Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Medical Center Ltc during CMS and state inspections, most recent first.
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 The staffing form displayed was outdated, and staff failed to complete and post the required forms for several days.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.
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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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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 July 2026) and official state health department websites.