Sugar Creek Care Center: Fecal Cross-Contamination Risk - PA
Inspectors watched it happen both times.
The first observation came at 1:45 p.m. on November 5. Two nursing assistants, identified in the inspection report as Employee E1 and Employee E2, and a licensed practical nurse, Employee E3, were providing incontinence care for a resident identified as R1. Employee E2 removed the resident's pants and brief, both soiled with urine and feces. Employee E1 then placed them on the floor.
The pants and the soiled brief sat there while care was completed. When it was over, Employee E2 picked them up and put them in a garbage can. All three staff members, the two nursing assistants and the nurse, walked across the section of floor where the waste-soiled items had been lying.
Thirty minutes later, at 2:15 p.m., Employees E1 and E2 were back, this time providing incontinence care for a second resident, R5. The same thing happened. Employee E1 removed the resident's brief, soiled again with urine and feces, and placed it on the floor. After care was finished, Employee E1 picked it up and carried it out of the room. Both nursing assistants walked across the floor where the brief had been.
Nobody sanitized the floor.
When inspectors interviewed Employees E1 and E2 at 2:35 p.m., the two confirmed everything. They acknowledged the briefs had contained urine and feces. They confirmed the briefs had gone on the floor. They confirmed they had walked across those spots. They told inspectors the floor should have been sanitized after the briefs were removed.
The Director of Nursing, interviewed five minutes later, said the same thing. Soiled briefs should not go on the floor. They should go directly into a designated container.
The facility's own written policies said as much. A perineal care policy, dated June 4, 2025, instructed staff to discard disposable items into designated containers. A separate policy on diarrhea and fecal incontinence, also dated June 4, said soiled disposable items must be handled so as to prevent contamination of the environment with feces.
The policies existed. The staff knew the policies. The Director of Nursing knew the policies. On the afternoon of November 5, none of that prevented two nursing assistants and a nurse from putting waste-soiled items on the floor, walking across them, and moving on to the next room.
The inspection was conducted as a complaint investigation. Inspectors cited the facility under the federal infection prevention and control requirement, which covers programs designed to prevent the spread of infection. The violation was classified as causing minimal harm or potential for actual harm, and inspectors noted that few residents were affected.
What the classification doesn't capture is the basic mechanics of what was observed. Feces on a floor, walked across by staff, in a building where elderly residents live, move, and receive care. The staff who walked across that floor then went elsewhere in the facility. The floor where R1 received care was not sanitized before staff arrived to care for R5 thirty minutes later.
The two nursing assistants were in both rooms.
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: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 22, 2026 · Our methodology
SUGAR CREEK CARE CENTER in FRANKLIN, PA was cited for violations during a health inspection on November 13, 2025.
Inspectors watched it happen both times.
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.