Health inspection·May 16, 2025

F 0585 Level of Harm - Minimal harm or potential for actual harm Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Based on review of facility policy, and resident and staff interview , it was determined that the facility failed to inform residents on the grievance policy and procedures for seven of seven residents. Residents Affected - Few Findings include: Review of facility policy Communication of Resident, Family, and Staff Concerns and Grievances, stated 3/17/25, indicated: The facility offers several communication avenues for residents, family members, and staff to questions and to report any concerns related to quality of care, customer service, regulatory issue or employee matter. Resident group interview on 5/14/25, at 10:40 a.m. indicated that residents did not know who the grievance officer was, how to file a grievance, where the grievance forms were or what the process was. Residents were asked how the facility responds to grievances and the residents said that they did not know how they respond to concerns. Review of resident council minutes for six months (November, December, January, Febraury, March, and April) failed to include discussion of resident rights, how residents file grievance, where the grievances were located, who the grievance officer was, or any information about resident rights or grievances. During an interview on 5/16/25, at 10:04 a.m. Social Worker Employee E5 confirmed that they are the grievance officer and they attend resident council. During a subsequent interview on 5/16/25, at 10:58 a.m. Social Worker Employee E5 confirmed that no information could be found to support that the facility had informed residents of the grievance process, and that the facility failed to inform residents on the grievance process policy and procedures. 28 Pa. Code 201.29(a)Resident rights FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395410 If continuation sheet Page 2 of 30 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 05/16/2025 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies, facility provided documents, clinical records and staff interviews, it was determined that the facility failed to make certain a resident was free from neglect for two of five residents reviewed (Resident R48 and R260) which resulted in actual harm of a skin tear (Resident R48) and a dislocation of right elbow, fracture of the right distal radius (bone near wrist) and a fractured of the right coronoid process of the ulna (bone of forearm) (Resident R260). Findings include: The facility's policy Resident Protection from Abuse, Neglect, Mistreatment or exploitation last reviewed 3/17/25, indicated it is the facility's policy to treat residents with kindness, respect and in a manner that is at all times free from abuse, neglect, misappropriation of property, exploitation or mistreatment. To protect our residents, procedures will be implemented in the areas of screening, training, prevention, identification, investigation, protection, reporting/response and corrective action. - Neglect is defined of the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. - Neglect occurs when the facility is aware of or should have been aware of goods or services that a resident requires but the facility fails to provide them to a resident, that has resulted or may result in physical harm, pain, mental anguish, or emotional distress. - Neglect includes cases where the facilities indifference or disregard for resident care, comfort or safety, resulted in or could have resulted in physical harm, pain, mental anguish or emotional distress. Identification: Abuse, neglect, misappropriation of property and exploitation will be identified through various methods that include but not inclusive to: - reports from employed or contracted staff. - utilization of resident incident reports to determine suspicious events. Reporting/Response - the following procedure will be implemented when an incident of abuse, neglect, exploitation, or mistreatment including injuries of unknow source alleged or suspected: - The Administrator (NHA) or Director of Nursing (DON) must be notified immediately. - The NHA or DON will notify the Pennsylvania department of health. Investigation - all reports of abuse, neglect, exploitation or mistreatment including injuries of unknown source will be investigated and documented. - An internal investigation will be conducted utilizing the resident incident report, the PB-22 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395410 If continuation sheet Page 3 of 30 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 05/16/2025 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few form, interviews of resident, staff, and family members and description of the resident's injuries. All investigations will be conducted thoroughly and attempts to gather as much factual information as possible. Review of admission record indicated Resident R48 was admitted to the facility on [DATE]. Review of Resident R48's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/19/25, indicated the diagnoses of anemia (low iron on the blood), heart failure (the heart can't pump blood as well as it should), and hypertension (high blood pressure). Section GG 5.E. Chair/bed-to-chair transfer is coded as 01, (01- indicating dependent). Review of Resident R48's care plan initiated on 10/18/24, indicated: Focus: The resident is to be transferred utilizing a front wheeled walker with assist x two. Focus: I am at high risk for falls related to confusion, deconditioning, gait/balance problems, history of frequent falls and falling out of bed. Review of incident note dated 5/3/25, at 1:30 a.m. indicated Nurse Aid (NA) informed writer that when she went to put the resident into bed the resident stated, Watch my leg. NA then looked at the resident's legs and saw a skin tear on the residents lower left lateral leg. Earlier in the shift resident was in bed yelling so a different NA assisted the resident up and into her chair to bring her to the nurse's station at 9:00 p.m. Resident sat at the nurse's station and did not say anything. The resident started falling asleep and was assisted back to her room around 1:30 a.m. when skin tear was discovered. When asked what had happened resident said, It happened when I got in my chair. Skin tear measures 3cm x 3cm and is in the shape of a triangle. Skin tear was cleansed with NSS, patted dry, 3 steri-strips applied, and covered with bordered gauze. Review of undated facility provided skin impairment huddle indicates: How was skin impairment acquired? During transfer was noted with a question mark (?). Residents' description of incident: when I got in my chair. Immediate intervention initiated: cleansed, patted dry, applied steri-strips, covered with border gauze. Review of undated, unsigned, typed interview investigation completed by Registered Nurse (RN) Employee E3 indicated resident stated watch my leg when she was transferred into bed around 1:30 a.m. due to falling asleep at nurse's station. Residents front of wheelchair faced the head of bed placing her left lower leg near bed frame during transfer. When resident was in bed NA lifted pant leg and noticed fresh blood to left lower leg and skin tear. Its likely resident obtained skin tear from rubbing against bed frame with transfer back into bed. During an interview completed on 5/14/25, at 12:33 p.m. the DON confirmed that Resident R48 was an assist of two for transfers, a high fall risk, and that Resident R48 was transferred with an assist of one back to bed and that the facility failed to make certain a resident was free from neglect by not following transfer orders.). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395410 If continuation sheet Page 4 of 30 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 05/16/2025 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 0600 Review of admission record indicated Resident R260 was admitted to the facility on [DATE]. Level of Harm - Minimal harm or potential for actual harm Review of Resident R260's MDS dated [DATE], indicated the diagnoses of arthritis (joint inflammation) Parkinson's (neurological condition that causes difficulty with movement), and depression. Section GG -F Toilet transfer: The ability to get on and off a toilet or commode is coded 88 (88 = Not attempted due to medical condition or safety concerns). Residents Affected - Few Review of physician orders dated 10/1/24, indicated activities/mobility: transfer with assist of two staff, no ambulation in room or corridor, safety devices bed and chair alarms, low bed to floor. Review of Resident R260's care plan dated 10/1/24, Focus indicated high risk for falls, Interventions: Be sure my call light is within reach and encourage me to use it for assistance. I need prompt response to all request for assistance. Focus: I have actual bowel incontinence related to decreased mobility. Interventions: Provide me with a bedpan or bedside commode as needed. Review of R260 progress note dated 10/14/24, at 5:24 p.m. indicated Nurse Aid (NA) put resident on toilet and went to answer another call light. As this writer was walking to her room, I heard an alarm going off and went to answer it. Upon returning this writer heard resident yelling for help and rushed with NA to residents' room to observe resident outside bathroom door lying on her right side of her body yelling it hurts with her head pointing toward bathroom door. Tylenol given for right side arm/shoulder pain. When this writer asked resident why she didn't pull call bell and get up off toilet she stated what does it matter. Notified RN to come to residents' room to assess for injuries' notified sister-in-law and DR. Able to move all extremities except her right arm, shoulder and wrist that she is complaining of hurting and unable to move. Resident was put in bed by staff. Neuro checks all within normal range. x-ray ordered, here at facility. Review of the facility provided incident reported dated 10/15/24, indicated NA entered Resident R260's room and observed her standing at the toilet pulling her pants down to use bathroom as she was self-transferring. Resident stated that she needed to have a bowel movement and would take a long period of time on the toilet. Requested staff to leave the bathroom for privacy. Staff transferred to toilet and instructed to use call bell when she was ready, they would wait outside her bathroom door. Call bell cord placed in resident's hand. Another resident's alarm was sounding across the hallway. Staff immediately responded to alarm. Within a few minutes nurse entered residents' room (alarm that had been sounding) NA asked nurse to check on Resident R260 while they provided care to resident that had alarm sounding. As nurse was walking over to Resident R260's room, she heard her calling out for help. Observed resident outside bathroom door lying on her right side of her body yelling it hurts with her head pointing toward bathroom door. Registered Nurse called for assessment. Resident R260 complained of right arm pain, wrist and shoulder discomfort. Resident R260 was able to move left upper extremity (LUE), and bilateral lower extremities (BLE), range of motion (ROM) within normal limits (WNL). Staff performed blanket lift assist x 4 to bed. RN immobilized right arm and contacted resident representative to update. Stated that she did not want Resident R260 to be transferred to the hospital and requested mobile x-ray. Physician contacted and approved mobile x-ray to come to facility. Review of Resident R260's mobile x-ray findings dated 10/14/24, at 5:59 p.m. indicated mobile x-ray completed impression right humerus no fracture, incidental fracture dislocation deformity of the elbow. Recommendation to follow up with a dedicated x-ray series of the right elbow. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395410 If continuation sheet Page 5 of 30 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 05/16/2025 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 0600 Level of Harm - Minimal harm or potential for actual harm Review of Resident R260's progress note dated 10/15/24, indicated physician was notified and orders to apply a sling and to follow up with orthopedics on 10/15/24. Facility called orthopedics and an appointment was scheduled for 10/15/24, orthopedics requested an x-ray to be obtained at the hospital one hour prior to appointment. The orthopedic physician called the facility and reported that Resident R260's right elbow is dislocated and they will send to the emergency room for sedation and to reset the elbow. Residents Affected - Few Review of Resident 260's hospital note dated 10/15/24, indicated x-ray of the right wrist shows a fracture of the distal radius, a fracture of the coronoid process and elbow dislocation. Using conscious sedation a reduction was completed. She was placed in a simple sling and wrist splint and advised to follow up with an orthopedic provider. Review of Resident R260's progress notes indicated a follow up appointment was scheduled on 10/22/24, with orthopedics for elbow dislocation, elbow fracture, and wrist fracture. During an interview completed on 5/14/25, at 12:33 p.m. the DON confirmed that resident R260 was an assist of two for transfers, a high fall risk, and that Resident R260 was left in the bathroom unattended resulting in a fall that caused a dislocation of right elbow, fracture of the distal radius and a fractured of the coronoid process of the ulna and the facility failed to make certain a resident was free from neglect. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(3) Management. 28 Pa. Code 211.10(d) Resident care policies. 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 6 of 30 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 05/16/2025 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 0605 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility provided documents, and staff interview, it was determined that the facility failed to ensure that residents medication regime was free from unnecessary psychotropic medication for three of five residents (Residents R4, R86 and, R106). Findings include: Review of facility Behavior Standard Index dated 3/17/25, indicated the facility will develop and implement behavior plans and medication regimes, in efforts to optimize the functional abilities of residents while monitoring for adverse side effects and improve behaviors. When control is needed to prevent harm and to allow evaluation and treatment, psychotropic medication may be required. Behavioral sheets will be utilized at the time of drug initiation or admission to home with drug order. Behaviors must be quantitatively and objectively documented by the nursing staff. Non-pharmacological interventions are implemented and assessed for effectiveness prior to considering initiation of medication. Review of the clinical record indicated Resident R4 was admitted to the facility on [DATE]. Review of Resident R4's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/20/25, indicated diagnoses of anemia (low iron in the blood), hypertension (high blood pressure), and anxiety. Review of Resident R4's physician order dated 2/21/25, indicated to administer Ativan oral tablet (a psychotropic medication used to treat anxiety) 0.5 milligram every eight hours as needed (PRN) for anxiety for six months. Review of Resident R4's physician order failed to include a 14 day stop date and there was no documented rationale by the physician for the medication to extend past 14 days for Resident R4's Ativan Review of Resident R4's Medication Administration Record (MAR) dated February 2025 through May 2025, indicated that resident received Ativan PRN 24 times per order. Review of Resident R4's Progress Notes dated February 2025 through May 2025 failed to indicate any documented non-pharmacological interventions used by staff prior to administering Resident R4's Ativan. Review of the clinical record indicated Resident R86 was admitted to the facility on [DATE]. Review of Resident R86's MDS dated [DATE], indicated diagnoses of high blood pressure, dementia (a group of symptoms that affects memory, thinking and interferes with daily life), and anxiety. Review of Resident R86's physician order revised on 5/15/25, indicated to administer Ativan Solution (a psychotropic medication used to treat anxiety), give 0.5 milliliters (ml) under tongue every four hours PRN for anxiety. Review of Resident R86's physician order failed to include a 14 day stop date and there was no (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395410 If continuation sheet Page 7 of 30 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 05/16/2025 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 0605 documented rationale by the physician for the medication to extend past 14 days for Resident R86's Ativan. Level of Harm - Minimal harm or potential for actual harm Review of Resident R86's Medication Administration Record dated January 2025 through May 2025, indicated that resident received Ativan PRN 11 times per order. Residents Affected - Some Review of Resident R86's Progress Notes dated January 2025 through May 2025 failed to indicate any documented non-pharmacological interventions used by staff prior to administering Resident R86's Ativan. Resident R106 was admitted to the facility on [DATE]. Resident R106 MDS dated [DATE], indicated the following diagnosis Unspecified Nondisplaced Fracture Of Second Cervical Vertebra Subsequent Encounter For Fracture With Routine Healing ( a cervical fracture often called a broken neck) , wandering (person becomes lost or confused) and unspecified dementia ( a condition where people lose the ability to think, remember, learn, make decisions and solve problems). Review of Resident R106's physican order dated 1/30/25: Ativan Oral Tablet 0.5 MG (Lorazepam) Give 0.25 mg by mouth every 8 hours as needed for anxiety -Start Date01/30/2025 Review of Resident R106's physician order failed to include a 14 days stop date and there was no documented rationale by the physician for the medication to extend past the 14 days for Resident R106's Ativan. Review of Resident R106 MAR's January 2025 through March 2025 indicated that resident received Ativan 10 times. Review of the progress notes dated January 2025 through March 2025 failed to indicate any documented non-pharmacological interventions used by staff prior to administering PRN Ativan. During an interview on 5/16/25, at 11:04 a.m. Director of Nursing confirmed that the facility failed to ensure that residents medication regime was free from unnecessary psychotropic medication for three of five residents (Residents R4, R86 and, R106). 28 Pa. Code 211.2(d)(3) Medical director 28 Pa. Code 211.10(a) Resident care policies FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395410 If continuation sheet Page 8 of 30 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 05/16/2025 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 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. 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 documents, facility policy, clinical records, and staff interviews, it was determined that the facility failed to implement written policies and procedures to prohibit and prevent abuse, neglect, and exploitation with a complete and thorough investigation of an incident involving the potential for neglect for one of four residents (Resident R260). Residents Affected - Few Findings include: The facility's policy Resident Protection from Abuse, Neglect, Mistreatment or exploitation last reviewed 3/17/25, indicated it is the facility's policy to treat residents with kindness, respect and in a manner that is at all times free from abuse, neglect, misappropriation of property, exploitation or mistreatment. To protect our residents, procedures will be implemented in the areas of screening, training, prevention, identification, investigation, protection, reporting/response and corrective action. - Neglect is defined of the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. - Neglect occurs when the facility is aware of, or should have been aware of goods or services that a resident requires but the facility fails to provide them to a resident, that has resulted or may result in physical harm, pain, mental anguish , or emotional distress. - Neglect includes cases where the facilities indifference or disregard for resident care, comfort or safety, resulted in or could have resulted in physical harm, pain, mental anguish or emotional distress. Identification: Abuse, neglect, misappropriation of property and exploitation will be identified through various methods that include but not inclusive to: - reports from employed or contracted staff. - utilization of resident incident reports to determine suspicious events. Reporting/Response - the following procedure will be implemented when an incident of abuse, neglect, exploitation, or mistreatment including injuries of unknow source alleged or suspected: - The Administrator (NHA) or Director of Nursing (DON) must be notified immediately. - The NHA or DON will notify the Pennsylvania department of health. Investigation - all reports of abuse, neglect, exploitation or mistreatment including injuries of unknown source will be investigated and documented. - An internal investigation will be conducted utilizing the resident incident report, the PB-22 form, interviews of resident, staff, and family members and description of the resident's injuries. All investigations will be conducted thoroughly and attempts to gather as much factual information as (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395410 If continuation sheet Page 9 of 30 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 05/16/2025 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 0607 possible. Level of Harm - Minimal harm or potential for actual harm Review of admission record indicated Resident R260 was admitted to the facility on [DATE]. Residents Affected - Few Review of Resident R260's MDS dated [DATE], indicated the diagnoses of arthritis (joint inflammation) Parkinson's (neurological condition that causes difficulty with movement), and depression. : Section GG -F Toilet transfer: The ability to get on and off a toilet or commode is coded 88 (88 = Not attempted due to medical condition or safety concerns). Review of Resident R260's physician orders dated 10/1/24, indicated activities/mobility: transfer with assist of two staff, no ambulation in room or corridor, safety devices bed and chair alarms, low bed to floor. Review of Resident R260's care plan dated 10/1/24, Focus indicated high risk for falls, Interventions: Be sure my call light is within reach and encourage me to use it for assistance. I need prompt response to all request for assistance. Focus: I have actual bowel incontinence related to decreased mobility. Interventions: Provide me with a bedpan or bedside commode as needed. Review of the facility provided incident reported dated 10/15/24, indicated NA entered resident 260's room and observed her standing at the toilet pulling her pants down to use bathroom as she was self-transferring. Resident stated that she needed to have a bowel movement and would take a long period of time on the toilet. Requested staff to leave the bathroom for privacy. Staff transferred to toilet and instructed to use call bell when she was ready, they would wait outside her bathroom door. Call bell cord placed in resident's hand. Another resident ' s alarm was sounding across the hallway. Staff immediately responded to alarm. Within a few minutes nurse entered residents room (alarm that had been sounding) NA asked nurse to check on Resident R260 while they provided care to resident that had alarm sounding. As nurse was walking over to Resident R260's room, she heard her calling out for help. Observed resident outside bathroom door lying on her right side of her body yelling it hurts with her head pointing toward bathroom door. Registered Nurse called for assessment. Resident R260 complained of right arm pain, wrist and shoulder discomfort. Resident R260 was able to move left upper extremity (LUE), and bilateral lower extremities (BLE), range of motion (ROM) within normal limits (WNL). Staff performed blanket lift assist x 4 to bed. RN immobilized right arm and contacted resident representative to update. Stated that she did not want Resident R260 to be transferred to the hospital and requested mobile x-ray. Physician contacted and approved mobile x-ray to come to facility. Review of Resident R260's mobile x- ray findings dated 10/14/24, at 5:59 p.m. indicated mobile x ray completed impression right humerus no fracture, incidental fracture dislocation deformity of the elbow. Recommendation to follow up with a dedicated x-ray series of the right elbow. Review of Resident R260's progress note dated 10/15/24, indicated physician was notified and orders to apply a sling and to follow up with orthopedics on 10/15/24. Facility called orthopedics and an appointment was scheduled for 10/15/24, orthopedics requested an x -ray to be obtained at the hospital one hour prior to appointment. The orthopedic physician called the facility and reported that Resident R260's right elbow is dislocated and they will send to the emergency room for sedation and to reset the elbow. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395410 If continuation sheet Page 10 of 30 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 05/16/2025 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 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident 260's hospital note dated 10/15/24, indicated x-ray of the right wrist shows a fracture of the distal radius, a fracture of the coronoid process and elbow dislocation. Using conscious sedation a reduction was completed. She was placed in a simple sling and wrist splint and advised to follow up with an orthopedic provider. Review of Resident R260's progress notes indicated follow up appointment was scheduled on 10/22/24, with orthopedics for elbow dislocation, elbow fracture, and wrist fracture. During an interview completed on 5/14/25, at 12:33 p.m. the DON confirmed that resident R260 was an assist of two for transfers, a high fall risk, and that Resident R260 was left in the bathroom unattended resulting in a fall that caused a dislocation of right elbow, fracture of the distal radius and a fractured of the coronoid process of the ulna and confirmed that the facility failed to implement written policies and procedures to ensure a complete and thorough investigation of an incident involving the potential for neglect for one of four residents (Resident R260). 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(e)(1) Management. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395410 If continuation sheet Page 11 of 30 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 05/16/2025 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, resident clinical record, incident reports, reports submitted to the State, and staff interview it was determined that the facility failed to report an allegation of neglect for one of three residents (Resident R260). Findings include: The facility's policy Resident Protection from Abuse, Neglect, Mistreatment or exploitation last reviewed 3/17/25, indicated it is the facility's policy to treat residents with kindness, respect and in a manner that is at all times free from abuse, neglect, misappropriation of property, exploitation or mistreatment. To protect our residents, procedures will be implemented in the areas of screening, training, prevention, identification, investigation, protection, reporting/response and corrective action. - Neglect is defined of the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. - Neglect occurs when the facility is aware of or should have been aware of goods or services that a resident requires but the facility fails to provide them to a resident, that has resulted or may result in physical harm, pain, mental anguish, or emotional distress. - Neglect includes cases where the facilities indifference or disregard for resident care, comfort or safety, resulted in or could have resulted in physical harm, pain, mental anguish or emotional distress. Identification: Abuse, neglect, misappropriation of property and exploitation will be identified through various methods that include but not inclusive to: - reports from employed or contracted staff. - utilization of resident incident reports to determine suspicious events. Reporting/Response - the following procedure will be implemented when an incident of abuse, neglect, exploitation, or mistreatment including injuries of unknow source alleged or suspected: - The Administrator (NHA) or Director of Nursing (DON) must be notified immediately. - The NHA or DON will notify the Pennsylvania department of health. Investigation - all reports of abuse, neglect, exploitation or mistreatment including injuries of unknown source will be investigated and documented. - An internal investigation will be conducted utilizing the resident incident report, the PB-22 form, interviews of resident, staff, and family members and description of the resident ' s injuries. All investigations will be conducted thoroughly and attempts to gather as much factual information as (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395410 If continuation sheet Page 12 of 30 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 05/16/2025 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 0609 possible. Level of Harm - Minimal harm or potential for actual harm Review of admission record indicated Resident R260 was admitted to the facility on [DATE]. Residents Affected - Few Review of Resident R260's MDS dated [DATE], indicated the diagnoses of arthritis (joint inflammation) Parkinson's (neurological condition that causes difficulty with movement), and depression.: Section GG -F Toilet transfer: The ability to get on and off a toilet or commode is coded 88 (88 = Not attempted due to medical condition or safety concerns). Review of Resident R260's physician orders dated 10/1/24, indicated activities/mobility: transfer with assist of two staff, no ambulation in room or corridor,safety devices bed and chair alarms, low bed to floor. Review of Resident R260's care plan dated 10/1/24, Focus indicated high risk for falls, Interventions: Be sure my call light is within reach and encourage me to use it for assistance. I need prompt response to all request for assistance. Focus: I have actual bowel incontinence related to decreased mobility. Interventions: Provide me with a bedpan or bedside commode as needed. Review of the facility provided incident reported dated 10/15/24, indicated NA entered resident 260's room and observed her standing at the toilet pulling her pants down to use bathroom as she was self-transferring. Resident stated that she needed to have a bowel movement and would take a long period of time on the toilet. Requested staff to leave the bathroom for privacy. Staff transferred to toilet and instructed to use call bell when she was ready, they would wait outside her bathroom door. Call bell cord placed in resident's hand. Another resident ' s alarm was sounding across the hallway. Staff immediately responded to alarm. Within a few minutes nurse entered residents ' room (alarm that had been sounding) NA asked nurse to check on Resident R260 while they provided care to resident that had alarm sounding. As nurse was walking over to Resident R260's room, she heard her calling out for help. Observed resident outside bathroom door lying on her right side of her body yelling it hurts with her head pointing toward bathroom door. Registered Nurse called for assessment. Resident R260 complained of right arm pain, wrist and shoulder discomfort. Resident R260 was able to move left upper extremity (LUE), and bilateral lower extremities (BLE), range of motion (ROM) within normal limits (WNL). Staff performed blanket lift assist x 4 to bed. RN immobilized right arm and contacted resident representative to update. Stated that she did not want Resident R260 to be transferred to the hospital and requested mobile x-ray. Physician contacted and approved mobile x-ray to come to facility. Review of Resident R260's mobile x-ray findings dated 10/14/24, at 5:59 p.m. indicated mobile x-ray completed: impression right humerus no fracture, incidental fracture dislocation deformity of the elbow. Recommendation to follow up with a dedicated x-ray series of the right elbow. Review of Resident R260's progress note dated 10/15/24, indicated physician was notified and orders to apply a sling and to follow up with orthopedics on 10/15/24. Facility called orthopedics and an appointment was scheduled for 10/15/24, orthopedics requested an x-ray to be obtained at the hospital one hour prior to appointment. The orthopedic physician called the facility and reported that Resident R260's right elbow is dislocated and they will send to the emergency room for sedation and to reset the elbow. Review of Resident 260's hospital note dated 10/15/24, indicated x-ray of the right wrist shows a fracture of the distal radius, a fracture of the coronoid process and elbow dislocation. Using (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395410 If continuation sheet Page 13 of 30 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 05/16/2025 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 0609 Level of Harm - Minimal harm or potential for actual harm conscious sedation a reduction was completed. She was placed in a simple sling and wrist splint and advised to follow up with an orthopedic provider. Review of Resident R260's progress notes indicated a follow up appointment was scheduled on 10/22/24, with orthopedics for elbow dislocation, elbow fracture, and wrist fracture. Residents Affected - Few Review of facility submitted events to the state survey agency failed to include the report of an allegation of neglect. During an interview completed on 5/14/25, at 12:33 p.m. the DON confirmed that that the facility failed to report an allegation of neglect for one of three residents (Resident R260). 28 Pa Code: 201.14 (a)(c )(e ) Responsibility of management 28 Pa Code: 201.18 (b)(1) (e)(1) Management. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395410 If continuation sheet Page 14 of 30 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 05/16/2025 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 0610 Respond appropriately to all alleged violations. 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 and staff interview, it was determined that the facility failed to fully investigate an incident to eliminate possible abuse neglect for one of four residents (Resident R260). Residents Affected - Few Findings include: The facility's policy Resident Protection from Abuse, Neglect, Mistreatment or exploitation last reviewed 3/17/25, indicated it is the facility's policy to treat residents with kindness, respect and in a manner that is at all times free from abuse, neglect, misappropriation of property, exploitation or mistreatment. To protect our residents, procedures will be implemented in the areas of screening, training, prevention, identification, investigation, protection, reporting/response and corrective action. - Neglect is defined of the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. - Neglect occurs when the facility is aware of, or should have been aware of goods or services that a resident requires but the facility fails to provide them to a resident, that has resulted or may result in physical harm, pain, mental anguish, or emotional distress. - Neglect includes cases where the facilities indifference or disregard for resident care, comfort or safety, resulted in or could have resulted in physical harm, pain, mental anguish or emotional distress. Identification: Abuse, neglect, misappropriation of property and exploitation will be identified through various methods that include but not inclusive to: - reports from employed or contracted staff. - utilization of resident incident reports to determine suspicious events. Reporting/Response - the following procedure will be implemented when an incident of abuse, neglect, exploitation, or mistreatment including injuries of unknow source alleged or suspected: - The Administrator (NHA) or Director of Nursing (DON) must be notified immediately. - The NHA or DON will notify the Pennsylvania department of health. Investigation - all reports of abuse, neglect, exploitation or mistreatment including injuries of unknown source will be investigated and documented. - An internal investigation will be conducted utilizing the resident incident report, the PB-22 form, interviews of resident, staff, and family members and description of the resident's injuries. All investigations will be conducted thoroughly and attempts to gather as much factual information as possible. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395410 If continuation sheet Page 15 of 30 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 05/16/2025 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 0610 Review of admission record indicated Resident R260 was admitted to the facility on [DATE]. Level of Harm - Minimal harm or potential for actual harm Review of Resident R260's MDS dated [DATE], indicated the diagnoses of arthritis (joint inflammation) Parkinson's (neurological condition that causes difficulty with movement), and depression.: Section GG -F Toilet transfer: The ability to get on and off a toilet or commode is coded 88 (88 = Not attempted due to medical condition or safety concerns). Residents Affected - Few Review of Resident R260's physician orders dated 10/1/24, indicated activities/mobility: transfer with assist of two staff, no ambulation in room or corridor, safety devices bed and chair alarms, low bed to floor. Review of Resident R260's care plan dated 10/1/24, Focus indicated high risk for falls, Interventions: Be sure my call light is within reach and encourage me to use it for assistance. I need prompt response to all request for assistance. Focus: I have actual bowel incontinence related to decreased mobility. Interventions: Provide me with a bedpan or bedside commode as needed. Review of the facility provided incident reported dated 10/15/24, indicated NA entered resident 260's room and observed her standing at the toilet pulling her pants down to use bathroom as she was self-transferring. Resident stated that she needed to have a bowel movement and would take a long period of time on the toilet. Requested staff to leave the bathroom for privacy. Staff transferred to toilet and instructed to use call bell when she was ready, they would wait outside her bathroom door. Call bell cord placed in resident's hand. Another resident ' s alarm was sounding across the hallway. Staff immediately responded to alarm. Within a few minutes nurse entered residents room (alarm that had been sounding) NA asked nurse to check on Resident R260 while they provided care to resident that had alarm sounding. As nurse was walking over to Resident R260's room, she heard her calling out for help. Observed resident outside bathroom door lying on her right side of her body yelling it hurts with her head pointing toward bathroom door. Registered Nurse called for assessment. Resident R260 complained of right arm pain, wrist and shoulder discomfort. Resident R260 was able to move left upper extremity (LUE), and bilateral lower extremities (BLE), range of motion (ROM) within normal limits (WNL). Staff performed blanket lift assist x 4 to bed. RN immobilized right arm and contacted resident representative to update. Stated that she did not want Resident R260 to be transferred to the hospital and requested mobile x-ray. Physician contacted and approved mobile x-ray to come to facility. Review of Resident R260's mobile x- ray findings dated 10/14/24, at 5:59 p.m. indicated mobile x- ray completed: impression right humerus no fracture, incidental fracture dislocation deformity of the elbow. Recommendation to follow up with a dedicated x-ray series of the right elbow. Review of Resident R260's progress note dated 10/15/24, indicated physician was notified and orders to apply a sling and to follow up with orthopedics on 10/15/24. Facility called orthopedics and an appointment was scheduled for 10/15/24, orthopedics requested an x-ray to be obtained at the hospital one hour prior to appointment. The orthopedic physician called the facility and reported that Resident R260's right elbow is dislocated and they will send to the emergency room for sedation and to reset the elbow. Review of Resident 260's hospital note dated 10/15/24, indicated x-ray of the right wrist shows a fracture of the distal radius, a fracture of the coronoid process and elbow dislocation. Using conscious sedation a reduction was completed. She was placed in a simple sling and wrist splint and advised to follow up with an orthopedic provider. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395410 If continuation sheet Page 16 of 30 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 05/16/2025 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 0610 Level of Harm - Minimal harm or potential for actual harm Review of Resident R260's progress notes indicated a follow up appointment was scheduled on 10/22/24, with orthopedics for elbow dislocation, elbow fracture, and wrist fracture. Review of facility submitted reports did not include the allegation of neglect or that an investigation was completed. Residents Affected - Few During an interview completed on 5/14/25, at 12:33 p.m. the DON confirmed that the facility failed to fully investigate an incident to eliminate possible neglect for one of four residents (R260). 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(e)(1) Management. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395410 If continuation sheet Page 17 of 30 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 05/16/2025 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 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for one of three residents sampled with facility-initiated transfers (Resident R57) and failed to provide a discharge summary completed by a physician for one of two residents (Resident R108). Findings include: Review of facility policy Transfer of Resident to Another Care Community dated 3/17/25, indicated transfer of resident to another care community is carried out based on physician order. Copy and prepare documents needed for transfer, including, but not limited to: - Medical Records Face sheet - Advanced Directives/POLST - Current physician orders - Medication Administration Record - Problem List - History and Physical - Appointments - Lab Work Review of the clinical record indicated Resident R57 was admitted to the facility on [DATE]. Review of Resident R57's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 4/8/25, indicated diagnoses of anemia (too little iron in the body causing fatigue), dementia (a group of symptoms that affects memory, thinking and interferes with daily life), and diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time) Review of the clinical record indicated Resident R57 was transferred to the hospital on [DATE] and returned to the facility on [DATE]. Review of Resident R57's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected to return, which included the resident's care plan goals, advanced directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the resident's specific needs at the receiving facility. Review of the clinical record indicated Resident R108 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 18 of 30 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 05/16/2025 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 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident R108's MDS dated [DATE], indicated diagnoses of chest pain, vitamin deficiency, and osteoporosis (condition when the bones become brittle and fragile). Review of clinical record indicated Resident R108 left the facility Against Medical Advice (AMA) on 2/12/25. During a closed record review on 5/15/25, at 1:10 p.m. the facility failed to provide a discharge summary completed by the physician after Resident R108 left the facility. During an interview on 5/15/25, at 1:23 p.m. Medical Records Employee E4 confirmed that the discharge summary was not included in Resident R108's medical record. During an interview on 5/16/25, at 10:54 a.m. Director of Nursing confirmed that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for one of three residents sampled with facility-initiated transfers (Resident R57) and failed to provide a discharge summary from a physician for one of two residents (Resident R108). 28 Pa. Code 201.29 (a) (c.3) (2) Resident rights. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395410 If continuation sheet Page 19 of 30 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 05/16/2025 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 a review of facility policy, clinical record, and staff interview, it was determined that the facility failed to provide an ongoing neurological assessment post unwitnessed fall for one of four residents (Resident R100). Residents Affected - Few Findings include: Review of the facility policy Falls: Care During and After last reviewed 3/17/25, indicates all residents experiencing a fall will receive appropriate care and investigation of the cause. Assess residents ' condition immediately to determine extent of injury for both witnesses and unwitnessed falls by following Guideline for Fall Aftercare. Guidelines for Fall Aftercare: - If head injury, assess neurological status. - Monitor resident, including vital signs and neurological checks as indicated and ordered. Review of the clinical record indicated that Resident R100 was admitted to the facility on [DATE]. Review of Resident R100's Minimum Data Set (MDS - a periodic assessment of care needs) dated 3/11/25, indicated diagnoses of unsteadiness on feet, abnormalities of gait and mobility, and hypertension (high blood pressure). Section C-cognitive patterns brief interview for mental status (BIMS-a tool to evaluate orientation and recall in residents) 0-7 points indicates severely impaired cognition, 8-12 indicates moderate impaired cognition and 13-15 indicates intact cognition. Resident R100's score C0400 is marked as 03, indicating severe impairment. Review of Resident R100's care plan initiated on 4/24/24, indicates at risk for falls. Review of Resident R100's fall with injury statement dated 12/25/24, indicates writer was assisting another resident when heard a thud. Upon investigation found resident laying on his side on the floor. He said he did not hit his head but did hit his arm off the nightstand and had four separate skin tears. The physician and resident's son were notified. Review of Resident R100's physician orders and treatment administration record (TAR) for December 2025, failed to include post fall neurological checks for the unwitnessed fall. During an interview on 5/16/25, at 10:43 a.m. the Director of Nursing (DON) confirmed the facility failed to provide an ongoing neurological assessment post unwitnessed fall for one of four residents (Resident R100). 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.18 (b)(1) Management. 28 Pa. Code: 211.10 (c)(d) Resident Care policies. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395410 If continuation sheet Page 20 of 30 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 05/16/2025 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 28 Pa. Code: 211.12 (d)(1)(2)(3)(5) Nursing services. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395410 If continuation sheet Page 21 of 30 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 05/16/2025 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical record review, and staff interview it was determined that the facility failed to provide adequate supervision to prevent elopement for one of three residents (Resident R106). Findings include: Review of the facility policy Accidents and Incidents dated 3/17/25, indicated: An accident/incident is any happening, which is not consistent with routine operations or the routine care of the particular resident. Resident R106 was admitted to the facility on [DATE]. Resident R106's MDS (minimum data set an assessment of resident needs) dated 3/10/25, indicated the following diagnosis Unspecified Nondisplaced Fracture Of Second Cervical Vertebra Subsequent Encounter For Fracture With Routine Healing ( a cervical fracture often called a broken neck) , wandering (person becomes lost or confused), and unspecified dementia ( a condition where people lose the ability to think, remember, learn, make decisions and solve problems). Review of facility documentation progress notes dated 3/13/25, indicated the following: Staff came to unit at approximately 4:40 pm, to notify nursing staff that resident was in the kitchen area. Employee E14 Nurse Aide went down to the kitchen and redirected Resident R106 back to the unit. Resident R106 has been wandering throughout the building this entire shift. Resident R106 requires continuous redirection to stay out of other residents' rooms. Review of Resident R106's clinical record failed to include a care plan for wandering. During an interview on 5/13/25, Employee E14 Nurse Aide indicated that staff from the kitchen came to the unit and said there was a resident in the kitchen who needed taken back to the nursing unit. Upon arrival to the area Resident R106 was in the area (a storage room) before the kitchen. I took Resident R106 back to the nursing unit. Resident R106 indicated that they were looking for a cup of coffee, I gave the Resident a cup of coffee once back on the nursing unit. During an interview on 5/14/25, Director of Nursing (DON) confirmed that Resident R106 has a history of wandering, did go into an area that was not designated for residents, that the resident was originally identified in the area by a dietary aide who in turn went to the nursing unit to get a nursing staff to bring resident back to the nursing unit. During an inteview on 5/14/25, at 2:30 p.m. DON was informed that the facility failed to provide adequate supervision to prevent elopement for one of three residents (Resident R106). 28 Pa. Code 201.14 (a) Responsibility of licensee 28 Pa. Code 201.18 (b)(1) Management 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 22 of 30 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 05/16/2025 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 0694 Provide for the safe, appropriate administration of IV fluids 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 review of facility policy, observations, and staff interviews, it was determined that the facility failed to provide adequate treatment and care for a peripheral inserted central catheter (PICC - a thin tube that's inserted through a vein in your arm and passed through to the larger veins near your heart) in accordance with professional standards of practice for one of two residents (Resident R70). Residents Affected - Few Findings include: Review of the facility provided quick reference guide last reviewed 3/17/25, indicates dressing changes to central lines: PICC should be performed every seven days and if needed as soiled using aseptic (practices to prevent infection) technique. Review of the clinical record indicated Resident R70 was admitted to the facility on [DATE]. Review of Resident R70's Minimum Data Set (MDS - a periodic assessment of care needs) dated 4/15/25, indicated diagnoses of heart failure (a progressive heart disease that affects pumping action of the heart muscles), diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and osteomyelitis (infection of bone) of the right ankle and foot. Review of physician orders dated 4/14/24, indicated Zosyn Solution Reconstituted 3- 0.375 gram (GM) Use 1 vial intravenously (IV) every eight hours. Review of Resident R70's care plan dated 4/15/25, focus indicates PICC line therapy related to infection. Intervention/task indicates check my IV site for any signs or symptoms of infection, such as redness, warmth or swelling and notify my physician if any are noted. Ensure that my dressing remains intact and is changed according to the protocol in my home or as otherwise ordered. During an observation on 5/13/25, at 9:35 a.m. Resident R70's left arm PICC site dressing was labeled with the date of 4/29/25. During an interview completed on 5/13/25, at 9:40 a.m. Licensed Practical Nurse (LPN) Employee E2 confirmed the dressing site was dated 4/29/25, and that the facility failed to provide adequate treatment and care for a peripheral inserted central catheter (PICC - a thin tube that's inserted through a vein in your arm and passed through to the larger veins near your heart) in accordance with professional standards of practice for one of two residents (Resident R70). 28 Pa. Code: 211.12 (d)(1)(2)(3)(5) Nursing 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 23 of 30 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 05/16/2025 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 0699 Provide care or services that was trauma informed and/or culturally competent. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of resident record review, and staff interviews, it was determined that the facility failed to provide a trauma survivor with trauma informed care to eliminate or mitigate triggers that may cause re-traumatization of the resident for two of two residents (Resident R4, and R9). Residents Affected - Few Findings include: Review of the clinical record indicated Resident R4 was admitted to the facility on [DATE]. Review of Resident R4's MDS (Minimum Data Set - a periodic mandatory Federal assessment used to determine a resident's care needs) dated 2/20/25, indicated diagnoses of post-traumatic stress disorder (PTSD-a mental health condition in people who have experienced or witnessed a traumatic event), anemia (low iron in the blood) and high blood pressure. Review of Resident R4's care plan indicated that resident had PTSD but failed to identify what the triggers were and how to avoid them. Review of the clinical record indicated Resident R9 was admitted to the facility on [DATE]. Review of Resident R9's MDS dated [DATE], indicated diagnoses of PTSD, coronary artery disease (damage or disease in the heart's major blood vessels), and dementia (a group of symptoms that affects memory, thinking and interferes with daily life). Review of Resident R9's care plan indicated that resident had PTSD but failed to identify what the triggers were and how to avoid them. During an interview on 5/16/25, at 10:17 a.m. Social Service Director Employee E5 confirmed that the facility failed to identify PTSD triggers for Resident R4, and R9 in order to eliminate or mitigate any triggers that may cause re-traumatization for the resident. 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: 395410 If continuation sheet Page 24 of 30 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 05/16/2025 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 review of facility policy, clinical records, and staff interview, it was determined that the facility failed to make certain medications were administered as ordered by the physician for one of three residents (Resident R88). Residents Affected - Few Findings include: Review of the facility policy Specific Medication Administration Procedures last reviewed 3/17/25, indicates to administer medications in a safe and effective manner. After administration, return to cart, replace medication container (if multi-dose and doses remain). Review of the facility policy Physician Orders last reviewed 3/17/25, last reviewed 3/17/25. indicated physician orders are followed in accordance with good nursing principles and practices and are transcribed and carried out by persons legally authorized to do so. Review of Resident R88's clinical record indicated she was admitted to the facility on [DATE]. Review of Resident R88's Minimum Data Set (MDS - periodic assessment of resident care needs) dated 4/2/25, indicated diagnosis of anemia (low iron in the blood), heart failure (the heart doesn't pump the way it should) and hypertension (high blood pressure) Review of a physician order dated 8/13/24, indicated to administer artificial tear solution one drop in both eyes two times a day. During a medication pass observation completed on 5/13/25, at 9:44 a.m. Licensed Practical Nurse (LPN) Employee E2 was preparing medications for Resident R88, LPN Employee E2 removed a box of artificial tears from the medication cart and placed into her scrub top pocket. LPN Employee E2 administered Resident R88's medication, however the eye drops were not given. LPN Employee E2 returned to medication cart and began preparing medication for the next resident. Upon asking about the eye drops LPN Employee E2 removed the eye drops from her pocket. During an interview completed on 5/13/25, at 10:52 a.m. LPN Employee E2 confirmed she did not administer Resident R88's eye drops as ordered and that the facility failed to make certain medications were administered as ordered by the physician 28 Pa. Code 211.12 (c)(1)(3) Nursing Services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395410 If continuation sheet Page 25 of 30 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 05/16/2025 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to store all drugs and biologicals in a safe, secure, and orderly manner for one of two medication rooms (Hemlock Medication Room), and failed to store medications and biologicals properly and securely in three of five medications carts (Hickory hall, Hemlock hall, and [NAME] hall medication carts). Findings include: Review of the facility policy Storage of Medications last reviewed [DATE], indicates medications and biologicals are stored safely, securely, and properly, following manufacture's recommendations or those of the supplier. Orally administered medications are kept separate from externally used medications and treatments. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled or without secure closures are immediately removed from inventory. The nurse will check the expiration date of each medication before administering it. Review of the facility policy Administration Procedures for all Medications last reviewed [DATE], indicated to administer medications in a safe effective manner. Check expiration date on package/container before administering any medication. When opening a multidose container, place the date on the container. During an observation on [DATE], at 11:25 a.m. the Hemlock medication room contained the following: 1. Two vials of Tuberculin (a substance used to detect a respiratory condition) that were expired. During an interview on [DATE], at 11:29 a.m. Licensed Practical Nurse (LPN) confirmed the above findings. During an observation on [DATE], at 1:51 p.m. the Hickory hall medication cart contained the following: 1. One medication cup of prepoured pills containing one white pill. 2. One medication cup of prepoured pills containing one black pill, two blue pills, two white and pink pills, two white pills, two peach pills, two orange pills, and one yellow pill. 3. One medication cup of prepoured pills containing nine white pills, two orange pills, one red pill, one blue pill, and one peach pill. 4. One cup of prepoured liquid containing a powdered medication. During an inteview on [DATE], at 2:05 p.m. LPN Employee E2 stated that they were three different resident's medications who were not in their room, and was waiting for them to return to their rooms. During an interview on [DATE], at 2:08 p.m. LPN Employee E2 confirmed the above findings. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395410 If continuation sheet Page 26 of 30 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 05/16/2025 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 During an observation on [DATE], at 2:20 p.m. the Hemlock hall medication cart contained the following: Level of Harm - Minimal harm or potential for actual harm 1. Lantus Insulin Pen (a medication used to treat diabetes-a metabolic disorder in which the body has high sugar levels for prolonged periods of time) with no open or expiration date. Residents Affected - Few During an interview on [DATE], at 2:22 p.m. LPN Employee E1 confirmed the above findings. During an observation on [DATE], at 9:35 a.m. the [NAME] hall medication cart contained the following: 1. Bisacodyl suppositories comingling with oral medications. 2. Tioujeo insulin pen unlabeled, not dated and not stored in a bag. 3. Two bottles of lactulose liquid opened and without a date. 4. A bottle of sore throat spray opened and without a date 5. A bottle fluticasone nose spray opened and without a date During an interview completed on [DATE], at 9:45 a.m. LPN Employee E11 confirmed the above findings. During an inteview on [DATE], at 3:00 p.m. the Director of Nursing confirmed the facility failed to store all drugs and biologicals in a safe, secure, and orderly manner for one of two medication rooms, and failed to store medications and biologicals properly and securely in three of five medications carts. 28 Pa. Code: 211.10(c)(d) Resident care policies. 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 27 of 30 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 05/16/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on a review of facility policy, observation and staff interview, it was determined that the facility failed to properly maintain cleanliness and sanitation of the Main Kitchen. (Main Kitchen). Residents Affected - Many Findings include: Review of facility policy Food Safety and Sanitation, dated 3/17/25, indicated that all local, state and federal standards and regulations are followed in order to assure a safe and sanitary food services department. During an observation of the main designated kitchen on 5/15/25, at 11:35 a.m. the following was observed: - Wall behind Cook's preparation area, build-up of food spillage/brown debris - Wall behind Robocoupe (food processor)/blender area, build-up of food spillage/brown debris - Wall behind garbage can located next to steamer, build-up of food spillage/brown debris During an interview conducted 5/15/25, at 11:36 a.m., Registered Dietitian (RD) Employee E13 confirmed that the facility failed to properly maintain cleanliness and sanitation of the Main Kitchen. (Main Kitchen). 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: 395410 If continuation sheet Page 28 of 30 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 05/16/2025 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 0880 Provide and implement an infection prevention and control program. 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 review, observation, and staff interview, it was determined that the facility failed to prevent cross contamination during a dressing change for one of three residents (Resident R107). Residents Affected - Few Findings include: Review of the facility policy Skin Integrity and Wound Management last reviewed 3/17/25, indicates to provide safe and effective care to prevent the occurrence of pressure ulcers, manage treatment and promote healing of all wounds. Review of the facility policy Wound Dressing Change last reviewed 3/17/25, indicates all wound care will be performed using medical aseptic technique, unless otherwise ordered by the physician, to prevent contamination of the wound bed. Procedure includes but not inclusive to: If a break in the aseptic technique occurs at any point, stop the procedure, remove your gloves, cleanse your hands, re-glove and/or re-gown and continue the procedure. Individual resident supplies may be placed on the over-bed table after it has been disinfected and a protective barrier has been placed on the table. Review of Resident R107's clinical record indicated he was admitted to the facility on [DATE]. Review of Residents R107's physician orders dated 5/7/25, indicate to cleanse right lateral unstageable wound with soap and warm water, pat dry, skin prep peri wound, apply nickel thick Santyl ointment, cover with dry dressing every day shift . During an observation on 5/24/25, at 1:34 p.m. Licensed Practical Nurse (LPN) Employee E11 entered Resident R107's room to complete his dressing change. LPN Employee E11 placed a towel on Resident R107's bed and placed the dressing supplies on the towel. She removed Resident R107's boot and sock and placed on chair, removed her gloves and placed new gloves. After applying the Santyl ointment she removed her gloves and removed a pen from her pocket and applied the date to the cover dressing, she returned the pen to her pocket and applied new gloves. During an interview on 05/24/25, at 1:57 p.m. LPN Employee E11 confirmed the failure to set up a clean barrier field, not completing hand hygiene after removal of gloves, and that the facility failed to prevent cross contamination during a dressing change for one of three residents (Resident R107). 28 Pa. Code: 211.10(d) Resident Care Policies. 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 29 of 30 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 05/16/2025 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of facility documentation, and staff interview, it was determined that the facility failed to make certain that equipment was in safe operating condition for one of three crash carts (Exam Room). Residents Affected - Few Findings include: Review of the facility Emergency Cart policy dated [DATE], indicated the emergency cart will be appropriately stocked and ready for use when attempting to resuscitate a resident. The cart will be readily available for use and its inventory maintained. During an observation of the Exam Room crash cart (a cart maintained with equipment used in cardiac emergencies) on [DATE], at 10:49 a.m. revealed the following expired supplies: - Foley Insertion Kit (a thin flexible tube inserted into the bladder to drain urine), expired [DATE]. - IV Start Kit expired [DATE]. - Syringe Piston not sealed closed. - Dressing Kit expired [DATE]. - Yanker Suction device (used to clear drainage out of a person ' s mouth) expired [DATE]. - Tracheostomy (an opening in the front of the neck that provides an airway for breathing) Care Tray expired [DATE]. During an interview on [DATE], at 10:45 a.m. Assistant Director of Nursing Employee E3 confirmed the above observations and confirmed that the facility failed to make certain that equipment was in safe operating condition for one of three crash carts, as required. 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 30 of 30