Tioga Medical Center LTC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to ensure the residents' right to request, refuse, and/or discontinue treatment for 1 of 12 sampled residents (Resident #6) reviewed for advanced directives. Failure to ensure the medical record accurately reflected each resident's code status limited the facilities ability to communicate to direct care staff and emergency personnel the residents' choice in the event of a medical emergency.Findings include:Review of facility policy titled Advance Directives Policy occurred on 06/03/26. This policy, dated June 2017, stated, Policy: It is the resident's right to formulate an Advance Directive, and to accept or refuse medical or surgical treatment. On admission, the facility will determine if the resident has executed an Advance Directive and if not, determine whether the resident would like to formulate an Advance Directive. copies will be made and placed on the chart . facility will periodically assess the resident .Review of Resident #6's medical…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, review of facility policy, and staff interview, the facility failed to notify the resident's provider of a change in condition for 1 of 1 sampled resident (Resident #3) reviewed for hospitalization. Failure to notify the provider timely of a change in condition delayed physician testing/treatment and contributed to Resident #3's hospitalization.Findings include: Review of the facility policy titled Notification of Changes occurred on 06/02/26. This undated policy, stated, . The facility must inform the resident/patient, consult with the resident's/patient's physician . when there is a change requiring such notification. Circumstances requiring notification include: Significant change in the resident's/patient's physical, mental or psychosocial conditions such as deterioration in health, mental or psychosocial status. This may include: Life-threatening conditions, or Clinical complications.Review of Resident #3's medical record occurred on all days of survey and identified current use of anticoagulants (a medication to thin the blood/prevent blood clots). The…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.20.1), the facility failed to complete a Minimum Data Set (MDS) that accurately reflected the resident's status for 1 of 1 sampled resident (Resident #22) with a restraint. Failure to accurately complete the MDS does not allow each resident's assessment to reflect their current status/needs and may affect the accurate development of a comprehensive care plan and the care provided to the residents.Findings include: The Long-Term Care Facility RAI User's Manual, revised October 2025, pages P-1 and P-5, stated, . PHYSICAL RESTRAINTS: Any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or normal access to one's body . Coding Instructions . code the frequency of use: Code 0, not used . Code 2, used daily .Review of Resident #22's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.19.1), and staff interview, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 5 of 12 sampled residents (Resident #3, #8, #9, #17 and #20) and one supplemental resident (Resident #6). Failure to accurately complete the MDS does not allow each resident's assessment to reflect their current status/needs and may affect the accurate development of a comprehensive care plan and the care provided to the residents. Findings include: SECTION H: BLADDER AND BOWEL The Long-Term Care Facility RAI User's Manual, revised October 2024, page H-6, stated, . H0200: Urinary Toileting Program . Steps for assessment: H200C, Current Toileting Program . 1. Review the medical record for evidence of a toileting program being used to manage incontinence during the 7-day look-back period. Note the number of days during the look-back period that the toileting program was implemented…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and resident and staff interview, the facility failed to ensure appropriate care and services for 1 of 2 sampled residents (Resident #26) reviewed for edema (fluid retention). Failure to ensure consistent implementation and resident refusals of support stockings may result in worsening edema. Findings include: Review of Resident #26's medical record occurred on all days of survey and identified a diagnosis of congestive heart failure. A physician's order, dated 01/23/25, stated, Ted Hose [support stockings to control edema] on in the AM and Off at HS [bedtime] . for Edema. The current care plan stated, . I have a diagnosis of . congestive heart failure . edema . I will remain free of complications related to diagnosis through next review date. I would like staff to monitor for and document any edema and notify my provider as needed. A nursing progress note, dated 01/24/25 at 9:37 a.m., stated, . Does have edema noted to bilateral [both] lower legs at which time resident stated her legs feel itchy at those times . A provider progress note, dated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, review of facility policy, and staff interview, the facility failed to ensure residents remained free from unnecessary psychotropic medications for 1 of 2 sampled residents (Resident #12) reviewed for as needed (PRN) psychotropic medication use. Failure to limit PRN psychotropic medication use to 14 days unless re-evaluated by a practitioner placed the resident at risk of receiving unnecessary medications and experiencing adverse drug effects and consequences related to their use. Findings include: Review of the facility policy titled Use of Psychotropic Medication occurred on 03/12/25. This policy, dated February 2023, stated, . PRN orders for all psychotropic drugs shall be used . for a limited duration (i.e. 14 days) . If the . prescribing practitioner believes that it is appropriate for the PRN order to extend beyond 14 days, he or she shall document their rationale in the resident's medical record and indicate the duration for the PRN order. Review of Resident #12's medical record occurred on all days of survey. A current physician's order included…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, policy review, and staff interview, the facility failed to follow standards of infection control and prevention for 2 of 2 sampled residents (Resident #3 and #26) observed in enhanced barrier precautions (EBP). Failure to practice infection control standards related to EBP, catheter care, and hand hygiene has the potential to spread infection throughout the facility. Findings include: Review of the facility policy titled Enhanced Barrier Precautions occurred on 03/12/25. This policy, dated April 2024, stated, . an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities. PPE [personal protective equipment] for enhanced barrier precautions is only necessary when performing high-contact care activities . High-contact resident care activities include: . dressing . providing hygiene . assisting with toileting . device care or use . Review of the facility policy titled Hand Hygiene occurred on 03/12/25. This policy, revised…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, review of facility policy, and staff interview, the facility failed to investigate and report to the State Survey Agency (SSA) potential incidents of abuse/neglect for 1 of 1 sampled resident (Resident #26) who experienced a major injury. Failure to investigate and report allegations of potential abuse/neglect to the SSA places all residents at risk of potential abuse/neglect. Findings include: Review of the facility policy titled Abuse, Neglect and Exploitation occurred on 01/31/24. This policy, dated January 2021, stated, . It is the policy of this facility to report all allegations of abuse/neglect/exploitation . including injuries of unknown sources . immediately to . appropriate agencies in accordance with state and federal regulations within prescribed timeframes. Immediately: Means as soon as possible . not later than 2 hours after . events that cause the allegation involve or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse . Injuries of unknown source: . injury was not observed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.18.11), and staff interview, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 1 of 11 sampled residents (Resident #5). Failure to accurately complete the MDS does not allow each resident's assessment to reflect their current status/needs and may affect the development of a comprehensive care plan and the care provided to the residents. Findings include: The Long-Term Care Facility RAI User's Manual, revised October 2023, Section K: Swallowing/Nutritional Status, pages K-3 through K-6, stated, . K0200A: Weight: 1. Base weight on the most recent measure in the last 30 days. K0300: Weight Loss . Coding Instructions . Code 1, yes on physician-prescribed weight-loss regimen: if the resident has experienced a weight loss of 5% or more in the past 30 days or 10% or more in the last 180 days, and the weight loss was planned and pursuant to a physician's order.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, review of the North Dakota Provider Manual for Preadmission Screening and Resident Review (PASRR) and Level of Care Screening Procedures for Long Term Care Services, and staff interview, the facility failed to complete a status change assessment for 1 of 4 sampled residents (Resident #13) reviewed for PASRR. Failure to complete a change in status assessment with a newly diagnosed mental illness and/or change in treatment may result in the delivery of care and services that are inconsistent with residents' needs. Findings include: The North Dakota PASRR Provider Manual, revised December 2020, page 13, states, . Change in Status Process: Whenever the following events occur, nursing facility staff must contact [the contracted agency] to update the Level I screen for determination of whether a first time or updated Level II evaluation must be performed. These situations suggest that a significant change in status has occurred: . If an individual with MI, ID, and/or RC [mental illness, intellectual disability, and conditions related to intellectual disability…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, review of facility policy, and resident and staff interview, the facility failed to provide appropriate assistance and assistive devices for 1 of 4 sampled residents (Resident #3) observed during a transfer. Failure to use a gait belt and provide appropriate assistance during a pivot transfer places the resident and staff at risk for accidents, falls, and/or injuries. Findings include: Review of the facility policy titled Transfer/Gait Belts occurred on 01/31/24. This policy, dated November 2015, stated, . Staff transferring residents will properly apply and use a transfer/gait belt . transferring residents whose . balance is impaired . strength is decreased . Review of Resident #26's medical record occurred on all days of survey. The current care plan stated, . Limited assist/one-person physical assist. Resident transfers with assistance but is unable to walk. Can stand well enough to transfer. A progress note, dated 11/28/2023 at 4:14 p.m., stated, . one person stand by assist for transfers with gait belt. Observation on 01/29/24 04:02 p.m.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, review of facility policy, and staff interview, the facility failed to ensure safe and secure storage of controlled medications for 1 of 1 medication cart. Failure to store medications securely may result in unauthorized access to medications. Findings include: Review of the facility policy titled Medication Storage occurred on 02/01/24. This policy dated January 2020, stated, . Schedule II drugs and back up stock for III, IV, and V medications are stored under double-lock and key. This policy failed to address the requirement of controlled medications II-V needing to be locked in a permanently affixed compartment within the medication cart. Observation of the medication cart with a nurse (#2) occurred on 02/01/24 at 11:10 a.m. and showed a bottle of gabapentin (nerve pain medication) for Resident #13 stored with non-controlled medications and not double locked. The nurse (#2) stated, I was unaware this needed to be locked. During an interview on the morning of 02/01/24, an administrative nurse (#1) confirmed staff failed to double lock the controlled…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, review of facility policy, and staff interview, the facility failed to follow standards of infection control for 1 of 7 sampled residents (Resident #26) observed during toileting cares. Failure to follow infection control standards has the potential to transmit infections to residents, staff, and visitors. Findings include: Review of the policy/procedure titled Hand Hygiene occurred on 02/01/24. This policy, dated January 2022, stated, . Hand hygiene is indicated and will be performed. After assistance with personal body functions . Observation on 01/29/24 at 2:49 p.m. showed two certified nurse aides (CNAs) (#5 and #6) transferred Resident #26 onto the toilet. The CNA (#5) donned gloves and performed perineal cares. Without removing the soiled gloves, the CNA (#5) transferred Resident #26 to bed, adjusted the resident in bed, moved the resident's bedside table, closed an open bag of chips, moved the resident's water, and adjusted the resident's call light pendant. The CNA (#5) then removed the soiled gloves and performed hand hygiene. The CNA (#5) failed to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.