Sugar Creek Care Center: Dignity Violations Found - PA
The resident, identified in inspection records as Resident R1, told inspectors three separate times on November 5, 2025, the same thing: in bed since before sunrise, up in the wheelchair since 6:30 a.m., and not once checked on or repositioned through the late morning and into the early afternoon. The interviews happened at 10:40 a.m., 11:35 a.m., and 1:30 p.m. Each time, the answer was the same.
The inspection, completed November 13, 2025, was a complaint survey. Someone had raised a concern about how residents were being treated at the 351 Causeway Drive facility. What inspectors documented when they arrived pointed to a failure that the facility's own leadership ultimately could not dispute.
Staff had placed two incontinence briefs on Resident R1, one on top of the other. A licensed practical nurse identified in the report as Employee E3 confirmed that doubling up briefs is not how the facility handles incontinence care or skin breakdown prevention. It is not protocol. The nursing home administrator said the same thing during an interview on November 12, 2025, and went further: the facility had failed to maintain the resident's dignity.
That word, dignity, is the center of what inspectors cited. The federal tag attached to this deficiency, F0550, addresses the right of residents to be treated with respect and dignity in all aspects of their care. The harm level was recorded as minimal harm or potential for actual harm, and the number of residents affected was listed as few. But the details behind those clinical categories are specific. A person sat alone in a wheelchair, in double briefs, for hours, and no one came to check.
The nursing home administrator's confirmation during the interview was unambiguous. The doubling of briefs was wrong. The failure to check, change, or reposition the resident through the morning and into the afternoon was wrong. Both acknowledgments came from the top of the facility's leadership, not from a line staff member being pressed by an inspector.
Sugar Creek Care Center is a long-term care facility in Franklin, in Venango County in western Pennsylvania. The inspection was conducted under CMS guidelines, and the deficiency was cited under Pennsylvania nursing services and resident care policy codes alongside the federal standard.
What the report does not contain is any explanation for why Resident R1 was left unattended for that stretch of time, or why two briefs were applied in the first place. No staffing numbers appear in the narrative. No explanation from the floor staff who were responsible for the resident's care that morning is included. The record shows what happened and who confirmed it. The reasons behind it are not documented.
Resident R1 sat in that wheelchair while inspectors came and went across the day, answering the same questions at 10:40, again at 11:35, again at 1:30. The answers did not change because the situation had not changed. Hours had passed. No one had come.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Sugar Creek Care Center from 2025-11-13 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 2, 2026 · Our methodology
SUGAR CREEK CARE CENTER in FRANKLIN, PA was cited for violations during a health inspection on November 13, 2025.
The interviews happened at 10:40 a.m., 11:35 a.m., and 1:30 p.m.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.