Sugar Creek Care Center: Skin Care Failures - PA
When inspectors observed the resident on November 5, 2025, at 1:45 p.m., the skin on the resident's perineal area and buttocks was described as extremely red. The resident had been in that wheelchair, in that condition, for more than seven hours.
The nursing assistant and licensed practical nurse who were present for the incontinence care that afternoon confirmed it themselves. The resident should have been checked and changed every two hours. He or she had not been. They also confirmed that placing two incontinence briefs on a resident at once is not the facility's protocol.
Nobody had checked. Nobody had repositioned. Nobody had changed.
The same day, inspectors documented what was happening in another resident's room down the hall. That resident, identified in the report as Resident R5, has Parkinson's disease and peripheral vascular disease, conditions that leave him or her entirely dependent on staff for every movement, from rolling over in bed to transferring from a chair. The resident's own medical assessment rated him or her as fully dependent across every mobility category.
R5 had an open wound on the right buttock and a second wound on the right hip. A wound care nurse practitioner had written a note that same day instructing staff to continue a turning and repositioning schedule. The resident's care plan called for a pressure-relieving cushion whenever he or she was seated in a chair.
Inspectors first observed Resident R5 sitting in a recliner at 9:30 a.m. No pressure-relieving cushion was in place. They checked again at 10:00, 10:40, 11:15, 11:35, noon, 12:10, 1:30, and 1:45. Each time, R5 was still in the recliner. Each time, no cushion.
That is more than four hours of a resident with active pressure wounds sitting directly on the surface those wounds were on, without the device the care plan required.
At 2:15 p.m., during incontinence care, inspectors observed the open area on R5's right buttock directly. Both sides of the buttocks were red.
The nursing assistant confirmed during an interview at 2:35 p.m. that residents who cannot reposition themselves are supposed to be repositioned by staff. The Director of Nursing and the Regional Clinical Director, interviewed together at 2:40 p.m., confirmed that pressure-relieving devices should be in place, that repositioning should happen, and that two briefs on a single resident is not facility policy.
What they confirmed, in other words, is that they knew exactly what should have been done. The inspection report documents, hour by hour, that it was not done.
These findings came from a complaint inspection completed November 13, 2025. The violations were cited under Pennsylvania nursing services regulations, which require that residents receive care consistent with their care plans and that nursing services meet each resident's needs. The level of harm was assessed as minimal harm or potential for actual harm.
That language, "minimal harm or potential for actual harm," is the regulatory floor. What the inspection actually describes is a resident with severely reddened skin who spent seven hours sitting in feces, and another resident with open pressure wounds who sat without a cushion for the better part of a morning while staff and a wound care provider both knew those wounds existed.
Resident R5's wounds to the right buttock and right hip were already documented in physician orders. Treatment orders were already in place. The nurse practitioner had already been there that morning. The care plan had already been written. The cushion that should have been on that recliner was not a new idea.
It just wasn't there.
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.
When inspectors observed the resident on November 5, 2025, at 1:45 p.m., the skin on the resident's perineal area and buttocks was described as extremely red.
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.