Health inspection·August 18, 2023

F 0656 Review of Resident R69's care plan failed to include a plan of care related to the periapical abscess. Level of Harm - Minimal harm or potential for actual harm Review of the clinical record indicated Resident R23 was admitted to the facility on [DATE]. Residents Affected - Some Review of the Minimum Data Set, dated [DATE], indicated diagnoses of muscle weakness, heart failure (a progressive heart disease that affects pumping action of the heart muscles), and diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time). Review of a physician order dated 7/7/23, indicated to apply humidified oxygen at 2 liters per minute via nasal cannula (an oxygen delivery device consisting of a lightweight tube which on one end splits into two prongs which are placed in the nostrils) continuous. Observation and interview on 8/14/23, at 10:50 a.m. revealed Resident R23 receiving oxygen at 2 liters via a nasal cannula. Review of Resident R23's care plan failed to include a plan of care related to the use of oxygen therapy and respiratory equipment. Review of the clinical record indicated Resident R55 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], indicated diagnoses of diabetes, hypertension, and coronary artery disease (damage or disease in the heart's major blood vessels). Review of a physician order dated 3/4/23, indicated to provide colostomy (an opening for the large intestine through the abdomen) care every shift and as needed. Review of Resident R55's care plan failed to include a plan of care related to colostomy care including required type of appliance, size of appliance and wafer, and type of collection bag. During an interview on 8/16/23, at 10:36 a.m., Licensed Practical Nurse Assessment Coordinator (LPNAC) Employee E4 confirmed the facility failed to develop and implement individualized plans of care for Resident R23, R52, and R55. Review of the admission record indicated Resident R71 was admitted to the facility on [DATE]. Review of Resident R71's MDS dated [DATE], indicated the diagnoses of anemia (the blood doesn't have enough healthy red blood cells), heart failure (heart doesn ' t pump blood as well as it should), and renal failure (condition where the kidneys lose the ability to remove waste and balance fluids) with dialysis. Review of documentation provided from the facility indicated Resident R71 was an active smoker. Interview on 8/14/23, at 9:50 a.m. Nursing Assistant (NA) Employee E11 indicated Resident R71 was an active smoker. Review of Resident R71's care plan failed to include a plan of care relating to smoking monitoring and management. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395410 If continuation sheet Page 2 of 16 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 395410 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Quality Life Services - Sugar Creek 120 Lakeside Drive Worthington, PA 16262 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview on 8/17/23, at 11:16 a.m. Registered Nurse Assessment Coordinator (RNAC) Employee E7 confirmed there was not a care plan for Resident R71's smoking monitoring and management. Review of the admission record indicated Resident R101 was admitted to the facility on [DATE]. Review of Resident R101's MDS dated [DATE], indicated the diagnoses of pelvic fracture (damage to the hip bones, sacrum or coccyx), anemia, and seizures (sudden, violent, irregular movement of a limb or the entire body caused by a brain disorder). Review of Resident R101's physician order dated 8/4/23, indicated hospice services via a contracted vendor. Review of Resident R101's care plan failed to include a plan of care relating to hospice care and management. Interview on 8/16/23, at 9:32 a.m. Licensed Practical Nurse Assessment Coordinator (LPNAC) Employee E4 confirmed the facility failed to have a plan of care relating to hospice care and management. Interview of 8/18/23, at 2:00 p.m. the Nursing Home Administrator confirmed the facility failed to develop and implement comprehensive care plans to meet care needs for six of ten residents (Resident R23, R52, R55, R69, R71, and R101). 28 Pa. Code 211.11 (a)(c) Resident care plans. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395410 If continuation sheet Page 3 of 16 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 395410 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Quality Life Services - Sugar Creek 120 Lakeside Drive Worthington, PA 16262 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 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, record review, and state scope of practice, it was determined that the facility failed to follow professional standards of practice when providing medication administration to two of six residents reviewed (Resident R44 and R101). Residents Affected - Few Findings include: Review of the facility's Medication Administration-General Guidelines policy dated 11/1/23, indicated medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. It was indicated the five rights- right resident, right drug, right dose, right route and right time are applied for each medication being administered. A triple check of these five rights is recommended at three steps in the process of preparation of a medication for administration: (1) when the medication is selected, (2) when the dose is removed from the container, and finally (3) just after the dose is prepared and the medication put away. Review of the facility's job description for Licensed Practical Nurse's (LPN) dated 11/1/23, indicated it is the responsibility of the LPN to follow established standards of nursing practices to implement company policies and procedures related to medication administration. Review of Resident R44's clinical record indicated she was admitted [DATE]. Review of Resident R44's MDS assessment (Minimum Data Set assessment: MDS - a periodic assessment of resident care needs) dated 8/2/23, indicated that she was admitted with diagnoses that included hypertension (elevated blood pressure) and apraxia (a neurological syndrome characterized by difficulty in performing daily tasks even if the instructions are understood.) The MDS indicated that these diagnose were current upon review. A review of the facility's incident report dated 8/14/23, indicated Resident R44 had a medication error incident on 8/1/23. A review of Resident R44's incident report dated 8/1/23, indicated LPN Employee E2 gave Resident R44 another resident's medications. It was indicated Resident R44 received 46 units of Toujeo (a long acting insulin), 5 mg Namenda (used to treat moderate to severe confusion related to Alzheimer's disease), 40 mg lisinopril (used to treat high blood pressure), and 5 mg amlodipine (used to treat high blood pressure), 20 mg Lexapro (used to treat anxiety and depression), 1000 mg metformin (used to control high blood sugar), and 20 mg prednisone (steroid used to decrease inflammation) in error. A review of LPN Employee E2's Employee Communication Record dated 8/2/23, indicted LPN, Employee E2 made a nursing error and actions taken included retraining on the five rights of medication administration. A review of the admission record indicated Resident R101 was admitted to the facility on [DATE]. A review of Resident R101's MDS dated [DATE], indicated the diagnoses of pelvic fracture (damage to the hip bones, sacrum or coccyx), anemia, and seizures (sudden, violent, irregular movement of a limb or the entire body caused by a brain disorder). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395410 If continuation sheet Page 4 of 16 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 395410 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Quality Life Services - Sugar Creek 120 Lakeside Drive Worthington, PA 16262 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 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of incident report documentation dated 5/9/23, Resident R101 received Tylenol for pain. Further review revealed a summary from 5/12/23, that indicated Resident has an allergy to Tylenol and Registered Nurse (RN) Employee E13 did not realize it until after the Tylenol was administered. A review of Registered Nurse (RN) Employee E13's Communication Record dated 5/10/23, indicated RN Employee E13 administered Tylenol to Resident R101 for complaints of pain. Resident R101 had no physician order for Tylenol and has a documented allergy to Tylenol. No ill effects to resident observed. During an interview on 8/17/23, at 10:40 a.m., Nursing Home Administrator (NHA) confirmed LPN Employee E2 failed to follow the five rights of medications administration for Resident R44 on 8/1/23, and R101 on 5/9/23, which resulted in medication errors. The NHA confirmed the facility failed to follow professional standards of practice when providing medication administration to two of six residents reviewed (Resident R44 and R101). 28 Pa. Code 211.12(d)(1)(5)Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395410 If continuation sheet Page 5 of 16 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 395410 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Quality Life Services - Sugar Creek 120 Lakeside Drive Worthington, PA 16262 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 0680 Ensure the activities program is directed by a qualified professional. Level of Harm - Minimal harm or potential for actual harm Based on staff interview, it was determined that the facility failed to ensure that the Activities department had a qualified director to oversee the Activities Program. Residents Affected - Some Findings include: Review of the Activity Supervisor job description dated 8/1/21, indicated the qualifictions for the position included a bachelor's degree in recreational therapy. During an interview on 8/15/23, at 1:00 p.m. with Activities Director Employee E3 indicated that she had been the Director for approximately one year and the assistant the year prior and had a bachelor's degree. During an interview on 8/16/23, at 12:26 p.m. the Human Resource Employee E5 confirmed that Activity Director Employee E3 did not complete a state approved program to be qualified to oversee the Activity Program and the bachelor's degree was not in recreational therapy. During an interview on 8/17/23, at 2:30 p.m. the Nursing Home Administrator confirmed the facility failed to ensure that the Activities department had a qualified director to oversee the Activities Program. 28 Pa. Code: 201.18(b)(3)Management. 28 Pa. Code 201.14(a) Responsibility of licensee. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395410 If continuation sheet Page 6 of 16 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 395410 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Quality Life Services - Sugar Creek 120 Lakeside Drive Worthington, PA 16262 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 records, and staff interview it was determined that the facility failed to follow physician orders and notify a physician of abnormal glucose readings via a Capillary Blood Glucose (CBG) level as per ordered for two of three residents (Resident R36 and R49). Residents Affected - Few Findings include: The Centers for Disease Control defines diabetes as: Diabetes Mellitus is a chronic (long-lasting) health condition that affects how your body turns food into energy. Most of the food you eat is broken down into sugar (also called glucose) and released into your bloodstream. When your blood sugar goes up, it signals your pancreas to release insulin. Insulin acts like a key to let the blood sugar into your body's cells for use as energy. If you have diabetes, your body either doesn't make enough insulin or can't use the insulin it makes as well as it should. When there isn't enough insulin or cells stop responding to insulin, too much blood sugar stays in your bloodstream. Over time, that can cause serious health problems, such as heart disease, vision loss, and kidney disease. Hypoglycemia is a condition that occurs when blood glucose is lower than normal, usually below 70 milligrams per deciliter (mg/dl). If left untreated, hypoglycemia may lead to weakness, confusion, unconsciousness, arrhythmias and even death. People with Diabetes Mellitus may be prescribed injectable insulin to assist in maintaining acceptable levels of CBG's. Hyperglycemia, or high blood glucose, occurs when there is too much sugar in the blood. This happens when your body has too little insulin. Hyperglycemia is blood glucose greater than 125 mg/dL while fasting (not eating for at least eight hours, or a blood glucose greater than 180 mg/dL one to two hours after eating. The facility Hypoglycemia Protocol policy dated 11/1/23, indicated that staff will appropriately assess for and respond to and treat residents who have a hypoglycemia episode. It was indicated treatment for hypoglycemia is glucose gel (a medication commonly used by people with diabetes to raise their blood sugar when it becomes dangerously low), however if the resident has difficulty swallowing or a decreased level of consciousness, Glucagon (a medication that is injected to raise the blood sugar) IM (intramuscular a type of injection that delivers medication into a muscle) should be given. It was indicated blood glucose must be rechecked and the doctor notified. Review of facility policy Nursing Services - NU 2.15 dated 11/1/22, indicated nursing care includes the provision of all prescribed medications and treatments, and nursing care will be provided within the scope of practice and in accordance with nursing standards of care. Review of facility policy Physician Notification - NU 2.17 dated 11/1/22, indicated upon identification of a resident who has clinical changes, a change in condition, or abnormal lab values, a licensed nurse will perform appropriate clinical observations and data collection and report to the physician as indicated. Review of Resident R36's clinical record indicated an admission date of 2/28/20. Review of Resident R36's MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment of resident care needs) dated 5/9/23, indicated that she was admitted with diagnoses that included diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), hyperglycemia (an excess of glucose in the bloodstream), and hypertension (a condition impacting blood circulation through the heart related to poor pressure). The MDS indicated that these diagnose (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395410 If continuation sheet Page 7 of 16 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 395410 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Quality Life Services - Sugar Creek 120 Lakeside Drive Worthington, PA 16262 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 were current upon review. Level of Harm - Minimal harm or potential for actual harm Review of Resident R36's care plan dated 3/5/20, indicated to administer diabetes medications as ordered, monitor for effectiveness and the occurrence of any side effects and report them to my physician. Residents Affected - Few Review of Resident R36's physician order dated 7/28/22, indicated to administer 37.5 gram Glucose Gel 40 %, by mouth as needed for Hypoglycemia. Notify pharmacy of amount used. Call physician if glucometer is less than 60, squeeze entire tube into mouth and swallow. May repeat one time in 15 minutes. If glucometer remains less than 60. If unconscious/ineffective refer to Glucagon IM. Review of Resident R36's physician order dated 7/28/22, indicated to administer 1 mg of Glucagon IM as needed for Hypoglycemia diabetes. Call physician. Inject if blood sugar is less than 60, resident is unconscious, or Glucose Gel is ineffective. If resident does not wake within 15 minutes or injection is ineffective, repeat one time in 15 minutes. Review of Resident R36's physician order dated 11/8/22, indicated to complete a Glucometer check at bedtime. No insulin coverage at bedtime. Alert physician if blood glucose is less than 60 or greater than 450. Review of Resident R36's bedtime blood glucose from 7/1/23 through 8/17/23 was the following: 7/13/23: 456 mg/dl 7/15/23: 473 mg/dl 8/2/23: 452 mg/dl Review of Resident R36's progress note from 7/13/23 through 8/2/23, failed to include documentation that a physician was notified for Resident R36's abnormal high blood glucose levels on 7/13/23, 7/15/23, and 8/2/23. Review of Resident R36's blood glucose from 7/1/23 through 8/17/23 indicated the following: 7/3/23: 41 mg/dl 7/10/23: 48 mg/dl 7/15/23: 52 mg/dl 7/25/23: 55 mg/dl 8/6/23: 27 mg/dl 8/12/23: 59 mg/dl Review of Resident R36's progress notes from 7/3/23 through 8/12/23, failed to include doucmentation that a physician was notified for Resident R36's abnormal low blood glucose levels on 7/3/23, 7/10/23, 7/15/23, 8/6/23, and 8/12/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395410 If continuation sheet Page 8 of 16 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 395410 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Quality Life Services - Sugar Creek 120 Lakeside Drive Worthington, PA 16262 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 Review of Resident R36's July's and August Medication Administration Record (MAR) failed to indicate the resident was administered the ordered 37.5 gram glucose gel or 1 mg of glucagon as needed for hypoglycemia on 7/3/23, 7/10/23, 7/15/23, 8/6/23, and 8/12/23. Review of the clinical record indicated Resident R49 was admitted to the facility on [DATE]. Residents Affected - Few Review of the MDS dated [DATE], indicated diagnoses of diabetes, pulmonary edema (a condition caused by too much fluid in the lungs), and coronary artery disease (damage or disease in the heart's major blood vessels). Review of a physician order dated 4/6/22, indicated to administer Glucose Gel 40% 37.5 grams by mouth as needed for hypoglycemia. May obtain from E-Box (emergency box). Notify pharmacy of amount used. Call MD (physician) if blood sugar is less than 60, squeeze entire tube into mouth and swallow. May repeat 1 time in 15 minutes if glucometer remains less than 60. If unconscious/ineffective, refer to Glucagon IM. Review of a physician order dated 4/6/22, indicated to inject 1 milligram intramuscularly as needed for hypoglycemia from E-Box. Notify pharmacy of amount used from E-Box. Call MD. Inject if blood sugar is less than 60, resident is unconscious, or Glucose Gel is ineffective. If resident does not wake within 15 minutes or injection is ineffective, repeat once in 15 minutes and call 911. Review of Resident R49's blood glucose from 1/15/23 through 1/24/23 indicated the following: 1/15/23: 53 mg/dl 1/16/23: 50mg/dl 1/22/23: 46 mg/dl 1/24/23: 46 mg/dl Review of Resident R49's progress notes from 1/15/23 through 1/25/23, failed to include documentation that a physician was notified for Resident R49's abnormal glucose levels on 1/15/23, 1/16/23, 1/22/23, and 1/24/23. Review of Resident R36's January MAR failed to indicate the resident was administered the ordered 37.5 gram glucose gel or 1 mg of glucagon as needed for hypoglycemia on 1/15/23, 1/16/23, 1/22/23, and 1/24/23. Review of a progress note dated 1/24/23, indicated Resident R49 did not receive the scheduled 34 units of Lantus (a long-acting insulin medication used to control high blood sugar) at 8:59 p.m. because the resident's blood sugar was 62 mg/dl. It stated the resident was experiencing reoccurring low blood sugars at night time and in the am. Resident was given orange juice. RN supervisor aware and ordered to hold Lantus and recheck resident at 0200. Will continue to observe. Review of Resident R49's clinical record and progress notes dated 1/24/23 and 1/25/23, failed to reveal communication to the physician regarding the blood sugar reading of 62, a physician order to hold the scheduled Lantus, and documentation of the resident's blood sugar level at 2 a.m. on 1/25/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395410 If continuation sheet Page 9 of 16 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 395410 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Quality Life Services - Sugar Creek 120 Lakeside Drive Worthington, PA 16262 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 During an interview on 8/17/23, at 10:40 a.m. the Assistant Director of Nursing (ADON), Employee E1 confirmed the facility failed to follow physician orders and notify a physician of abnormal glucose readings as ordered for two of three residents (Resident R36 and R49). 28 Pa. Code: 211.10(c)(d) Resident care policies. 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: 395410 If continuation sheet Page 10 of 16 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 395410 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Quality Life Services - Sugar Creek 120 Lakeside Drive Worthington, PA 16262 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. 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 and clinical record and staff interview it was determined that the facility failed to make certain consistent dialysis communication was maintained for one of two dialysis residents. (Resident R71). Residents Affected - Few Findings include: Review of CMS guidelines, 483.25(1) states the facility assures that each resident receives care and services for the provision of dialysis (a machine filters wastes, salts and fluid from your blood when your kidneys are no longer healthy enough to do this work adequately) including the ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments. Review of the admission record indicated Resident R71 was admitted to the facility on [DATE]. Review of Resident R71's Minimum Data Set (MDS - a periodic assessment of care needs) dated 8/2/23, indicated the diagnoses of anemia (the blood doesn ' t have enough healthy red blood cells), heart failure (heart doesn ' t pump blood as well as it should), and renal failure (condition where the kidneys lose the ability to remove waste and balance fluids) with dialysis. A review of the physician order dated 5/1/23, indicated that Resident R71 goes to dialysis on Monday, Wednesday and Friday. Review of Resident R71's care plan failed to include a plan for dialysis management and monitoring. A review of the clinical record did not include complete communication forms for fifteen of the previous 15 dialysis visits (8/11/23, 8/9/23, 8/7/2, 8/4/23, 7/31/23, 7/27/23, 7/17/23, 7/14/23, 7/7/23, 7/5/23, 7/3/23, 6/21/23, 6/23/23, 6/19/23, 6/14/23), with 3 additional undated forms with partial information on them. Interview on 8/15/23, at 12:27 p.m. Licensed Practical Nurse (LPN) Employee E10 confirmed the above dates did not include complete communication forms as required for Resident R71. Interview on 8/16/23, at 10:00 a.m. the Nursing Home Administrator confirmed that the facility failed to make certain consistent dialysis communication was maintained for Resident R71. 28 Pa. Code: §211.12(c)(d)(1)(3)(5) Nursing services. 28 Pa. Code 211.5(f) Clinical records. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395410 If continuation sheet Page 11 of 16 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 395410 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Quality Life Services - Sugar Creek 120 Lakeside Drive Worthington, PA 16262 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy, clinical record and staff interviews, it was determined that the facility failed to ensure medications were administered according to physician orders, to the correct resident, and according to the accepted standards of practice to make certain residents were free of significant medication errors for two of six residents reviewed (Residents R44 and R101). Residents Affected - Few Findings include: Review of the facility's Medication Administration-General Guidelines policy dated 11/1/23, indicated medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. It was indicated the five rights- right resident, right drug, right dose, right route and right time are applied for each medication being administered. A triple check of these five rights is recommended at three steps in the process of preparation of a medication for administration: (1) when the medication is selected, (2) when the dose is removed from the container, and finally (3) just after the dose is prepared and the medication put away. Review of Resident R44's clinical record indicated she was admitted [DATE]. Review of Resident R44's MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment of resident care needs) dated 8/2/23, indicated that she was admitted with diagnoses that included hypertension (elevated blood pressure), atrial fibrillation (irregular heart rhythm), diabetes (high blood glucose in the blood), and stroke. The MDS indicated that these diagnoses were current upon review. A review of Resident R44's progress note dated 8/1/23, stated LPN accidently gave resident another resident's medications. Medications given in error were 46 units of Toujeo (a long acting insulin), 5 mg Namenda (used to treat moderate to severe confusion related to Alzheimer's disease), 40 mg lisinopril (used to treat high blood pressure), and 5 mg amlodipine (used to treat high blood pressure), 20 mg Lexapro (used to treat anxiety and depression), 1000 mg metformin (used to control high blood sugar), and 20 mg prednisone (steroid used to decrease inflammation). It was indicated the Resident's order for Atenolol (used to treat high blood pressure), Nifedical (used to prevent chest pains and lower blood pressure), Dicyclomine (used to treat irritable bowel syndrome) and Eliquis (blood thinner) were placed on hold for one day. A review of Resident R44's physician order dated 8/1/23, indicated to hold the ordered 60 mg of Nifedical, in the morning for hypertension until 8/2/23, at 4:00 a.m. A review of Resident R44's physician order dated 8/1/23, indicated to hold the ordered 50mg of Atenolol, in the morning for hypertension until 8/2/23, at 4:00 a.m. A review of Resident R44's physician order dated 8/1/23, indicated to hold the ordered 2.5 mg of Eliquis, two times a day for atrial fibrillation until 8/2/23, at 4:00 a.m. A review of the Employee Communication Record dated 8/2/23, indicted LPN, Employee E2 made a nursing error and actions taken included retraining on the five rights of medication administration. A review of the admission record indicated Resident R101 was admitted to the facility on [DATE]. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395410 If continuation sheet Page 12 of 16 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 395410 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Quality Life Services - Sugar Creek 120 Lakeside Drive Worthington, PA 16262 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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of Resident R101's MDS dated [DATE], indicated the diagnoses of pelvic fracture (damage to the hip bones, sacrum or coccyx), anemia, and seizures (sudden, violent, irregular movement of a limb or the entire body caused by a brain disorder). A review of incident report documentation dated 5/9/23, Resident R101 received Tylenol for pain. Further review revealed a summary from 5/12/23, that indicated Resident has an allergy to Tylenol and Registered Nurse (RN) Employee E13 did not realize it until after the Tylenol was administered. A review of RN Employee E13's Communication Record dated 5/10/23, indicated RN Employee E13 administered Tylenol to Resident R101 for complaints of pain. Resident R101 had no physician order for Tylenol and has a documented allergy to Tylenol. No ill effects to resident observed. During an interview on 2/24/23, at 2:30 p.m. the Nursing Home Administrator (NHA) confirmed the facility failed to ensure medications were administered according to physician orders, to the correct resident, and according to the accepted standards of practice to make certain residents were free of significant medication errors for two of six residents reviewed (Residents R44 and R101). 28 Pa Code: 211.9 (a) Pharmacy services. 28 Pa code: 211.12 (d) (1) (5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395410 If continuation sheet Page 13 of 16 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 395410 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Quality Life Services - Sugar Creek 120 Lakeside Drive Worthington, PA 16262 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observations and staff interviews, it was determined that the facility failed to properly store biologicals and medications safely on two of three units (Maple and Hemlock ). Findings include: Review of the facility policy ID:1 Storage of Medications dated 11/1/23, indicated that when the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated. It was indicated all expired medications must be removed from the active supply and destroyed in the facility regardless of amount remaining. During an observation on 8/14/23, at 12:09 p.m. the Maple Unit's medication storage room refrigerator indicated a vial of tuberculin solution opened and failed to have a date opened. Interview on 8/14/23, at 12:10 p.m. Licensed Practical Nurse (LPN) Employee E6 confirmed the tuberculin vial was opened and failed to have a date opened. During an observation on 8/15/23, at 12:14 p.m. the Hemlock Unit's medication storage room refrigerator indicated a vial of tuberculin solution opened with an expiration date of 6/11/23. Interview on 8/15/23, at 12:17 p.m. Licensed Practical Nurse (LPN) Employee E12 confirmed the tuberculin vial was expired and left in the refrigerator. Interview on 8/17/23, at 2:30 p.m. the Nursing Home Administrator confirmed the facility failed to properly store biologicals and medications safely on two of three units (Maple and Hemlock). 28 Pa. Code: 211.12(d)(1)(3)(5) Nursing Services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395410 If continuation sheet Page 14 of 16 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 395410 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Quality Life Services - Sugar Creek 120 Lakeside Drive Worthington, PA 16262 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 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on a review of observation and staff interview, it was determined that the facility failed to properly maintain kitchen equipment in a sanitary condition creating the potential for unsafe conditions & the potential for cross contamination in the main kitchen of the facility. Residents Affected - Few Findings include: During an observation made on 8/14/23, at 10:15 a.m., dishwasher in the main kitchen had towels on the floor underneath the right side catching a slow drip of water. Dietary Manager Employee E8 on 8/14/23, at 10:30 a.m., stated it had been leaking for about a month, maintenance was aware. Reviewed maintenance logs January 2023 through current, no main kitchen dishwasher work order. During an dish room observation 8/16/23, at 12:37 p.m., there was a puddle of water under the dishwasher that continued half way across the kitchen. During an interview with Environmental Services Director E9 on 8/17/23, at 11:55 a.m., she stated she was unaware of the dishwasher leaking and confirmed the creating the potential for unsafe conditions. 28 Pa. Code: 201.18(b)(1) Management. 28 Pa. Code: 211.6(c) Dietary services. 28 Pa. Code: 201.14(a) Responsibility of licensee. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395410 If continuation sheet Page 15 of 16 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 395410 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Quality Life Services - Sugar Creek 120 Lakeside Drive Worthington, PA 16262 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 0922 Have enough backup water supply for essential areas of the nursing home. Level of Harm - Minimal harm or potential for actual harm Based on review of the facility disaster plan, observation, and staff interview, it was determined that the facility failed to establish written procedures to ensure that potable (drinking) water was available to essential areas during periods when there was a loss of normal water supply. Residents Affected - Few Findings include: Review of the facility disaster preparedness plan plan last reviewed 11/01/22, revealed the facility does not have provisions to obtain the minimum amount of water required in the event of an emergency. Observation of the dry storage room of the main kitchen 8/14/23 at 10:15 a.m. revealed there was no emergency drinking water stored onsite. Interviewed with Environmental Services Director Employee E9 on 8/16/23 at 11:34 a.m. revealed the facility has two wells and there is a holding tank that stores so much water. In an interview on 8/17/23, at 11:30 a.m., the Nursing Home Administrator stated that the facility does not have provisions to obtain the minimum amount of water required in the event of an emergency. 28 Pa.Code 201. 18(b)(1)(3)Management. 28 Pa. Code 209.7(a) Disaster preparedness. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395410 If continuation sheet Page 16 of 16