Health inspection·June 27, 2025

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 Peripherally Inserted Central Catheter (PICC-a thin soft flexible tube placed in the vein of the upper arm also called an IV to deliver fluids and medications) dressing changes for two of three residents reviewed with PICC lines in the treatment record. (Residents R1 and R2) Findings include: Review of facility policy entitled Peripheral and Midline IV Dressing Changes dated 5/9/25, indicated Change the dressing if it becomes damp, loosened or visibly soiled and at least every 7 days . Review of Resident R1's clinical record revealed an admission date of 11/24/24, with diagnoses that included hypertension (high blood pressure), cellulitis (and infection of the skin), and diabetes (a health condition that is caused by the body's inability to produce enough insulin). Review of Resident R1's physician's orders for May 2025, revealed an order dated 5/5/25, to change PICC line dressing weekly. Review of Resident R1's treatment administration record for May 2025, lacked evidence that his/her PICC line dressing was changed on 5/12/25, 5/19/25, and 5/26/25. Review of his/her treatment administration record for June 2025, lacked evidence that his/her PICC line dressing was changed on 6/1/25. Review of Resident R2's clinical record revealed an admission date of 4/6/25, with diagnoses that included osteomyelitis (an infection in the bone), bacteremia (infection in the blood), and gastro esophageal reflux disease (a condition when stomach acid repeatedly flows back up into your throat). Review of Resident R2's physician's orders for April 2025, revealed an order dated 4/6/25, to change PICC line dressing weekly. Review of Resident R2's treatment administration record for April 2025, lacked evidence that his/her PICC line dressing was changed on 4/21/25, and 4/28/25. Review of his/her treatment administration record for May 2025, lacked evidence that his/her PICC line dressing was changed on 5/5/25. During an interview on 6/18/25, at 12:56 p.m. the Regional Clinical Director Employee E1 confirmed that Residents R1 and R2's treatment records did not have complete documentation regarding PICC line dressing changes. He/she also confirmed that the dressing changes should be completed per physician's orders and documented in the clinical record. Page 1 of 3 395777 395777 06/27/2025 Sugar Creek Care Center 351 Causeway Drive Franklin, PA 16323

F 0842 28 Pa. Code 211.5(f)(xiii)(ix) Medical Records Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 211.12(d)(1)(5) Nursing Services Residents Affected - Few 395777 Page 2 of 3 395777 06/27/2025 Sugar Creek Care Center 351 Causeway Drive Franklin, PA 16323

F 0882 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. Based on review of facility infection control program and staff interview, it was determined that the facility failed to ensure the designated Infection Preventionist (IP) was qualified with specialized training in infection prevention and control from 4/10/25 to 5/25/25. Findings include: Review of facility policy entitled Infection Preventionist dated 5/9/25, indicated The Infection Preventionist has obtained specialized IPC training beyond initial professional training . and Evidence of training is provided through a certificate of completion . Review of Registered Nurse (RN) Employee E2's daily timecard revealed he/she worked as the facility's IP from 4/16/25, to 5/21/25. Upon request, the facility was unable to produce a certificate of completion for the IP specialized training for RN Employee E2. During an interview with Regional Clinical Director Employee E1 on 6/17/25, at 11:00 a.m. he/she revealed that RN Employee E2 started covering the IP position in the facility when the former IP left the position on 4/9/25, and he/she continued covering the position until the facility's new IP started the position on 5/26/25. During an interview on 6/24/25, at 8:37 a.m. the Nursing Home Administrator confirmed that the facility had no evidence that RN Employee E2 had successfully completed the required specialized IP training. 28 Pa. Code 201.18(b)(1)(3) Management 395777 Page 3 of 3