Sugar Creek Care Center
SUGAR CREEK CARE CENTER in FRANKLIN, PA — inspection on December 23, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
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 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 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 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 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 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 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
Facility ID: