Sugar Creek Care Center: Missing G-Tube Order - PA
The resident, identified in the inspection report only as Resident R1, was admitted in August 2025 with spastic quadriplegic cerebral palsy, intellectual disabilities, and diabetes. Spastic quadriplegic cerebral palsy is the most severe form of the condition, causing stiffness and poor control of all limbs, the trunk, and the face. R1 relies on a gastrostomy tube, surgically placed directly into the stomach, for feedings and fluids.
On December 1, 2025, nursing notes recorded that a staff member flushed R1's G-tube with a 50/50 mix of hydrogen peroxide and water to clear a clog. The flush happened. The documentation of the order authorizing it did not.
Inspectors reviewed R1's current physician's orders and found no entry for the December 1 flush. The Medical Director, reached by phone on December 22, confirmed he had given a verbal telephone order for the one-time flush and said the procedure was clinically safe. The Director of Nursing, interviewed the same afternoon, confirmed the order was missing from the clinical record.
The gap is a documentation failure, not a disputed treatment. The doctor ordered it. The nurse carried it out. Nobody recorded it.
Sugar Creek was cited under Pennsylvania regulations governing medical records and nursing services. Inspectors classified the harm level as minimal.
For a resident who cannot speak for herself and depends entirely on staff to manage every aspect of her nutrition and medical care, the record of what was done to her body, and on whose authority, is not a paperwork formality. It is the only account that exists.
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.
Download the official CMS inspection PDF from Medicare.gov
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 19, 2026 · Our methodology
SUGAR CREEK CARE CENTER in FRANKLIN, PA was cited for violations during a health inspection on December 23, 2025.
Spastic quadriplegic cerebral palsy is the most severe form of the condition, causing stiffness and poor control of all limbs, the trunk, and the face.
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.