Quality Life Services - Sugar Creek

In the surveyor’s words

From the most serious findings on record at Quality Life Services - Sugar Creek, in the surveyor’s own words.

• Immediate jeopardy, widespreadF880May 8, 2024

  Based on Centers for Disease Control and Prevention (CDC) guidance, Pennsylvania Department of Health (PADOH) guidance, facility policy and documents, review of clinical records, and resident and staff interviews, it was determined that the facility failed to maintain an infection prevention and control program by failing to timely investigate and document surveillance, exclude ill staff from working, failed to educate staff on appropriate precautions related to GI illness, and failed to implement preventative measures to address an outbreak of gastrointestinal illness among residents for 10 of 17 residents (Residents R1, R2, R3, R4, R5, R6, R7, CR8, R9, and R14) The facility's failure created a situation in which all 100 of 100 residents were placed in Immediate Jeopardy related to a lack… […]

• Immediate jeopardy, patternF805Mar 5, 2026

  Based on facility policy review, medical literature review, clinical record reviews, review of facility documents, and staff interviews, it was determined that the facility failed to provide an altered texture diet, as prescribed by the physician, for one of 40 residents (Resident R1). This failure resulted in Resident R1 choking on food that he was not ordered which caused him to cease to breathe. This failure placed an additional 40 residents that had similar diet needs at risk which resulted in an Immediate Jeopardy situation for 40 of 107 residents.Findings include: Review of facility policy Dysphagia (difficulty swallowing) Diets dated 2/16/26, indicated the following: Individuals with observed indicators of dysphagia (coughing, choking, delayed swallow, pocketing of food [storing… […]

• Immediate jeopardy, isolatedF600May 20, 2022

  Based on review of facility policies, clinical records, review of facility investigation and staff interviews, it was determined that the facility failed to implement adequate safeguards to protect cognitively impaired residents in a secured memory unit from sexual abuse, the facility failed to identify abuse as sexual and failed to assess current and past residents that may have been sexually abused, these failures resulted in sexual abuse on one Resident of 29 cognitively impaired residents (Resident R2). This failure placed 29 residents at risk of sexual assault and resulted in an Immediate Jeopardy situation. […]

• Actual harm, isolatedF742May 20, 2022

  Based on clinical record review and staff interview, it was determined that the facility failed to provide the necessary services to meet the psychosocial needs resulting in actual harm of the commitment of resident to resident sexual abuse for one of two residents with increased sexual behaviors. (Resident R1). Findings include: Review of the facility policy, Behavior Monitoring dated 11/1/21, indicated the facility will monitor the behaviors of residents receiving [CONDITION(S)] medications. […]

• No harm, potential for more than minimal, widespreadF812Jun 5, 2026

  Based on review of facility policy, observations and staff interviews, it was determined that the facility failed to ensure foods were not held in the danger zone temperatures which are between 41 degrees Fahrenheit (F) and 135 degree F and properly store food products.Findings: Review of the facility's Food Storage policy dated 2/12/26, revealed sufficient storage facilities are provided to keep foods safe, wholesome, and appetizing. Food is dated as it is placed on the shelves, and old stock is always used first. Date marking to indicate the date by which a ready-to-eat, potentially hazardous food should confused or discarded will be visible on all high risk food. Foods with a manufacturer use by date, must be used or discarded by the stamped date. […]