Tioga Community Care Center

Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure a resident was treated with respect and dignity and cared for in a manner that promoted maintenance or enhancement of his or her own quality of life by failing to honor a resident's right to be shaved prior to going to his medical appointment for 1 (Resident #71) of 2 residents reviewed for dignity.

Inspectors wroteBased on interview and record review, the facility failed to promptly notify the physician and responsible party after a change in resident's condition for 1 (Resident #9) of 2 residents investigated for accidents. The facility failed to notify the physician and responsible party in a timely manner after a witnessed fall, which resulted in an injury.

Inspectors wroteBased on record review, observation, and interviews, the facility failed to implement a comprehensive person-centered care plan for each resident as evidenced by failing to provide the required two-person assistance with transferring for 1 (Resident #71) and failing to provide supervised smoking for 1 (Resident #26) out of a sample of 36 residents.

Inspectors wroteBased on record review and interview, the facility failed to promote and facilitate resident self-determination through support of resident choice about aspects of his or her life in the facility that were significant to the resident for 1 (#3) of 3 sampled residents. The facility failed to ensure Resident #3 had a choice of when to get out of bed.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide respiratory care consistent with professional standards for 2 (#55, and #87) of 5 (#13, #22, #38 #55, and #87) residents reviewed for respiratory care. The facility failed to:1. Store nebulizer mask appropriately for Resident #55; and2. Ensure oxygen was given or set at prescribed rate for Resident #87.

Inspectors wroteBased on observation and interview, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety by failing to:Ensure food, dish washer, refrigerator, and freezer temperatures were performed and recorded appropriately; and Ensure food was properly stored in the kitchen. This deficient practice had the potential to affect the 93 residents that received meals prepared in the kitchen.

Inspectors wroteBased on record review and interview, the facility failed to ensure the physician documented a clinical rationale for a denial of a gradual dose reduction for 2 (#30 and #77) of 5 (#6, #30, #55, #77, and #79) sampled residents reviewed for unnecessary medications. The facility failed to ensure the physician documented on the Pharmaceutical Consultant Report a clinical rationale for not reducing psychoactive medications recommended for gradual dose reduction (GDR).

Inspectors wroteBased on observations, record review, and interviews, the facility failed to implement the care plan for 2 (#5 and #13) of 31 sampled residents. The facility failed to: 1. Place an assist rail to the left side of Resident #5's bed, ensuring the resident could reposition himself as needed to maintain bed mobility as indicated on the patient-centered care plan; and2. Use ear protectors on Resident #13's nasal cannula as indicated in the resident's care plan.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who are unable to carry out ADLS (Activities of Daily Living) received the necessary services to maintain good personal hygiene for 2 (#61 and #77) of 3 (#11, #61, and #77) residents reviewed for ADL care. The facility failed to ensure oral care was provided for Resident #61; and Bath/Shower was provided for Resident #77.

Inspectors wroteBased 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. Resident #4 reported the incident to staff and told them he did not want S3 CNA in his room again.

Inspectors wroteBased on record review and interview, the facility failed to ensure an incident of abuse was reported immediately, but not later than 2 hours after the allegation was made, to the State Survey Agency in accordance with state law for 1 (#4) of 9 (#1, #2, #3, #4, R1, R2, R3, R4, and R5) residents reviewed for abuse The provider failed to report staff to resident verbal abuse for Resident #4.

Inspectors wroteBased on interview and record review the facility failed to ensure Resident #1's Responsible Party (RP) was informed of changes in the resident's condition for 1 (Resident #1) of 3 (Resident #1, Resident #2 and Resident #3) sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Quality Assessment and Assurance (QAA) committee meeting included the required 6 staff members for the facility's last 4 quarterly committee meetings.

Inspectors wroteBased on record review and interview, the facility failed to implement the person-centered care plan for 1 (#81) of 3 (#76, #81, & #87) residents reviewed for pain management by failing to order and administer Lidocaine patches for pain, as recommended by the resident's orthopedic doctor.

Inspectors wroteBased on interviews, and record review, the facility failed to ensure services were provided by the facility to meet quality professional standards for 1 (Resident #3) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents. The facility failed to ensure Resident #3's physician order was transcribed and a urinalysis was collected as ordered by the physician.

Inspectors wroteBased on observation and interview the facility failed to provide a safe, functional, sanitary and comfortable environment for residents who received showers or whirlpools in a facility spa room.