Below average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Tioga Community Care Center during CMS and state inspections, most recent first.
A resident with morbid obesity, vascular dementia, and an above-the-knee amputation, who was cognitively intact and dependent on a mechanical lift with two-person assist for transfers, was not assisted out of bed over a weekend despite repeatedly requesting to get up. CNAs and an LPN reported that lifts on the resident’s hall and other halls were not working or had uncharged batteries, resulting in residents who required lifts not being gotten out of bed. The resident’s responsible party stated the resident had been reporting ongoing difficulty getting out of bed due to lift problems, and administration later acknowledged there had been lift issues, while also confirming staff should have used a working lift to honor the resident’s request to get out of bed.
Staff failed to consistently monitor and record food, refrigerator, freezer, and dishwasher temperatures, and did not properly store food items, such as leaving opened dough boxes exposed in the freezer. These lapses were confirmed by dietary staff and were not in accordance with facility policies, potentially affecting all residents receiving meals.
Missing Orders and Unsafe Storage for Oxygen and Rescue Inhaler: A resident with emphysema and severe cognitive impairment was observed receiving continuous O2 at 4 L via concentrator despite current orders only for 2 L NC PRN, and the ADON confirmed no order existed for the continuous flow. Another resident with COPD and intact cognition reported daily use of a rescue inhaler, but no current inhaler order was in the chart and the inhaler was observed on the bedside dresser; staff confirmed it should have been reconciled and locked in the med box when not in use.
Respiratory care was not provided as ordered for two residents. One resident with COPD and SOB had an O2 order for 2 LPM via NC, but the flowmeter was repeatedly observed set between 2.5 and 3 LPM, and an LPN confirmed it was not set at the ordered rate. Another resident with multiple chronic conditions had an albuterol neb order and care plan instructions for nebulizer equipment, but the neb mask was observed sitting open to air on the dresser instead of being bagged, and an LPN confirmed it should not have been left that way.
Failure to document clinical rationale for psychotropic GDR denials. Two residents receiving psychotropic medications, including trazodone for depression and aripiprazole plus sertraline for dementia-related mood disturbance and depression, had pharmacy consultant GDR requests that were not supported by physician or NP documentation explaining why dose reduction was not appropriate or clinically contraindicated. The records showed intact cognition and no behaviors for one resident, while the other had no documented rationale in the consultant reports or progress notes, and the DON acknowledged the missing GDR rationale.
A facility failed to implement care plan interventions for two residents. One resident’s care plan called for bilateral side rails and a trapeze for bed mobility, but the left assist rail was not installed despite staff awareness of the need. Another resident with severe cognitive impairment and oxygen use had a care plan for nasal cannula ear cushions, yet observations showed no ear protectors in place and redness behind both ears, with the wound care RN confirming a stage 1 MDRI on the right ear.
The facility failed to ensure needed ADL care was provided for two residents. One resident with severe cognitive impairment and dependence for oral hygiene was observed multiple times with heavy brown and yellow buildup on the teeth, lips, and gums, and oral care remained incomplete even when staff later attempted it with the DON present. Another resident with dementia and other chronic conditions required assistance with bathing, but there was no bathing documentation for over a week, the resident said she had not been offered a bath, and the ADON acknowledged she had not been bathed in a week.
A resident experienced verbal abuse from a CNA during a showering session, leading to mental anguish. Despite the resident's cognitive intactness and corroboration from witnesses, the facility's administration did not classify the incident as verbal abuse, instead labeling it as an unprofessional interaction. The resident, with a history of anxiety and depression, reported feeling disrespected and insulted by the CNA's profane language.
A facility failed to report a verbal abuse incident involving a CNA and a cognitively intact resident with anxiety and major depressive disorder. The resident reported being cursed at by the CNA during a shower, which was confirmed by another CNA. Despite this, the Administrator did not report the incident to the State Agency, believing it did not constitute abuse due to lack of psychological harm, violating state law and facility policy.
A facility failed to inform a resident's responsible party of changes in the resident's medication regimen, despite the resident having severe cognitive impairment and multiple diagnoses. Interviews with staff confirmed that the responsible party should have been notified, but there was no documentation of such communication.
The facility failed to ensure the QAA committee meetings included the required six staff members for the last four quarterly meetings. The review of sign-in sheets revealed that only the Medical Director, Administrator, DON, and Infection Preventionist were in attendance. The Administrator was unaware of the requirement for additional members.
A resident with Lumbago and Sciatica did not receive recommended Lidocaine patches for pain management due to inadequate follow-up by an LPN. The resident's care plan included administering analgesic medications as ordered, but the facility failed to implement the orthopedic doctor's recommendation.
Failure to Honor Resident Choice Due to Unresolved Lift Equipment Issues
Penalty
Summary
The facility failed to promote and facilitate resident self-determination and resident choice regarding when to get out of bed for one cognitively intact resident who was dependent on staff and mechanical lifts for transfers. The resident, admitted with multiple diagnoses including unspecified atrial flutter, type 2 diabetes mellitus, morbid obesity, hypertensive heart disease, vascular dementia, and an above-the-knee left leg amputation, had a care plan indicating an ADL self-care performance deficit requiring use of a lift system with a brown sling and assistance of two staff for transfers. Despite this, over a specified weekend the resident reported being left in bed after repeatedly asking to get up and being told there were no lift pads available or that the lift was not working. Multiple staff interviews confirmed that lifts on the resident’s hall were reportedly not working during that weekend, and that residents requiring lifts, including this resident, were not gotten out of bed due to lift issues and problems with keeping batteries charged. One CNA stated she attempted to obtain a lift from other halls but found those lifts also not working, and another CNA reported that at times only one lift in the building was working and that the resident typically did not get out of bed when lift problems occurred. An LPN acknowledged knowing the resident did not get out of bed that weekend and heard the resident state he expected to get up on Monday. The resident’s responsible party reported receiving calls from the resident over the preceding weeks about difficulty getting out of bed due to lift problems and was later informed by administration that there had been lift issues. The administrator stated he had been aware of lift issues earlier in the week and had maintenance check all lifts, batteries, and charging ports, but he was not informed of lift problems on the specific weekend in question, and confirmed that if the resident had requested to get out of bed, staff should have used a working lift.
Failure to Maintain Food Safety Standards and Temperature Monitoring
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, staff did not ensure that food, dishwasher, refrigerator, and freezer temperatures were performed and recorded as required. Observations revealed that two opened boxes of yeast roll dough were left open to air in the walk-in freezer, and review of temperature logs showed that no refrigerator, freezer, or dishwasher temperatures were recorded on multiple dates. Additionally, food temperatures for dinner meal services were not completed on two occasions. Interviews with dietary staff confirmed that temperature checks were not completed appropriately and that there was a lack of monitoring to ensure logs were filled out as required. Facility policies reviewed indicated that food should be covered, labeled, and dated, and that temperatures should be checked and recorded at specified intervals, but these procedures were not followed. This deficient practice had the potential to affect all 93 residents who received meals prepared in the kitchen.
Missing Orders and Unsafe Storage for Oxygen and Rescue Inhaler
Penalty
Summary
The facility failed to ensure proper physician orders were obtained for Resident #13’s oxygen requirements. Resident #13 was admitted with diagnoses including Parkinson’s disease, type II diabetes mellitus with other specified complication, emphysema, and schizophrenia, and had severe cognitive impairment with a BIMS score of 7. The current physician orders included oxygen at 2 liters per nasal cannula as needed for shortness of breath or oxygen saturation less than 92%, with a start date of 07/21/2025, and no other current oxygen orders were present. However, nursing progress notes documented oxygen therapy at 4 liters nasal cannula on 07/20/2025 and 07/21/2025, and observations on 07/21/2025 and 07/22/2025 showed the resident receiving continuous oxygen at 4 liters via concentrator. The ADON confirmed there were no current physician orders for continuous 4-liter oxygen and that the nurse should have obtained the required oxygen orders before applying it. The facility also failed to ensure proper physician orders were obtained for Resident #36’s rescue inhaler and failed to store the inhaler in a safe and secure manner. Resident #36 was admitted with diagnoses including systolic congestive heart failure, NSTEMI, hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, cerebral infarction, and COPD, and had a BIMS score of 15 indicating intact cognition. Current physician orders contained no inhaler orders, although the care plan addressed COPD and stated the resident would receive aerosol or bronchodilators as ordered. The resident stated she used her rescue inhaler daily and kept it at her bedside, and an inhaler was observed on the bedside dresser. Staff confirmed there were no current physician orders for the inhaler, that the inhaler should have been reconciled on admission with proper orders obtained, and that it should have been stored in the medication box rather than at the bedside when not in use.
Respiratory Care Not Provided as Ordered
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for two residents. One resident had diagnoses including COPD and shortness of breath, and a physician order for oxygen at 2 LPM via nasal cannula. During three separate observations, the resident’s oxygen flowmeter was found set between 2.5 and 3 LPM instead of the ordered rate, and an LPN confirmed the flowmeter should have been set at 2 LPM but was not. The facility’s oxygen administration policy stated staff are to verify a physician’s order for oxygen administration and provide oxygen at the prescribed flow rate. Another resident had diagnoses including cerebrovascular disease sequelae, atherosclerotic heart disease, schizoaffective disorder, dysphagia, epilepsy, dementia, and heart failure, and had an order for albuterol solution via nebulizer every 6 hours as needed for shortness of breath. The resident’s care plan included nebulizer use as ordered and changing the nebulizer mask and tubing as ordered. On two observations, the resident’s nebulizer mask was sitting on the dresser on top of the nebulizer machine, not bagged and left open to air. An LPN confirmed the nebulizer mask was left open to air and should not have been.
Failure to Document Clinical Rationale for Psychotropic GDR Denials
Penalty
Summary
The facility failed to ensure the physician documented a clinical rationale for denying gradual dose reductions for psychotropic medications for 2 of 5 sampled residents reviewed for unnecessary medications. The deficiency involved Resident #30 and Resident #77, where the pharmacy consultant requested GDRs and the physician or NP did not document why the reductions were not appropriate or clinically contraindicated on the Pharmaceutical Consultant Report or in the clinical record. Resident #30 was admitted with diagnoses including atherosclerotic heart disease, chronic diastolic CHF, atrial fibrillation, and depression. The resident had an order for Trazodone HCl 50 mg at bedtime for depression and a Quarterly MDS showing a BIMS of 13, indicating intact cognition. The 03/28/2025 Pharmaceutical Consultant Report requested a GDR for Trazodone HCl 50 mg, but the physician did not document whether a dose reduction was appropriate or provide a clinical rationale for continuing the medication. During interview, the ADON confirmed the GDR form lacked the required documentation. Resident #77 was admitted with diagnoses including Alzheimer’s disease, unspecified dementia with mood disturbance, major depressive disorder, and other conditions, and had a BIMS of 14 with no behaviors on the Quarterly MDS. The resident received Aripiprazole 2 mg daily and Sertraline HCL 100 mg daily. Multiple Pharmaceutical Consultant Reports dated 11/12/2024, 11/24/2024, and 05/26/2025 showed the pharmacy consultant requested GDR review, but the NP did not provide a handwritten clinical rationale explaining why dose reduction was clinically contraindicated; entries such as “no changes” and “continue current plan of care” were documented instead. Progress notes from the psychiatric NP, MD, and NP also did not include rationales for continued therapy, and the DON acknowledged there had been no GDR attempt and no physician rationale documented as required.
Care Plan Interventions Not Implemented for Bed Mobility and Oxygen Tubing Protection
Penalty
Summary
The facility failed to implement the comprehensive, person-centered care plan for 2 of 31 sampled residents. One resident had a care plan that included bilateral side rails and a trapeze for bed mobility, but the left assist rail was not in place. The resident was observed lying in bed with the head of bed elevated, with an assist rail on the right side and a trapeze above the bed, and stated he could reposition himself. He also stated staff did not come routinely or every two hours to help reposition him, that he could use the right assist rail and trapeze, and that he had requested a left assist rail. The resident demonstrated that the trapeze was loose and said he had been told the left assist rail had been ordered. The resident’s care plan for ADL self-care performance deficit, revised on 06/24/2025, specified bed mobility interventions of total dependent x2 assistance, a trapeze, and bilateral side rails. The MDS coordinator confirmed the bed should have two assist rails. The request for the left rail was sent to maintenance, and maintenance staff stated he had been told about the need for the rail a couple of days earlier, but had not installed it and said he had forgotten about it. The DON and ADON later confirmed the resident’s care plan specified two assist rails and that the resident did not have them in place. Another resident had diagnoses including Parkinson’s disease, type II diabetes mellitus with other specified complication, emphysema, and schizophrenia, and had severe cognitive impairment with a BIMS of 7. The resident’s care plan identified a pressure injury related to oxygen tubing and included the approach of nasal cannula ear cushions. The resident received oxygen therapy via nasal cannula on multiple days, and during observations the resident had redness behind both ears with no ear protectors or cushions on the tubing. An LPN confirmed the resident had no ear cushions applied and had redness behind both ears, and the wound care RN confirmed the right ear had a medical device acquired injury, stage 1 pressure injury, while also confirming the ear cushions were not in place.
Failure to Provide Needed ADL Assistance for Oral Care and Bathing
Penalty
Summary
The facility failed to ensure residents who were unable to complete activities of daily living received the services needed to maintain good personal hygiene. Resident #61, admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction, spinal stenosis, dysphagia, and disturbance of salivary secretions, had a Quarterly MDS showing severely impaired cognition with a BIMS of 03 and required substantial/max assistance with oral hygiene and was dependent on staff for personal hygiene. The care plan identified a need for extensive assistance with personal hygiene and oral care, yet observations on multiple occasions showed a large amount of brown and yellow buildup on the resident’s teeth, lips, and gums. A CNA stated oral care had been provided but the resident still had a lot of buildup, and when oral care was later observed with the DON present, a significant amount of buildup remained after care was given. Resident #77, admitted with diagnoses including type 2 diabetes mellitus, Alzheimer’s disease, dementia, depression, hypertension, hyperlipidemia, constipation, vitamin D deficiency, and seizures, had a Quarterly MDS showing a BIMS of 14 and required partial/moderate assistance with bathing. Her care plan called for limited assist with bathing, but the CNA task record showed no documentation of bathing since 07/15/2025. The resident stated she had not received a bath or bed bath in 7 days and had not been offered one, and there were no toiletries in her room. Staff gave conflicting statements about her bathing status, including that she was independent or could not go to whirlpool because she was on isolation. The ADON acknowledged there was no documentation of bathing in over a week and that the resident had not been bathed in a week.
Verbal Abuse Incident During Resident Care
Penalty
Summary
The facility failed to protect a resident from verbal abuse by a staff member, resulting in mental anguish and psychosocial harm. The incident involved a cognitively intact resident who was verbally abused by a CNA during ADL care. The resident, who has a history of anxiety disorder and major depressive disorder, reported feeling disrespected and insulted after the CNA used profane language during a showering session. The incident occurred when the resident expressed dissatisfaction with the CNA's handling of the shower, leading to a verbal altercation. The CNA responded with profanity, telling the resident to "Shut the F*** up" and "F*** this Sh**." Witnesses, including another CNA and a treatment nurse, confirmed the resident's account of the incident. Despite the resident's clear distress and the corroboration of the event by other staff members, the facility's administration did not classify the incident as verbal abuse. The Director of Nursing and the Administrator conducted an investigation but did not report the incident as verbal abuse, instead categorizing it as an unprofessional interaction. The facility's policy defines verbal abuse as actions that cause mental anguish, yet the administration did not recognize the incident as such, despite the resident's reported emotional distress. The lack of appropriate classification and reporting of the incident highlights a deficiency in the facility's handling of abuse allegations.
Failure to Report Verbal Abuse Incident
Penalty
Summary
The facility failed to report an incident of verbal abuse involving a resident and a Certified Nursing Assistant (CNA) to the State Survey Agency within the required timeframe. The incident involved a resident who was cognitively intact, as indicated by a BIMS score of 14, and had diagnoses including anxiety and major depressive disorder. The resident was dependent on staff for various activities of daily living. The incident occurred when the resident complained about a CNA's behavior during a shower, leading to the CNA cursing at the resident. This interaction was reported to the Director of Nursing (DON) and the Administrator by a Nurse Aide Supervisor. Despite the resident's report and confirmation by the Administrator that the incident was witnessed by another CNA, the Administrator did not report the incident to the State Agency. The Administrator believed the incident did not meet the definition of abuse as there was no evidence of psychological harm to the resident. Consequently, the incident was not reported to the State Agency, and a Statewide Incident Tracking System (SIMS) report was not completed, which is a violation of the facility's policy and state law requiring immediate reporting of abuse allegations.
Failure to Notify Resident's Responsible Party of Medication Changes
Penalty
Summary
The facility failed to ensure that the responsible party (RP) of a resident with severe cognitive impairment was informed of changes in the resident's medication regimen. The resident, who had diagnoses including Alzheimer's disease, Generalized Anxiety Disorder, Major Depressive Disorder, and Dementia, was prescribed various medications for anxiety and depression. The resident's clinical records showed changes in medication dosages and types over several months, but there was no documentation indicating that the RP was notified of these changes. Interviews with facility staff, including an LPN and the Assistant Director of Nursing (ADON), confirmed that the RP should have been informed of the medication changes but was not. The Director of Nursing (DON) also verified that there was no evidence of notification to the RP regarding the changes in the resident's medication regimen. This lack of communication with the RP represents a deficiency in the facility's adherence to its policy on notifying residents and their representatives of changes in medical conditions or treatments.
QAA Committee Meetings Lacked Required Members
Penalty
Summary
The facility failed to ensure the Quality Assessment and Assurance (QAA) committee meetings included the required six staff members for the last four quarterly meetings. The review of the facility's quarterly QAA committee sign-in sheets for meetings held on April 11, 2024, January 18, 2024, October 3, 2023, and July 13, 2023, revealed that only the Medical Director, Administrator, Director of Nurses, and the Infection Preventionist were in attendance. During an interview on May 22, 2024, the Administrator indicated that he was not aware of the requirement for additional members to attend the quarterly QAPI meetings.
Failure to Implement Pain Management Care Plan
Penalty
Summary
The facility failed to implement the person-centered care plan for a resident who was reviewed for pain management. The resident, who was cognitively intact and used a walker to ambulate, had a primary medical condition of Lumbago with Sciatica. The resident's orthopedic doctor recommended Lidocaine patches for pain management, but the facility did not order or administer these patches. The resident's care plan included administering analgesic medications as ordered by the physician and monitoring for side effects and effectiveness every shift. However, the Lidocaine patches were not included in the resident's medication regimen despite the doctor's recommendation. The deficiency was identified through a series of interviews and record reviews. The resident expressed ongoing pain and dissatisfaction with the current pain management, which only included Tylenol. The LPN acknowledged receiving the recommendation for Lidocaine patches but did not follow up adequately to obtain the necessary order. The Assistant Director of Nursing confirmed that the LPN should have contacted the facility's Medical Director or the resident's Nurse Practitioner to carry out the order but failed to do so. This lapse resulted in the resident not receiving the recommended pain management treatment.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Pineville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Oaks Care Center | 2.6 mi | ★★★★★ | 7 | 0 |
| Hilltop Nursing & Rehabilitation Center | 4.4 mi | ★★★★★ | 16 | 2 |
| Matthews Memorial Health Care Center | 5.5 mi | ★★★★★ | 10 | 0 |
| Legacy Nursing At St. Christina | 6 mi | ★★★★★ | 23 | 0 |
| Lexington House | 7 mi | ★★★★★ | 3 | 0 |
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