Sugar Creek Care Center

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

and LPN Employee E3 confirmed also that having two briefs placed on a resident is not the facility ' s protocol for incontinence/prevention of skin breakdown. Interviews with Resident Resident R1 on 11/05/25, at 10:40 a.m., 11:35 a.m., and 1:30 p.m. indicated he/she had been out of bed sitting in his/her wheelchair since 6:30 a.m. and not checked/changed or repositioned since 6:30 a.m. During an interview on 11/12/25, at 12:30 p.m. the Nursing Home Administrator (NHA), confirmed that the facility failed to maintain dignity for Resident Resident R1 by placing two briefs on for incontinence care. The NHA further confirmed that it is not the facility ' s policy to have two briefs on a resident for incontinence care. 28 Pa. Code 211.12(d)(3)(5) Nursing services. 28 Pa. Code 211.10(d) Resident care policies

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/13/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Sugar Creek Care Center

351 Causeway Drive Franklin, PA 16323

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

(not applicable).During an interview on 11/05/25, at 1:20 p.m. Resident Resident R4 indicated that he/she does not always get his/her bath as scheduled, and the staff tell him/her if they have time, he/she will get one.

Resident Resident R4 indicated that their preference is Monday and Thursday. An observation at that time revealed Resident Resident R4 with greasy hair.An interview with the Nursing Home Administrator (NHA) on 11/07/25, at 1:30 p.m. confirmed showers are given per resident ' s preference and are encouraged twice a week. The NHA further confirmed that baths/showers were not provided according to Resident Resident R1, Resident R2, Resident R3, and Resident R4 ' s scheduled days and preference for the period of 10/09/25, through 11/07/25. The facility line listing report for respiratory illness on 11/12/25, revealed no new positive residents since 11/4/25, which indicated that

the spread of the infection had slowed.Resident interviews on 11/5/25, between 11:35 a.m. and 12:30 p.m. with Residents Resident R1, Resident R4, Resident R6, Resident R7, Resident R8, and Resident R9 indicated they enjoy eating their meals in the dining room with other residents. They also indicated that they enjoy attending group activities, however the dining room and group activities have been stopped. Observations on 11/5/25, between 9:30 a.m. and 3:30 p.m. revealed residents participating in therapy, interacting with staff and ambulating throughout the facility. No

observations were made of residents participating in individual activities, social distancing activities, or social distancing with meals in the dining room. During an interview on 11/5/25, at 2:40 p.m. the NHA and

the Director of Nursing (DON) confirmed that the residents do not eat in the dining room or attend group activities, due to COVID in the building. 28 Pa. Code 211.10 (d) Resident care policies28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/13/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Sugar Creek Care Center

351 Causeway Drive Franklin, PA 16323

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

incontinence care was provided by Nursing Assistant (NA) Employee E2 and Licensed Practical Nurse (LPN) Employee E3. Resident Resident R1 was observed with his/her incontinence briefs (two briefs) filled with feces overflowing outside of briefs and onto pants and skin of both extremities. Resident Resident R1 ' s peri area and buttocks were observed extremely red. NA Employee E2 and LPN Employee E3 confirmed during incontinence care at 1:45 p.m. that Resident Resident R1 should have been checked/changed every two hours, but was not due to large amount of feces overflowing the two incontinence briefs onto his/her clothing and legs, and Resident Resident R1 had severely reddened skin from not being repositioned and checked/changed timely. NA Employee E2 and LPN Employee E3 confirmed also that having two briefs placed on a resident is not the facility ' s protocol for incontinence/prevention of skin breakdown. Interviews with Resident Resident R1 on 11/05/25, at 10:40 a.m., 11:35 a.m., and 1:30 p.m. indicated he/she had been out of bed sitting in their wheelchair since 6:30 a.m. and not checked/changed or repositioned since 6:30 a.m. Review of Resident Resident R5 ' s clinical

record revealed an admission date of 7/2/24, with diagnoses that included Parkinson ' s (a chronic and progressive movement disorder that causes shaking, slows a person ' s ability to move and worsens over time), and peripheral vascular disease (a condition when there is restricted blood flow to the limb, usually legs).Review of Resident Resident R5 ' s care plans revealed a plan of care for potential impairment to skin integrity, with interventions for pressure relieving cushion while up in chair. Care plan also revealed pressure ulcer and skin break down to right hip and buttock. Review of Residents Resident R5 ' s MDS dated [DATE REDACTED], under section GG0170 mobility revealed A. roll left and right response was 01 Dependent, B. sit to lying response was 01 Dependent, C. lying to sitting response was 01 Dependent, D. sit to stand response was 01 Dependent, E. chair to bed/bed to chair transfer response was 01 Dependent.Review of Resident Resident R5 ' s physician orders revealed treatment orders for wound to right buttock and treatment orders for wound to right trochanter (hip). Review of Resident Resident R5 ' s clinical documentation revealed a note from the wound Nurse Practitioner dated 11/05/25, indicating to continue with turning and repositioning schedule per protocol for pressure prevention.Observations on 11/05/25, at 9:30 a.m. revealed Resident Resident R5 was sitting in his/her recliner chair

in their room on his/her buttocks, and no pressure relieving cushion was on their recliner. Observations at 10:00 a.m., 10:40 a.m., 11:15 a.m., 11:35 a.m., 12:00 p.m., 12:10 p.m., 1:30 p.m. and 1:45 p.m. revealed Resident Resident R5 remained sitting in his/her recliner in their room on his/her buttocks and no pressure relieving cushion was in place. Observations on 11/05/25, at 2:15 p.m. of incontinence care for Resident Resident R5 revealed that he/she had an open area to his/her right buttock and his/her bilateral buttocks were red. During an

interview on 11/05/25, at 2:35 p.m. Nursing Assistant Employee E2 confirmed that residents that can not reposition independently should be repositioned by staff.During an interview on 11/05/25, at 2:40 p.m. the Director of Nursing and Regional Clinical Director, confirmed that residents' pressure relieving devices should be in place and residents should be repositioned with incontinence care provided timely. It was also confirmed that it is not the facility ' s policy to have two briefs on a resident for incontinence care. 28 Pa.

Code 211.12(d)(3)(5) Nursing services. 28 Pa. Code 211.10(d) Resident care policies

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/13/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Sugar Creek Care Center

351 Causeway Drive Franklin, PA 16323

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Level of Harm - Minimal harm or potential for actual harm

Based on review of facility policy and records, observations, and resident and staff interview it was determined that the facility failed to provide food that was palatable and at an appetizing temperature for one of one test trays completed. Findings include:A facility policy entitled, Meal Service Line dated 6/4/25, revealed Food will be prepared by methods that conserve nutritive value, flavor and appearance, and will be placed on trays in an attractive manner as near to the time of actual tray service as possible. This is done to ensure acceptable temperatures of food when the tray is served to the resident. Resident council and food committee minutes from 8/5/25, and 10/13/25, indicated that a toasted cheese sandwich was cold and that lunch and dinner trays on the unit are being served up to 45 minutes late. During an interview on 11/5/25, at 12:30 p.m. Resident Resident R6 who resides on 600 Hall indicated his/her food is often served cold. Review of temperature logs completed by kitchen staff on 11/5/25, revealed the following lunch meal temperatures: Pork 170 degrees Fahrenheit (F)Baked Potatoes 170 degrees FCorn 169 degrees FObservations on 11/5/25, at approximately 11:55 a.m. in the main kitchen revealed Cart 1 for the 600 Hall had just left the kitchen. Tray line was observed for Cart 2 of the 600 Hall and a test tray was prepared last and placed on

the cart. The Dietary Manager escorted the cart to the 600 Hall at 12:26 p.m. and arrived at the 600 Hall at 12:27 p.m. Cart 1 was still sitting in the hall and had not been passed to the residents. Tray pass was completed for 600 Hall Cart 1 and Cart 2 at 12:42 p.m.A test tray at the conclusion of resident room tray delivery on the 600 Hall was completed at 12:42 p.m. and revealed the following temperatures:Pork 138 degrees FBaked Potatoes 145 degrees FCorn 143 degrees FAll the items were tasted and were not palatable due to the cool temperatures. Dietary Manager Employee E4 confirmed the unacceptable temperatures and poor palatability at the time of the tray testing. 28 Pa. Code 201.14(a) Responsibility of licensee

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/13/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Sugar Creek Care Center

351 Causeway Drive Franklin, PA 16323

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880

Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or potential for actual harm

Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to prevent the potential for cross-contamination during completion of incontinence care (care provided for someone who has lost control of their bladder and/or bowel movements) for two of two residents observed (Residents Resident R1 and Resident R5). Findings include:Review of facility policy entitled Perineal Care dated 6/4/25, indicated Steps in the procedure . discard disposable items into designated containers. Review of facility policy entitled Diarrhea and Fecal Incontinence dated, 6/4/25, indicated Disposable items soiled with feces (i.e., disposable briefs .) must be handled as so to prevent contamination of the environment with feces. Observations on 11/5/25, at 1:45 p.m. revealed Nursing Assistant (NA) Employee E1, NA Employee E2, and Licensed Practical Nurse (LPN) Employee E3 completing incontinence care for Resident Resident R1.

During incontinence care NA Employee E2 removed resident Resident R1 ' s pants and brief (a disposable incontinence pad) which was soiled (contained urine and feces). NA Employee E1 then placed the pants and brief onto the floor. After completing incontinence care NA Employee E2 picked up Resident Resident R1 ' s pants and brief and placed them in a garbage can. Employees E1, E2 and E3 walked across the floor where the soiled pants and soiled brief had been lying.Observations on 11/5/25, at 2:15 p.m. revealed NA Employee E1 and NA Employee E2 completing incontinence care for Resident Resident R5. During incontinence care NA Employee E1 removed resident Resident R5 ' s pants and brief, NA Employee E1 then placed Resident Resident R5 ' s soiled brief onto the floor. After completing incontinence care, NA Employee E1 picked up Resident Resident R5's soiled brief and took it out of the room. Both NA Employees E1 and E2 walked across the floor where the soiled brief had been lying.During an interview on 11/5/25, at 2:35 p.m. NA Employees E1 and E2 confirmed that Resident Resident R1 and Resident Resident R5 ' s briefs contained urine and feces, and the soiled briefs were placed on the floor. They confirmed that they had walked across the floor where the soiled briefs had been lying, and the floor should have been sanitized after the briefs were removed. During an interview on 11/5/25, at 2:40 p.m. the Director of Nursing confirmed that soiled briefs should not be placed on the floor and that the soiled briefs should be placed in a designated container.28 Pa. Code 211.10(c) Resident care policies28 Pa. Code 211.12(d)(1)(5) Nursing services

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet