Tioga Community Care Center

In the surveyor’s words

From the most serious findings on record at Tioga Community Care Center, in the surveyor’s own words.

• Actual harm, patternF600Aug 11, 2022

  Based on record review and interview, the facility failed to protect 4 (#4, #6, #8, and #9) of 9 (#1, #2, #3, #4, #5, #6, #7, #8, #9) residents from staff to resident verbal, mental, and physical abuse. This deficient practice resulted in an actual harm situation for Residents #4, #6, #8 and #9 that began on 07/17/2022 at 2:08 p.m. when S2 DON and S3 ADON became aware of a grievance filed by Resident #6, which alleged verbal and physical abuse by S4 CNA. S2 DON and S3 ADON received grievances that alleged verbal and physical abuse by S4 CNA from Resident #4 on 07/17/2022 at 2:22 p.m., and Resident #8 on 07/17/2022 at 2:36 p.m. During an interview, Resident #4 reported S4 CNA was rude to her and rough when changing her which made it painful. […]

• Actual harm, isolatedF600Feb 26, 2025

  Based on interview and record review, the facility failed to ensure a resident was free from staff to resident verbal abuse for 1 (Resident #4) of 9 (#1, #2, #3, #4, R1, R2, R3, R4, and R5) sampled residents investigated for abuse. Resident #4, a cognitive residents, experienced mental anguish and psyshosocial harm as a result of the verbal abuse by staff. This deficient practice resulted in an actual harm on 02/11/2025 at 10:00 a.m., when S3 CNA told Resident #4, Shut the F*** up and F*** this Sh**! during ADL care (showering). Resident #4 stated this caused him mental anguish and psychosocial harm/emotional distress, as he felt disrespected, insulted, and pissed off that S3 CNA cursed and spoke to him in that way. […]

• Actual harm, isolatedF689Jun 3, 2022

  Based on interview and record review the facility failed to ensure an agency CNA provided one person assistance during a transfer for Resident #3 as indicated on the Comprehensive Person Centered Plan of care, for 1 (#3) of 5 (#1, #2, #3, #4 and #5) sampled residents. This failed practice resulted in an actual harm situation for Resident #3 on 04/29/2022 at approximately 9:15 p.m., when Resident #3 fell after S4 Agency CNA allowed Resident #3 to transfer himself from the wheelchair to the bed without one person physical assistance for transfers as indicated on his person centered plan of care. Resident #3 complained of pain to his left hip. […]

• Actual harm, isolatedF689Apr 20, 2022

  Based on observation, interview and record review, the facility failed to use a two-person transfer, as determined necessary by the resident's person centered comprehensive plan of care, during a transfer from the wheelchair to bed for 1 (#26) of 3 sampled residents reviewed for accidents (#26, #27, and #57) out of a sample of 33. This failed practice resulted in an actual harm situation on 04/18/2022 at 1:20 p.m., when Resident #26, who required two-person assistance for transfers, was transferred from the wheelchair to bed by S6 CNA without the assistance of another staff member. Resident #26 hit her leg on the foot pedal of her wheelchair during the transfer causing a large laceration that measure 10.55 cm X 3.23 cm. […]

• No harm, potential for more than minimal, patternF658Jul 23, 2025

  Based on observation, record review, and interview the facility failed to provide care and services that met professional standards of quality. The sampled residents were 31. The facility failed to: 1. Ensure proper physician orders were obtained for Resident #13's oxygen requirements.2. Ensure proper physician orders were obtained for Resident #36's rescue inhaler.3. Ensure Resident #36's rescue inhaler was stored in a safe and secure manner. Findings: Review of an undated facility policy on 07/23/2025 at 9:34 a.m. titled, Oxygen Administration revealed the following in part.The purpose of this procedure is to provide guidelines for safe oxygen administration. Verify that there is a physician's order for this procedure. […]