Health inspection·August 8, 2025

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm Based on review of the Pennsylvania Code Title 49. Professional and Vocational Standards, facility job descriptions, clinical records, and staff interview, it was determined that the facility failed to follow nursing standards of practice to ensure physician orders were entered into point click care (PCC-a healthcare software used to track and administer healthcare operations in a long-term care facility) upon admission to ensure timely medication availability and timely medication administration for one of 17 residents reviewed (Resident R1). Findings include: Review of Pennsylvania Code Title 49. Professional and Vocational Standards 21.11. General functions of the Registered Nurse (RN) (a)(4) stated, Carries out nursing care actions which promote, maintain and restore the well-being of individuals and (b) The RN is fully responsible for all actions as a licensed nurse and is accountable to clients for the quality of care delivered and (d) The Board recognizes standards of practice and professional codes of behavior, as developed by appropriate nursing associations, as the criteria for assuring safe and effective practice. Review of the facility's job description for RNs revealed To provide direct nursing care under the medical direction and supervision of the residents' attending physicians, the Director of Nursing Services, and the Medical Director of the facility. Responsible for interpretation and execution of physician's orders and calling the physician as indicated. Is responsible for competent administration of care and treatments according to physicians orders and facility policy and procedure.Prepare residents for admission.Assure documentation is complete and incorporated into the clinical records in compliance with facility policy. Review of Resident R1's clinical record revealed an admission date of 3/4/23, with diagnoses that included idiopathic pulmonary fibrosis (a lung disease that causes irreversible scarring in the lungs), sleep apnea (breathing starts and stops during sleep), and acute and chronic respiratory failure. Resident R1's clinical record revealed he/she returned to the facility from the hospital on 6/12/25, at 4:15 p.m. His/her medication orders were not placed into PCC for floor nurses to be alerted when scheduled medications were due to be administered or for the administration of PRN (as needed) medications until 6/13/25, at 10:31 a.m., which was approximately 18 hours after Resident R1 had returned from the hospital. Resident R1's clinical record progress notes dated 6/13/25, at 2:30 p.m. and 2:34 p.m. documented that Resident R1 was short of breath and his/her pulse ox (test used to measure the amount of oxygen in the blood) was 76% on room air, which was well below the desired percentage of 90% or higher. The nurses on duty had to call the physician for an order to treat the resident due to the orders not being placed in PCC timely. Resident R1 indicated that he/she had not had breathing treatment since returning from the hospital the day prior. Resident R1's admission orders included Albuterol 90 MCG [microgram] inhaler (medication used to treat and prevent breathing difficulties) 2 puffs every 4 hours PRN and Budesonide 2 milliliters (medication used to reduce inflammation and swelling in the airways making it easier to breath) twice a day via nebulizer (a machine used to convert liquid medication into an inhalable mist), which could have been used during their documented episode of respiratory Residents Affected - Few (continued on next page) 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 Page 1 of 3 Event ID: 395777 Printed: 05/15/2026 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 395777 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/08/2025 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)