Sugar Creek Care Center
Inspection Findings
F-Tag F0842
F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to have complete and accurate documentation regarding physician's orders for a gastrostomy (G-tube-tube placed in the stomach for feedings and fluids) for one of three residents reviewed with a G-tube. (Resident Resident R1). Findings include: Review of facility policy entitled Telephone Orders dated 6/4/25, indicated the order must be recorded in the residents clinical record . Review of Resident Resident R1's clinical
record revealed an admission date of 8/21/25, with diagnoses that included spastic quadriplegic cerebral palsy (most severe type of cerebral palsy causing severe stiffness and poor control of all limbs, trunk and face due to brain damage), intellectual disabilities, and diabetes (a health condition that is caused by the body's inability to produce enough insulin). Review of Resident Resident R1's nurse's notes dated 12/01/25, indicated that the G-tube was flushed with a 50/50 mix of hydrogen peroxide and water as instructed.
Review of Resident Resident R1's current physician's orders, lacked an order dated 12/01/25, to administer a one-time flush with a 50 cubic centimeter (cc) of hydrogen peroxide and 50 cc of hot water to clear clogged G-tube. During a telephone interview on 12/22/25, at 12:29 p.m. the Medical Director confirmed that he did give a telephone verbal order for one time flush with 50 cc of hydrogen peroxide and 50 cc of hot water to unclog Resident Resident R1's G-tube and also confirmed that this was safe practice. During an interview on 12/22/25, at 2:00 p.m. the Director of Nursing confirmed that Resident Resident R1's clinical record lacked evidence of a physician's order for the 50/50 hydrogen peroxide and water G-tube flush completed on 12/01/25. 28 Pa. Code 211.5(f)(i) Medical records 28 Pa. Code 211.12(d)(1)(5) Nursing services
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
Facility ID:
If continuation sheet
Event ID:
SUGAR CREEK CARE CENTER in FRANKLIN, PA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in FRANKLIN, PA, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from SUGAR CREEK CARE CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.