Average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Tioga Medical Center Ltc during CMS and state inspections, most recent first.
A resident with impaired cognition had a physician order for DNR, but the medical record did not reflect the resident's accurate code status. The resident's existing health care directive addressed end-of-life wishes and listed treatments the resident would accept, and an administrative staff member confirmed staff failed to obtain an updated advance directive to match the code status.
A resident on anticoagulants had a black tarry stool and a positive FOBT, but the facility did not notify the provider as directed by the on-call MD. The DON was notified and a stool specimen was sent, yet provider notification was delayed until several days later, when the resident was found to have a Hgb of 5.8 and was sent to the hospital.
MDS Did Not Accurately Code Thigh Belt Restraint: A resident with Huntington’s disease was observed seated in a wheelchair with a thigh belt fastened behind the chair, and the resident stated they could not release the strap. The care plan described the thigh belt as a safety device used to help the resident sit upright in a Broda chair, but the quarterly MDS did not code the thigh belt as a restraint, despite RAI guidance defining such devices as physical restraints when the resident cannot remove them easily.
Staff failed to accurately code the MDS for several residents, including incorrectly documenting individualized toileting programs, misclassifying bed rails as physical restraints, and coding exit door alarms as 'other alarms' without supporting evidence, as confirmed by administrative staff.
A resident with CHF and edema did not consistently receive support stockings as ordered, with observations showing the resident without stockings and visible swelling present. The resident refused the stockings due to discomfort, and staff failed to accurately document these refusals, instead recording the stockings as applied in the MAR. Nursing staff did not verify or document actual use or refusals as required.
Staff did not follow infection control standards for two residents on Enhanced Barrier Precautions, including failing to perform hand hygiene when changing or removing gloves and not wearing gowns during high-contact care activities such as catheter and JP drain care. These actions were inconsistent with facility policy and infection prevention protocols.
The facility did not post current nurse staffing information for multiple consecutive days, as required by policy. The staffing form displayed was outdated, and staff failed to complete and post the required forms for several days. An administrative nurse confirmed the lapse in posting was due to the night shift not completing the task.
A resident with a history of aggressive behavior and another resident, both diagnosed with dementia and anxiety, were involved in a physical altercation in the dining room that was not witnessed by staff. The confrontation escalated, resulting in one resident sustaining a hip fracture after being pushed to the floor. Care plans for both individuals required monitoring and redirection, but staff were not present at the time, leading to a failure to prevent the incident.
Missing Updated Advance Directive and Code Status Documentation
Penalty
Summary
The facility failed to ensure that the resident's right to request, refuse, and/or discontinue treatment was honored for 1 of 12 sampled residents reviewed for advance directives. Review of the facility's Advance Directives Policy showed that residents have the right to formulate an advance directive and accept or refuse medical or surgical treatment, and that the facility should determine on admission whether a resident has executed an advance directive and place copies on the chart. In this case, the resident's quarterly MDS identified impaired cognition, and a physician's order signed on 05/12/25 listed the code level as DNR. The resident's health care directive, signed on 04/04/21, stated that the resident did not want life prolonged if the situation was hopeless and listed treatments the resident would accept, including continuous circulation for cell salvage, heart-lung machine, dialysis, fractions-discuss, a pacemaker, and medications. However, the medical record lacked documentation reflecting the resident's accurate code status. During interview on 06/03/26 at 2:26 p.m., an administrative staff member confirmed staff failed to obtain an updated advance directive to reflect the resident's code status.
Delayed Provider Notification for Resident With Black Tarry Stool
Penalty
Summary
The facility failed to notify the resident's provider of a change in condition for 1 of 1 sampled resident reviewed for hospitalization. Resident #3 was receiving anticoagulants and, on 12/12/25, a CNA reported a black tarry stool. Nursing notes documented that the resident had no pain, the DON was notified, and a stool specimen was collected and sent to the lab. The facility policy required informing the resident, consulting the physician, and notifying appropriate parties when there was a significant change in physical, mental, or psychosocial condition, including deterioration in health or clinical complications. At 5:10 p.m. on 12/12/25, the DON spoke with the on-call provider, who did not want to give new orders regarding the positive stool specimen results and suggested waiting for the resident's regular provider on Monday, 12/15/25. However, a provider telephone encounter note dated 12/17/25 documented that the resident had dark tarry stools, a FOBT was positive, and the hemoglobin was 5.8, down from 8.6 on 10/23/25, after which the hospital was called and ground transport was arranged. During interview, administrative staff confirmed the provider notification occurred on 12/17/25 and not on 12/15/25 as requested, and the facility failed to contact the provider on 12/15/25 as directed by the on-call provider.
MDS Did Not Accurately Code Thigh Belt Restraint
Penalty
Summary
The facility failed to complete an MDS that accurately reflected Resident #22’s status for a restraint. Resident #22 had a diagnosis of Huntington’s disease and the care plan stated the resident preferred to use Huntington’s package thigh belts attached to the chair and over the thighs to provide safety and allow sitting upright in a Broda chair, with staff to monitor belt use and remove it at the resident’s request. During observation on 06/01/26 at 12:40 p.m., the resident was seated in a wheelchair with the straps of the thigh belt fastened behind the chair, and when asked if the resident could release the strap, the resident stated, “No.” Review of the quarterly MDS showed the facility did not code the thigh belt as a restraint, despite the RAI Manual defining a physical restraint as a device attached to or adjacent to the resident’s body that the individual cannot remove easily and instructing that daily use be coded as 2.
Inaccurate MDS Coding for Toileting Programs, Restraints, and Alarms
Penalty
Summary
Facility staff failed to ensure accurate coding of the Minimum Data Set (MDS) for six residents, as identified through record review, reference to the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, and staff interviews. Specifically, for two residents, the MDS was coded to indicate participation in a daily individualized toileting program, but the medical records did not contain evidence of such a program being implemented during the required look-back period. An administrative staff member confirmed that these residents did not have individualized or resident-centered toileting programs in place, despite the coding. Additionally, the facility incorrectly coded the use of physical restraints and alarms for several residents. For two residents, bed rails were coded as being used daily as physical restraints, even though assessments indicated the bed rails did not meet the definition of a restraint for these individuals. For three other residents, the MDS was coded to indicate daily use of 'other alarms,' but the records lacked evidence that alarms, as defined by the RAI manual, were actually used. An administrative staff member confirmed that exit door alarms were incorrectly coded as 'other alarms' on the MDS for these residents.
Failure to Ensure Consistent Implementation and Documentation of Edema Care
Penalty
Summary
A deficiency was identified when a resident with a diagnosis of congestive heart failure and edema did not consistently receive care as ordered and according to her care plan. The physician's order required the application of support stockings (ted hose) in the morning and removal at bedtime to manage edema, and the care plan directed staff to monitor and document edema and notify the provider as needed. Observations showed the resident was not wearing support stockings on multiple occasions, despite visible swelling in both lower legs. The resident reported refusing the stockings because they caused discomfort, and also indicated difficulty remembering to elevate her legs as encouraged by her provider. Further review revealed that the medication administration record (MAR) documented the ted hose as applied on days when observations and staff interviews confirmed the resident was not wearing them. A CNA stated the resident refused the stockings, but the administrative nurse confirmed that refusals should be reported to the nurse, and the nurse should verify and document the actual use of ted hose before recording it on the MAR. This lack of accurate documentation and failure to follow up on resident refusals led to the deficiency.
Failure to Follow Enhanced Barrier Precautions and Hand Hygiene Protocols
Penalty
Summary
The facility failed to adhere to infection prevention and control standards for two residents who required Enhanced Barrier Precautions (EBP) due to the presence of a suprapubic catheter and a Jackson Pratt (JP) drain. Observations revealed that a certified nurse aide (CNA) did not perform hand hygiene when changing or removing gloves and touched various surfaces, including a resident's side table and blanket, after handling a catheter collection bag and urinal. The CNA also failed to follow proper infection control practices during catheter care. Additionally, both the CNA and a nurse did not don gowns while performing high-contact care activities, such as perineal care and emptying a JP drain, despite facility policy requiring gown and glove use for such activities under EBP. Review of facility policies confirmed that staff are expected to perform hand hygiene before donning gloves, after removing gloves, and to wear appropriate personal protective equipment (PPE) during high-contact care activities. Interviews with administrative staff confirmed these expectations. The observed failures to follow hand hygiene protocols and PPE requirements during high-contact care activities for residents with EBP were directly contrary to facility policy and infection control standards.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure daily posting of nurse staffing information as required by its policy, which states that the Nurse Staffing Sheet must be posted at the beginning of each shift and maintained for review. Observations during the survey revealed that the staffing form displayed on the board was outdated, showing a date from three days prior, and there was no current staffing information posted for two of the three survey days. Review of records confirmed that staff did not complete the staffing forms for a four-day period. An administrative nurse confirmed during interview that the night shift was responsible for posting the information and acknowledged that it had not been completed for the specified days.
Failure to Prevent Resident-to-Resident Abuse Resulting in Injury
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse, resulting in a resident sustaining a hip fracture following an altercation with another resident. The incident involved two residents, both with histories of dementia and anxiety, and one with a documented history of aggressive behavior toward others. On the day of the incident, the resident with aggressive tendencies entered the dining room, engaged in a confrontation, and physically pushed another resident, who then responded by pushing the first resident to the floor. This event was not witnessed by staff but was observed by other residents, and the injured resident reported pain and was found sitting on the floor. Prior to this incident, there had been a similar altercation between the same two residents, which was also not directly witnessed by staff but reported by witnesses. The care plans for both residents indicated the need for monitoring and redirection when in proximity to each other or other residents. However, at the time of the incident, staff were not present in the dining room, and the required supervision and interventions were not provided, directly leading to the altercation and resulting injury.
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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 Tioga
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mountrail Bethel Home | 26 mi | ★★★★★ | 6 | 0 |
| Bethel Lutheran Nursing & Rehabilitation Center | 36.3 mi | ★★★★★ | 14 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.