents dated August 2025, indicated it is the policy to lift/transfer residents as safely as possible. All residents requiring assistance with transfer will be transferred and/or lifted using mechanical device unless otherwise indicated by a physician order, or unless the resident is able to bear weight on his/her own. Mechanical lifts are done by 2 nursing/therapy personnel.Review of the facility policy Unexplained Injuries dated August 2025, indicated an investigation of all unexplained injuries (including bruises, abrasions, and injuries of unknown source) will be conducted by an individual to ensure that the safety of our residents has not been jeopardized.Review of the facility policy Investigation of Incidents dated August 2025, indicated it is the policy of the facility to conduct a thorough and timely investigation of incidents and accidents.Review of facility Nurse Aide (NA) job description indicated the NA will follow each resident's/patient's plan of care to provide direct care to improve or maintain resident's/patient's abilities.Review of the clinical record indicated Resident R28 was admitted to the facility on [DATE].Review of Resident R28's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/26/25, indicated diagnoses of high blood pressure, glaucoma (a group of eye conditions that can cause blindness), and anemia (too little iron in the blood). Review of facility submitted document dated 12/7/24, indicated the following: Administration was made aware on 12/9/24, that on 12/7/24 at 1930, the CNA (Certified Nurse Aide) was assisting the resident in the bathroom and bumped heads with the resident causing the resident to sustain a contusion (a bruise) to the left side of her head. The area was raised and bruised. It was 3 cm (centimeters) x 2 cm. There was no bleeding or laceration (a tear or cut in the skin). Upon investigation, it was noted that the CNA transferred the resident independently instead of a Sara lift (a mechanical lift). The aide stated that she wanted to hurry up and transfer the resident off of the toilet. Review of a witness statement dated 12/11/24, completed by NA Employee E9 stated, On 12/7/24 I was providing care from 3 pm - 7 pm on the 3rd floor. Prior to providing care for any patients I grabbed a day planner that correlated with my given assignment for that evening. Around 6:40 p.m. I provided care for Page 1 of 7 395713 395713 10/15/2025 Willows of Presbyterian Senior 1215 Hulton Road Oakmont, PA 15139

F 0600 Level of Harm - Actual harm Residents Affected - Some Resident R28. When I went to transfer her, I transferred as a one assist no one was around to help, and the nurse also did not help with the transfer, so I transferred as a one assist. As I was transferring Resident R28 we had collided heads, she did not hit the floor, I was trying to prevent that, and that's when we collided heads. I got her in bed provided my care for her. When I was done with care, I noticed she had a knot forming on her head and that I was starting to swell and gain a headache as well. I got the nurse immediately to let her know what happened. We provided an ice pack for Resident R28, and I wrote my statement. I also asked one of the supervisors for medication because at that point I had a severe migraine. Review of a physician order dated 7/14/23, indicated Resident R28 transferred with Sara lift and assist x 2 at the time of the incident on 12/7/24.Review of the clinical record indicated Resident R117 was admitted to the facility on [DATE].Review of Resident R117's MDS dated [DATE], indicated diagnoses of high blood pressure, hyperlipidemia (high levels of fat in the blood), and diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time).Review of a facility submitted document dated 4/1/25, indicated the following: It was brought to administration's attention that on 4/2/25, Resident R117 sustained a skin tear to her right lower extremity following a transfer into her wheelchair and assistance was needed with first aid. The RN (Registered Nurse) immediately went to assess the resident and there was a 3 cm skin tear noted to Resident R117's right skin that was actively bleeding. Resident R117 stated, her CNA was transferring her from the toilet onto the chair and resident stood up and went to turn around and sit in her chair, then her CNA stated that she is bleeding. Resident R117 said I did not know how or what happened until CNA said I was bleeding she did not feel anything. Upon investigation, although Resident R117 is a transfer assist x 2, the CNA assigned to her did confirm that she transferred her by herself.Review of a witness statement dated 4/4/25, completed by NA Employee E10 stated, On Monday March 31, 2025. It was the beginning of my shift 3 pm - 11 pm. I went to my section to check on my residents as I always do. I can't remember if Resident R117 put her call light on or if was in her room already, but she said she needed to go to the bathroom. I said let me see where my aide is or find someone else to help, but everyone was busy with their residents. My hall aide still hasn't arrived yet. So, I went back to Resident R117's room to let her know I'm still looking for help. That's when Resident R117 said I really need to go can we just go in and I can stand and turn. I told her we need help. Resident R117 said I really need to go. I said I'll be back, so I went to look for help again but everyone was still busy. I still didn't know when my all aide was coming. Went back to Resident R117 room. Resident R117 said she really needs to go. Yes, I always use the Sara lift on her. I couldn't find help and I felt bad that Resident R117 needed to use the bathroom, so I took her in she did great. When Resident R117 turned to get back into her chair is when she got a skin tear. The nurse came in to fix Resident R117 leg up. After I got Resident R117 settled in chair, in her room.Review of a physician order dated 9/21/24, indicated Resident R117 transferred with Sara lift assist x 2 at the time of the incident on 3/31/25.Review of Resident R134's admission record indicated resident was admitted to the facility on [DATE]. Review of Resident R134's MDS assessment dated [DATE], indicated diagnoses of high blood pressure, heart failure (a progressive heart disease that affects pumping action of the heart muscles), and osteoporosis (condition when the bones become brittle and fragile). Resident R134's MDS assessment section C0200 Brief Interview for Mental Status (BIMS, a screening test that aides in detecting cognitive impairment). The BIMS total score suggests the following distributions: 13-15: cognitively intact, 8-12: moderately impaired, 0-7: severe impairment. Resident R134's BIMS score was a 10 indicating Resident R134 was moderately impaired.During a review of a facility submitted document dated 1/9/25, indicated the following: It was brought to 395713 Page 2 of 7 395713 10/15/2025 Willows of Presbyterian Senior 1215 Hulton Road Oakmont, PA 15139

F 0600 Level of Harm - Actual harm Residents Affected - Some nursing administration's attention that at 0900, Resident R134 sustained a skin tear to her left lower extremity following a transfer into her wheelchair and assistance was needed with first aid. RN immediately went to assess the resident and there was a 6cm skin tear noted to Resident R134's left shin that was actively bleeding. I asked Resident R134 what happened, and she stated, I had to go to the bathroom and when I was transferred into my chair, I bumped my leg and got a cut. She also denied pain. First aid was completed and family and physician was made aware. Description of Follow-up Action: Upon investigation, although Resident R134 is a transfer assist of two, the NA assigned to her did confirm that she transferred her by herself. Although she had a day planner and nameplate sticker indicating Resident R134's transfer status, she immediately was educated on safe transfers and following transfer statuses. NA was then sent home and suspended pending investigation.During a review of witness statement dated 1/9/25, completed by NA Employee E23 stated, On 1/9/25, at around 8:00 a.m. Resident R134 put her call light on. I went to answer it and she told me she had to go to the bathroom. I did know she was a two person assist for transfers from shift-to-shift report, as well as my day planner. I walked down the north hall to check the charting station to see if anyone was there to help but I didn't see anyone. When I transferred Resident R134, her leg hit the wheelchair, and she got a skin tear. I got the nurse who started to apply first aid. The supervising nurse came to speak with me after this occurred to learn more about what happened. I told her everything that happened and that I did transfer her by myself since I didn't see anyone in the north hall.During an interview on 10/14/25, at 2:36 p.m. Assistant Director of Nursing (ADON) Employee E3 stated, I was the nurse that night who went to assess Resident R134. She was transferred with an assist of one and it should have been an assist of two. There was nothing wrong with her wheelchair, I checked it to make sure nothing was wrong with it. There was no sharp objects or anything. It ' s because her leg hit off the wheelchair due to a wrong transfer.During a review of a physician order dated 11/25/24, Resident R134 transferred with an assist of two at the time of the incident on 1/9/25.During an interview on 10/14/25, at 10:20 a.m. NA Employee E15 stated, We have a day planner that is updated daily to find a transfer status and our name badges have color codes on them that tell us what a residents transfer status is according to the color of sticker by their name. We also have relay radios that we can call for help if needed. We have skill reviews throughout the year and go over transfers. I would prepare the resident and call for help before I would transfer someone.During an interview on 10/14/25, at 11:11 a.m. NA Employee E16 stated, I wouldn't transfer a resident by myself if someone was an assist of two. We have papers we get every morning that tell us the transfer status. Something could happen or someone could get hurt if we transferred someone by ourselves.During an interview on 10/14/25, at 11:27 a.m. NA Employee E17 stated, I would check the color sticker on a resident's door and look on my name badge to find a transfer status. We have a day planner and care plans to look at. We have education all year long. I wouldn't transfer someone myself if they required two. They could get hurt.During an interview on 10/15/25, at 9:47 a.m. NA Employee E12 stated, Resident transfer statuses are on our census sheet and in a daily planner that tells you how to take care of a resident. If a resident was ordered to be transferred using a mechanical lift, I would never not follow the order. You need two people.During an interview on 10/15/25, at 9:51 a.m. NA Employee E13 stated, Resident transfer statuses are on our day planners. I absolutely would not transfer someone by myself if they were ordered to be transferred using a lift.During an interview on 10/15/25, at 9:54 a.m. NA Employee E14 stated, Resident transfer statuses are posted in several places. We have our day planner, and each resident has colored sticker outside of their room that correlates with a transfer status. No, I would never transfer someone by myself and against the order if they were ordered to 395713 Page 3 of 7 395713 10/15/2025 Willows of Presbyterian Senior 1215 Hulton Road Oakmont, PA 15139

F 0600 Level of Harm - Actual harm Residents Affected - Some be transferred using two people. During an interview on 9/30/25, at 2:24 p.m. the Director of Nursing (DON)-1 confirmed that the facility failed to make certain each resident was free from neglect by not ensuring adequate supervision and assistance for transfers, which resulted in actual harm of a head contusion (bruise) for one of four residents (Resident R28), and actual harm of a skin tear for two of four residents (Residents R117 and R134).During an interview on 9/29/25, at 11:01 a.m. Resident R134 was sitting at bedside in a wheelchair with the tv on. Observation was made of a clear, see through, bandage on Resident R134's left forearm dated 9/4/25. During an interview on 9/29/25, at 11:19 a.m. Licensed Practical Nurse (LPN) Employee E5 confirmed the dressing and the date on the dressing. During a review of facility provided documentation of incidents and accidents failed to include an incident involving Resident R134's skin condition that required a dressing to her arm.During a review of Resident R134's clinical record on 9/29/25, at 11:30 a.m. Unit Manager LPN Employee E6 was unable to provide documentation for resident's skin condition, physician orders, progress notes, or skin follow up notes. Unit Manager LPN Employee E6 interviewed Resident R134, after State Agency (SA) brought it to the facility's attention. During an interview on 9/29/25, at 2:05 p.m. the Director of Nursing (DON) was made aware of Resident R134's dressing that was dated 9/4/25 and that no information, physician notification and orders, assessments, or progress notes were able to be provided. During an interview on 10/14/25, at 11:30 a.m. Unit Manager LPN Employee E6 stated, If an incident causing a skin condition happened, it should be measured, a nurse is to assess it and do an incident report. They should notify the physician for orders and notify family. I didn't see any of it was done. During an interview on 10/14/25, at 11:45 p.m. LPN Employee E18 stated, I would assess the site, measure, cleanse it, put a dressing on, document, and notify supervisor, physician and family. I would investigate and complete an incident report to figure out the cause.During an interview on 9/29/25, at 2:20 p.m. Director of Nursing confirmed that the facility failed to ensure that residents were free from neglect for an unknown skin condition injury for one of four residents reviewed (Resident R134).28 Pa. Code: 201.14(a) Responsibility of licensee28 Pa. Code: 201.18(b)(1) Management.28 Pa. Code: 211.10(d) Resident care policies.28 Pa. Code: 211.12(d)(1)(5) Nursing services. 395713 Page 4 of 7 395713 10/15/2025 Willows of Presbyterian Senior 1215 Hulton Road Oakmont, PA 15139

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Some **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Findings include: Review of facility policy Skilled Nursing - Lifting and Transferring Residents dated August 2025, indicated it is the policy to lift/transfer residents as safely as possible. All residents requiring assistance with transfer will be transferred and/or lifted using mechanical device unless otherwise indicated by a physician order, or unless the resident is able to bear weight on his/her own. Mechanical lifts are done by 2 nursing/therapy personnel.Review of the facility policy Unexplained Injuries dated August 2025, indicated an investigation of all unexplained injuries (including bruises, abrasions, and injuries of unknown source) will be conducted by an individual to ensure that the safety of our residents has not been jeopardized.Review of the facility policy Investigation of Incidents dated August 2025, indicated it is the policy of the facility to conduct a thorough and timely investigation of incidents and accidents.Review of facility Nurse Aide (NA) job description indicated the NA will follow each resident's/patient's plan of care to provide direct care to improve or maintain resident's/patient's abilities.Review of the clinical record indicated Resident R28 was admitted to the facility on [DATE].Review of Resident R28's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/26/25, indicated diagnoses of high blood pressure, glaucoma (a group of eye conditions that can cause blindness), and anemia (too little iron in the blood). Review of facility submitted document dated 12/7/24, indicated the following: Administration was made aware on 12/9/24, that on 12/7/24 at 1930, the CNA (Certified Nurse Aide) was assisting the resident in the bathroom and bumped heads with the resident causing the resident to sustain a contusion (a bruise) to the left side of her head. The area was raised and bruised. It was 3 cm (centimeters) x 2 cm. There was no bleeding or laceration (a tear or cut in the skin). Upon investigation, it was noted that the CNA transferred the resident independently instead of a Sara lift (a mechanical lift). The aide stated that she wanted to hurry up and transfer the resident off of the toilet. Review of a witness statement dated 12/11/24, completed by NA Employee E9 stated, On 12/7/24 I was providing care from 3 pm - 7 pm on the 3rd floor. Prior to providing care for any patients I grabbed a day planner that correlated with my given assignment for that evening. Around 6:40 p.m. I provided care for Resident R28. When I went to transfer her, I transferred as a one assist no one was around to help, and the nurse also did not help with the transfer so I transferred as a one assist. As I was transferring Resident R28 we had collided heads, she did not hit the floor, I was trying to prevent that, and that's when we collided heads. I got her in bed provided my care for her. When I was done with care, I noticed she had a knot forming on her head and that I was starting to swell and gain a headache as well. I got the nurse immediately to let her know what happened. We provided an ice pack for Resident R28, and I wrote my statement. I also asked one of the supervisors for medication because at that point I had a severe migraine. Review of a physician order dated 7/14/23, indicated Resident R28 transferred with Sara lift and assist x 2 at the time of the incident on 12/7/24.Review of the clinical record indicated Resident R117 was admitted to the facility on [DATE].Review of Resident R117's MDS dated [DATE], indicated diagnoses of high blood pressure, hyperlipidemia (high levels of fat in the blood), and diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time).Review of a facility submitted document dated 4/1/25, indicated the following: It was brought to administration's attention that on 4/2/25, Resident R117 sustained a skin tear to her right lower extremity following a transfer into her wheelchair and assistance was needed with first aid. The RN (Registered Nurse) immediately went to assess the resident and there was a 3 cm skin tear noted to Resident R117's right skin that was actively bleeding. Resident R117 stated, her CNA was 395713 Page 5 of 7 395713 10/15/2025 Willows of Presbyterian Senior 1215 Hulton Road Oakmont, PA 15139

F 0689 Level of Harm - Actual harm Residents Affected - Some transferring her from the toilet onto the chair and resident stood up and went to turn around and sit in her chair, then her CNA stated that she is bleeding. Resident R117 said I did not know how or what happened until CNA said I was bleeding she did not feel anything. Upon investigation, although Resident R117 is a transfer assist x 2, the CNA assigned to her did confirm that she transferred her by herself.Review of a witness statement dated 4/4/25, completed by NA Employee E10 stated, On Monday March 31, 2025. It was the beginning of my shift 3 pm - 11 pm. I went to my section to check on my residents as I always do. I can't remember if Resident R117 put her call light on or if was in her room already, but she said she needed to go to the bathroom. I said let me see where my aide is or find someone else to help, but everyone was busy with their residents. My hall aide still hasn't arrived yet. So, I went back to Resident R117's room to let her know I'm still looking for help. That's when Resident R117 said I really need to go can we just go in and I can stand and turn. I told her we need help. Resident R117 said I really need to go. I said I'll be back, so I went to look for help again but everyone was still busy. I still didn't know when my all aide was coming. Went back to Resident R117 room. Resident R117 said she really needs to go. Yes, I always use the Sara lift on her. I couldn't find help and I felt bad that Resident R117 needed to use the bathroom, so I took her in she did great. When Resident R117 turned to get back into her chair is when she got a skin tear. The nurse came in to fix Resident R117 leg up. After I got Resident R117 settled in chair, in her room.Review of a physician order dated 9/21/24, indicated Resident R117 transferred with Sara lift assist x 2 at the time of the incident on 3/31/25.Review of Resident R134's admission record indicated resident was admitted to the facility on [DATE]. Review of Resident R134's MDS assessment dated [DATE], indicated diagnoses of high blood pressure, heart failure (a progressive heart disease that affects pumping action of the heart muscles), and osteoporosis (condition when the bones become brittle and fragile). Resident R134's MDS assessment section C0200 Brief Interview for Mental Status (BIMS, a screening test that aides in detecting cognitive impairment). The BIMS total score suggests the following distributions: 13-15: cognitively intact, 8-12: moderately impaired, 0-7: severe impairment. Resident R134's BIMS score was a 10 indicating Resident R134 was moderately impaired.During a review of facility submitted document dated 1/9/25 indicated the following: It was brought to nursing administration's attention that at 0900, Resident R134 sustained a skin tear to her left lower extremity following a transfer into her wheelchair and assistance was needed with first aid. Registered Nurse (RN) immediately went to assess the resident and there was a 6cm (centimeter) skin tear noted to Resident R134's left shin that was actively bleeding. I asked Resident R134 what happened, and she stated, I had to go to the bathroom and when I was transferred into my chair, I bumped my leg and got a cut. She also denied pain. First aid was completed and family and physician was made aware. Description of Follow-up Action: Upon investigation, although Resident R134 is a transfer assist of two, the Nurse Aide (NA) assigned to her did confirm that she transferred her by herself. Although she had a day planner and nameplate sticker indicating Resident R134's transfer status, she immediately was educated on safe transfers and following transfer statuses. NA was then sent home and suspended pending investigation.During a review of witness statement dated 1/9/25, completed by NA Employee E23 stated, On 1/9/25, at around 8:00 a.m. Resident R134 put her call light on. I went to answer it and she told me she had to go to the bathroom. I did know she was a two person assist for transfers from shift-to-shift report, as well as my day planner. I walked down the north hall to check the charting station to see if anyone was there to help but I didn't see anyone. When I transferred Resident R134, her leg hit the wheelchair, and she got a skin tear. I got the nurse who started to apply first aid. The supervising nurse came to speak with me after this occurred to learn more about what 395713 Page 6 of 7 395713 10/15/2025 Willows of Presbyterian Senior 1215 Hulton Road Oakmont, PA 15139

F 0689 Level of Harm - Actual harm Residents Affected - Some happened. I told her everything that happened and that I did transfer her by myself since I didn't see anyone in the north hall.During an interview on 10/14/25, at 2:36 p.m. Assistant Director of Nursing (ADON) Employee E3 stated, I was the nurse that night who went to assess Resident R134. She was transferred with an assist of one and it should have been an assist of two. There was nothing wrong with her wheelchair, I checked it to make sure nothing was wrong with it. There were no sharp objects or anything. It's because her leg hit off the wheelchair due to a wrong transfer.During a review of a physician order dated 11/25/24, Resident R134 transferred with an assist of two at the time of the incident on 1/9/25.During an interview on 10/14/25, at 10:20 a.m. NA Employee E15 stated, We have a day planner that is updated daily to find a transfer status and our name badges have color codes on them that tell us what a residents transfer status is according to the color of sticker by their name. We also have relay radios that we can call for help if needed. We have skill reviews throughout the year and go over transfers. I would prepare the resident and call for help before I would transfer someone.During an interview on 10/14/25, at 11:11 a.m. NA Employee E16 stated, I wouldn't transfer a resident by myself if someone was an assist of two. We have papers we get every morning that tell us the transfer status. Something could happen or someone could get hurt if we transferred someone by ourselves.During an interview on 10/14/25, at 11:27 a.m. NA Employee E17 stated, I would check the color sticker on a resident's door and look on my name badge to find a transfer status. We have a day planner and care plans to look at. We have education all year long. I wouldn't transfer someone myself if they required two. They could get hurt.During an interview on 10/15/25, at 9:47 a.m. NA Employee E12 stated, Resident transfer statuses are on our census sheet and in a daily planner that tells you how to take care of a resident. If a resident was ordered to be transferred using a mechanical lift, I would never not follow the order. You need two people.During an interview on 10/15/25, at 9:51 a.m. NA Employee E13 stated, Resident transfer statuses are on our day planners. I absolutely would not transfer someone by myself if they were ordered to be transferred using a lift.During an interview on 10/15/25, at 9:54 a.m. NA Employee E14 stated, Resident transfer statuses are posted in several places. We have our day planner, and each resident has a colored sticker outside of their room that correlates with a transfer status. No, I would never transfer someone by myself and against the order if they were ordered to be transferred using two people. During an interview on 9/30/25, at 2:24 p.m. the Director of Nursing confirmed that the facility failed to make certain each resident received adequate supervision and assistance for transfers to prevent accidents which resulted in actual harm of a head contusion for one of four residents (Resident R28), and actual harm of a skin tear for two of four residents (Residents R117 and R134).28 Pa. Code: 201.14 (a) Responsibility of licensee.28 Pa. Code: 201.18 (b)(1) Management.28 Pa. Code: 211.10(d) Resident care policies.28 Pa. Code: 211.12 (d)(1)(5) Nursing services. 395713 Page 7 of 7