Sugar Creek Care Center: Missing G-Tube Order - PA
The resident, identified in inspection records only as Resident R1, was admitted to the Franklin facility on August 21. The inspection report lists diagnoses of spastic quadriplegic cerebral palsy, the most severe form of the condition, which causes profound stiffness and loss of voluntary control over all four limbs, the trunk, and the face. R1 also lives with intellectual disabilities and diabetes. The resident receives nutrition and fluids through a gastrostomy tube, a device surgically placed directly into the stomach.
On December 1, nursing notes recorded that the G-tube had become clogged. Staff flushed it with a 50/50 mix of hydrogen peroxide and water, 50 cubic centimeters of each, as instructed. The notes said the flush was done as instructed, indicating a physician had been reached by phone and had given the go-ahead.
What the chart did not contain was the order itself.
Inspectors reviewed R1's current physician's orders during a complaint inspection completed December 23. The December 1 order for the one-time hydrogen peroxide and water flush was absent. The facility's own policy on telephone orders, dated June 4, 2025, required that any verbal order given over the phone be recorded in the resident's clinical record. It had not been.
On December 22, inspectors reached the facility's Medical Director by phone. He confirmed he had given the verbal order for the flush. He also confirmed the procedure was safe. But confirming it after the fact, weeks later and only because inspectors were asking, is not the same as having a documented order in place before the procedure was carried out.
The Director of Nursing, interviewed the same afternoon, confirmed what the chart showed. Or rather, what it didn't. There was no evidence of a physician's order for the flush completed on December 1.
The violation was cited under F0842, which covers the accuracy and completeness of medical records. Inspectors rated the level of harm as minimal, or potential for actual harm, and noted that few residents were affected. One of three residents reviewed with a G-tube had this documentation gap. The other two did not.
The harm rating matters, but it doesn't fully capture what a missing order means in practice. A medical record is not a formality. It is the mechanism by which one nurse, one shift, one physician knows what another has already done and why. A G-tube flush with hydrogen peroxide and water, carried out on a resident who cannot speak for herself and cannot advocate for her own care, happened and then effectively disappeared from the record. The next clinician to review that chart would have had no way of knowing it occurred.
The Medical Director's confirmation that the flush was safe closes one question. It does not close the question of what happens when a procedure is performed on a nonverbal, profoundly disabled resident and the authorization for that procedure exists only in a phone call that nobody wrote down.
Sugar Creek Care Center is a long-term care facility in Franklin, in Venango County in northwestern Pennsylvania. The inspection was a complaint survey, meaning someone raised a concern that triggered the visit. The inspection report does not identify who filed the complaint or what specifically prompted it.
R1 has been at the facility since late August. The clogged tube, the phone call to the doctor, the flush with hydrogen peroxide and water, the nursing note that acknowledged it happened, and then the gap where the order should have been, that is the full sequence of what inspectors found. A resident who depends on a tube in her stomach for every calorie and every sip of fluid, and whose care on at least one occasion was carried out without a complete paper trail to show for it.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Sugar Creek Care Center from 2025-12-23 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 19, 2026 · Our methodology
SUGAR CREEK CARE CENTER in FRANKLIN, PA was cited for violations during a health inspection on December 23, 2025.
The resident, identified in inspection records only as Resident R1, was admitted to the Franklin facility on August 21.
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.