Inspection Reports for
Tabor Manor Care Center
209 Main Street, Tabor, IA, 516532061
Back to Facility ProfileDeficiencies (last 7 years)
Deficiencies (over 7 years)
18.1 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
311% worse than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
80
60
40
20
0
Census
Latest occupancy rate
39 residents
Based on a November 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy over time
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jan 13, 2026
Visit Reason
The document is a statement of deficiencies and plan of correction related to the facility's compliance with health requirements, certifying substantial compliance effective January 9, 2026.
Findings
The facility was found to be in substantial compliance based on the credible allegation and plan of correction submitted, resulting in certification of compliance with health requirements.
Inspection Report
Complaint Investigation
Census: 39
Deficiencies: 2
Date: Nov 13, 2025
Visit Reason
The inspection was conducted due to complaints regarding failure to notify family of a resident's fall and transfer to the Emergency Department, and failure to provide weekly skin assessments for pressure ulcers for two residents.
Complaint Details
The complaint investigation found that Resident #1's family was not notified immediately after the resident fell from a mechanical lift and was transferred to the Emergency Department. The family was notified approximately two hours later. For Residents #2 and #3, the facility failed to provide weekly wound assessments as required, with documentation gaps noted.
Findings
The facility failed to notify Resident #1's family promptly after a fall and transfer to the hospital, resulting in delayed family notification. Additionally, the facility failed to provide weekly wound assessments for two residents with pressure ulcers, with documentation gaps noted during the review.
Deficiencies (2)
Failure to notify resident's family/POA promptly after a fall and transfer to the Emergency Department.
Failure to provide weekly skin assessments and wound measurements for residents with pressure ulcers.
Report Facts
Census: 39
Residents affected: 3
Wound assessment dates missing: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Registered Nurse (RN) | Named in failure to notify family and wound assessment findings |
| Director of Nursing (DON) | Named in family notification and wound assessment findings | |
| Staff E | Licensed Practical Nurse (LPN) | Provided information on wound assessment practices |
Inspection Report
Complaint Investigation
Census: 19
Deficiencies: 4
Date: Nov 12, 2025
Visit Reason
Investigation of complaint #2663246-C and facility reported incident #2662462-I conducted from November 10 to November 13, 2025, related to notification of changes and medication administration issues.
Complaint Details
Complaint #2663246-C resulted in a deficiency related to failure to notify changes and medication refusals. The investigation was conducted from November 10 to November 13, 2025.
Findings
The facility was found deficient in notifying the primary care physician and family regarding resident changes and refusals of medication. Deficiencies included failure to notify the physician of medication refusals, failure to document catheter care for residents, failure to follow medication orders, and inadequate infection control practices including hand hygiene and use of enhanced barrier precautions.
Deficiencies (4)
Failure to notify the primary care physician and family of resident changes and medication refusals.
Failure to provide medications as ordered and document refusals properly.
Failure to maintain catheter care and document catheter output for residents with urinary catheters.
Failure to establish and maintain an infection prevention and control program including hand hygiene and use of enhanced barrier precautions.
Report Facts
Census: 19
Deficiencies cited: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Stated inability to find phone number on transfer face sheet and notified administrator and Director of Nursing. | |
| Staff D | Interim Director of Nursing (IDON) | Acknowledged PCP had not been notified of medication refusals and stated documentation requirements. |
| Staff A | Licensed Practical Nurse (LPN) | Stated if no entries on MAR, medication/treatment had not been provided. |
| Staff B | Registered Nurse (RN) | Completed Resident #2's treatment and notified PCP of refusals. |
| Administrator | Stated expectations for documentation and notification regarding medication refusals. | |
| Staff E | Certified Nursing Assistant (CNA) | Completed hand hygiene and catheter care following infection control practices. |
| Staff F | Certified Nursing Assistant (CNA) | Assisted with transfer and grooming tasks following infection control practices. |
| Staff G | Certified Nursing Assistant (CNA) | Completed hand hygiene and catheter care following infection control techniques. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 16, 2025
Visit Reason
A complaint investigation for complaints #2598782-C and #2599345-C was conducted on October 15 and October 16, 2025.
Complaint Details
Complaint investigation for complaints #2598782-C and #2599345-C; facility found to be in substantial compliance.
Findings
The facility was found to be in substantial compliance.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Sep 22, 2025
Visit Reason
This document is a statement of deficiencies and plan of corrections related to the facility's compliance status following a prior inspection or complaint.
Findings
Based on acceptance of the facility's credible allegation of substantial compliance and Plan of Correction, the facility will be certified in compliance effective September 19, 2025.
Deficiencies (1)
Initial comments regarding acceptance of credible allegation of substantial compliance and Plan of Correction.
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 2
Date: Aug 20, 2025
Visit Reason
The inspection was conducted due to complaints regarding failure to complete required background checks for employees and failure to provide needed services according to professional standards, including medication administration issues for multiple residents.
Complaint Details
The visit was complaint-related, triggered by allegations of failure to complete required background checks and failure to provide medications as ordered. The complaint was substantiated with findings of minimal harm.
Findings
The facility failed to complete required Iowa Criminal History and Abuse Registry checks prior to employment for one staff member. Additionally, the facility failed to follow physician orders for medication administration for 4 of 4 residents reviewed, including late or missed medications and failure to check medication availability, resulting in minimal harm or potential for harm.
Deficiencies (2)
Failed to complete Iowa Criminal History, Sex Offender Registry, and Abuse Registry checks prior to employment for one staff member.
Failed to provide needed services in accordance with professional standards by not following physician orders for medication administration for 4 residents, including late or missed medications and failure to check medication availability.
Report Facts
Residents affected: 1
Residents affected: 4
Census: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff E | Licensed Practical Nurse (LPN) | Named in background check deficiency |
| Staff A | Licensed Practical Nurse (LPN) | Interviewed regarding medication availability and administration |
| Staff B | Certified Medication Aide (CMA) | Interviewed regarding medication availability and ordering |
| Staff C | Certified Medication Aide (CMA) | Interviewed regarding medication availability and administration |
| Staff D | Certified Medication Aide (CMA) | Interviewed regarding medication availability and ordering |
| Director of Nursing | Director of Nursing (DON) | Provided statements regarding medication administration policies and issues |
| Administrator | Administrator | Provided statements regarding background check and medication availability issues |
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 2
Date: Aug 20, 2025
Visit Reason
The inspection was conducted as a result of investigation of complaint #2578835-C and facility reported incident #2577762-I from August 18 to August 20, 2025.
Complaint Details
The complaint #2578835-C was substantiated resulting in deficiencies. The facility reported incident #2577762-I resulted in no deficiency.
Findings
The facility was found deficient in developing and implementing abuse/neglect policies and meeting professional standards of care, including failure to complete required background checks for employees and failure to follow physician orders for residents' care. Medication administration issues were also identified, including delays and missing medications.
Deficiencies (2)
Failure to develop and implement written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents, including failure to complete required background checks for employees.
Failure to provide services that meet professional standards of quality, including failure to follow physician orders for 4 of 4 residents reviewed.
Report Facts
Facility census: 40
Employees reviewed: 1
Residents reviewed: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff E | Licensed Practical Nurse (LPN) | Named in background check deficiency |
| Administrator | Administrator | Provided statements regarding background check approval process and medication administration issues |
| Director of Nursing | Director of Nursing (DON) | Provided statements regarding medication administration delays and staff issues |
| Staff A | Licensed Practical Nurse (LPN) | Reported medication delivery issues |
| Staff C | Certified Medication Aide (CMA) | Reported medication administration issues |
| Staff B | Certified Medication Aide (CMA) | Reported occasional medication and breathing treatment availability issues |
| Staff D | Reported medication shortages |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Apr 1, 2025
Visit Reason
A revisit of the survey ending February 10, 2025 was conducted on March 31, 2025 to April 1, 2025 to verify correction of previous deficiencies.
Findings
All deficiencies were corrected and the facility is in substantial compliance effective the plan of correction date March 10, 2025.
Inspection Report
Routine
Census: 43
Deficiencies: 9
Date: Feb 10, 2025
Visit Reason
Routine inspection of Tabor Manor Care Center to assess compliance with regulatory standards including resident rights, environment, abuse prevention, care planning, and fall prevention.
Findings
The facility was found deficient in multiple areas including failure to treat residents with dignity, inadequate care environment, incomplete abuse prevention and investigation, deficient care planning, failure to follow physician orders, inadequate restraint assessments, and failure to prevent accidents resulting in resident injuries.
Deficiencies (9)
Failed to treat residents with dignity and respect during medication administration for Resident #15.
Failed to provide a safe, clean, and homelike environment by leaving feces and urine in a commode for at least 8 hours for Resident #20.
Failed to implement abuse and neglect policies including background checks and annual abuse training.
Failed to thoroughly investigate and report allegations of abuse within required timeframes for Resident #15.
Failed to provide comprehensive care plans with goals, desired outcomes, and interventions for psychotropic, antianxiety, opioid, anticoagulant, and diuretic medication use for multiple residents.
Failed to update care plans timely to reflect significant changes such as hospice care and wound management for Residents #19, #23, and #33.
Failed to enter physician's order for mitt/glove use into electronic health record and failed to complete required assessments for Resident #22.
Failed to complete restraint assessments and occupational therapy evaluations related to mitt/glove use for Resident #22.
Failed to protect residents from accidents and injuries related to falls for Residents #33 and #193, including failure of alarms and inadequate supervision.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Census: 43
Deficiency count: 9
Fall risk score: 80
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse (LPN) | Named in medication administration forcing and abuse allegation involving Resident #15 |
| Staff I | Certified Nurse Assistant (CNA) | Named in background check deficiency |
| Staff P | Licensed Practical Nurse (LPN)/MDS Coordinator | Acknowledged care plan deficiencies and mitt/glove order issues |
| Staff Q | Registered Nurse (RN) | Documented physician order for mitt/glove for Resident #22 |
| Staff S | Contract Occupational Therapist | Acknowledged lack of assessment for mitt/glove restraint for Resident #22 |
| Staff AA | Physical Therapist Assistant (PTA)/Program Coordinator | Discussed therapy and alarm removal decision for Resident #193 |
| Staff Y | Certified Occupational Therapy Assistant (COTA) | Provided therapy details for Resident #193 |
| Staff Z | Certified Nurse Assistant (CNA) | Provided assistance details for Resident #193 |
| Staff N | Certified Nurse Assistant (CNA)/Restorative Aide (RA) | Provided assistance details for Resident #193 |
| Director of Nursing (DON) | Director of Nursing | Provided multiple interviews regarding deficiencies and expectations |
| Administrator | Facility Administrator | Provided multiple interviews regarding deficiencies and facility policies |
Inspection Report
Annual Inspection
Census: 43
Deficiencies: 22
Date: Feb 10, 2025
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey and investigation of complaints.
Findings
The facility was found deficient in multiple areas including resident rights, required postings, advance directives documentation, Medicaid/Medicare coverage notifications, safe and clean environment, grievance procedures, abuse prevention and investigation, accuracy of assessments, PASARR coordination, comprehensive care planning, medication labeling and storage, food safety, resident record confidentiality, payroll based journal reporting, QAPI program implementation, resident call system functionality, abuse training, and nurse aide in-service training.
Deficiencies (22)
Failure to treat residents with dignity and respect, including improper medication administration to Resident #15.
Failure to post required notifications of State Survey Agencies and other support for advocacy in a form or manner accessible and understandable to residents or representatives.
Failure to have correct documentation of residents' choice related to advance directives for 3 residents.
Failure to provide residents and families with 48 hour notification of financial responsibility when Medicare Part A services were discontinued for 2 residents.
Failure to provide a comfortable homelike environment by leaving feces and urine in a commode for at least 8 hours for Resident #20.
Failure to make information on how to file a grievance available to residents and failure to resolve complaints for 1 resident.
Failure to complete background checks prior to staff employment and failure to provide annual abuse prevention training.
Failure to thoroughly investigate, prevent further potential abuse or mistreatment, and report all results of allegations of abuse to the State Survey Agency within 5 working days for Resident #15.
Failure to accurately assess the use of insulin and antianxiety medication for Resident #2.
Failure to complete a PASRR for Resident #3 with new mental disorder diagnoses.
Failure to provide a comprehensive care plan that included goals, desired outcomes and interventions for use of psychotropic medication, opioids, anticoagulants, and other treatments for multiple residents.
Failure to update care plans in a timely manner to reflect residents' conditions for 3 residents.
Failure to enter physician's orders into the electronic health record and follow physician orders for Resident #22 with an order to wear a mitt/glove.
Failure to complete an assessment related to the use of a restraint ordered by the physician for Resident #22.
Failure to protect residents from accidents and injuries for Residents #33 and #193 related to fall prevention and alarm system failures.
Failure to ensure all drugs and biologicals are labeled in accordance with professional standards, including expiration dates and appropriate accessory and cautionary instructions.
Failure to submit accurate staffing reports for the Payroll Based Journal Staffing Data Report.
Failure to maintain and implement an effective, comprehensive QAPI program and plan, including failure to provide documentation of ongoing QAPI activities and committee membership.
Failure to maintain records of QAPI committee meetings for all quarters reviewed and failure to include required members such as the Infection Preventionist and Medical Director.
Failure to provide a resident call system that reliably relays calls to staff due to system outages and failures.
Failure to provide training to staff on activities that constitute abuse, neglect, exploitation, and misappropriation of resident property and procedures for reporting such incidents.
Failure to provide required in-service training for nurse aides to ensure continuing competence, including dementia management and resident abuse prevention training.
Report Facts
Deficiencies cited: 21
Resident census: 43
PBJ quarter: 4
MDS BIMS scores: 8
Medication dosages: 30
Medication dosages: 15
Medication dosages: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse | Named in medication error and abuse investigation |
| Staff I | Certified Nurse Assistant | Named in background check and abuse training deficiencies |
| Staff M | Certified Nurse Assistant | Named in abuse training deficiency |
| Staff E | Assistant Administrator | Named in staffing and training deficiencies |
| Staff P | Licensed Practical Nurse/MDS Coordinator | Named in care planning and assessment deficiencies |
| Staff Q | Registered Nurse | Named in medication order and restraint deficiencies |
| Staff D | Certified Nurse Assistant | Named in training deficiency |
| Administrator | Facility Administrator | Named in multiple deficiencies and QAPI program issues |
| Staff J | Administrative Assistant | Named in nurse aide certification deficiency |
| Staff B | Registered Nurse | Named in medication labeling deficiency |
| Staff T | Licensed Practical Nurse | Named in medication order discrepancy |
| Staff G | Certified Nurse Assistant | Named in call light system deficiency |
| Staff H | Certified Nurse Assistant | Named in call light system deficiency |
| Staff N | Certified Nurse Assistant/Restorative Aide | Named in fall prevention deficiency |
| Staff S | Contract Occupational Therapist | Named in restraint and fall prevention deficiencies |
| Staff AA | Physical Therapist Assistant/Program Coordinator | Named in fall prevention deficiency |
| Staff Y | Certified Occupational Therapy Assistant | Named in fall prevention deficiency |
| Staff Z | Certified Nurse Assistant | Named in fall prevention deficiency |
Inspection Report
Routine
Census: 43
Deficiencies: 23
Date: Feb 10, 2025
Visit Reason
Routine inspection of Tabor Manor Care Center to assess compliance with healthcare facility regulations including resident care, medication administration, safety, and quality assurance.
Findings
The facility had multiple deficiencies including failure to treat residents with dignity, inadequate posting of required notifications, incomplete documentation of advance directives, failure to provide timely Medicare/Medicaid financial notifications, inadequate environmental cleanliness, incomplete grievance follow-up, failure to complete background checks and abuse training for staff, incomplete abuse investigations, inaccurate resident assessments, failure to complete PASRR for residents with new mental health diagnoses, incomplete care plans, failure to ensure medication labeling accuracy, inadequate call light system functionality, and deficiencies in QAPI program implementation.
Deficiencies (23)
Failed to treat residents with dignity and respect during medication administration for Resident #15.
Failed to post required notifications of State Survey Agencies and advocacy groups accessibly.
Failed to have correct documentation of residents' advance directives for 3 residents.
Failed to provide 48 hour notification of financial responsibility for Medicare Part A discontinuation for 2 residents.
Failed to provide a comfortable homelike environment by leaving feces and urine in a commode for at least 8 hours for Resident #20.
Failed to make grievance information available and follow up on grievances for residents.
Failed to complete background checks prior to employment and provide annual abuse prevention training for staff.
Failed to thoroughly investigate and report allegations of abuse within required timeframes for Resident #15.
Failed to ensure accurate resident assessments, including medication use coding errors.
Failed to complete PASRR for Resident #3 with new mental health diagnoses.
Failed to develop and implement comprehensive care plans with measurable goals and interventions for multiple residents.
Failed to ensure medication orders for mitt/glove use were entered and assessed properly for Resident #22.
Failed to ensure proper treatment and assessment related to use of restraint mitt/glove for Resident #22.
Failed to label medications accurately including insulin pens with correct dosage labels.
Failed to ensure medication orders and labels matched and to provide stickers for medication changes.
Failed to store food properly with expired items and undated opened food in dry storage and freezer.
Failed to safeguard resident-identifiable information on unattended, unlocked medication cart computer monitor.
Failed to submit accurate Payroll Based Journal staffing data due to missing agency nurse time sheets.
Failed to maintain an effective QAPI program with comprehensive plans, tracking, and committee membership.
Failed to maintain records of QAPI committee meetings and required attendees for all quarters reviewed.
Failed to maintain a working call light system in resident bathrooms and rooms, causing delays in staff response.
Failed to provide staff education on abuse, neglect, exploitation, and mandatory reporting for all required staff.
Failed to provide required annual in-service training for nurse aides on resident rights, dementia care, infection control, and behavioral health.
Report Facts
Residents affected: 43
Deficiencies cited: 22
Morse Fall Scale score: 80
Morse Fall Scale score: 80
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse | Named in medication error and abuse incident involving Resident #15 |
| Staff I | Certified Nurse Assistant | Named in background check and abuse training deficiency |
| Staff M | Certified Nurse Assistant | Named in abuse training deficiency |
| Staff B | Registered Nurse | Named in medication administration observation |
| Staff E | Assistant Administrator | Named in background check and staffing data reporting deficiencies |
| Staff P | Licensed Practical Nurse / MDS Coordinator | Named in care plan and assessment deficiencies |
| Staff Q | Registered Nurse | Named in restraint order and assessment deficiency |
| Staff D | Certified Nurse Assistant | Named in annual training deficiency |
| Staff G | Certified Nurse Assistant | Named in call light system deficiency |
| Staff H | Certified Nurse Assistant | Named in call light system deficiency |
| Staff J | Administrative Assistant | Named in background check deficiency |
| Staff T | Licensed Practical Nurse | Named in medication order and labeling deficiency |
| Staff S | Contract Occupational Therapist | Named in restraint assessment deficiency |
| Staff AA | Physical Therapist Assistant / Program Coordinator | Named in fall prevention and care plan deficiency |
| Staff Y | Certified Occupational Therapy Assistant | Named in fall prevention and care plan deficiency |
| Staff Z | Certified Nurse Assistant | Named in fall prevention and care plan deficiency |
| Administrator | Administrator | Named in multiple findings and interviews |
| Director of Nursing | Director of Nursing | Named in multiple findings and interviews |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Sep 7, 2024
Visit Reason
The document reflects acceptance of a credible allegation of compliance and plan of correction for the facility.
Findings
The facility will be certified in compliance effective September 7, 2024, based on acceptance of the plan of correction.
Inspection Report
Complaint Investigation
Census: 39
Deficiencies: 2
Date: Aug 7, 2024
Visit Reason
The inspection was conducted due to complaints regarding the facility's failure to notify a resident's primary care provider about the resident refusing scheduled breathing treatments and failure to properly manage a resident's leaking PEG tube and medication administration via Foley catheter.
Complaint Details
The complaint investigation focused on Resident #1's refusal of scheduled nebulizer treatments and the facility's failure to notify the PCP, as well as the management of Resident #1's leaking PEG tube and medication administration via Foley catheter without proper physician orders.
Findings
The facility failed to notify the primary care provider of Resident #1's refusal of scheduled nebulizer treatments and failed to replace a leaking PEG tube timely, instead using a Foley catheter without proper physician orders for medication and feeding administration. The facility's policies and practices regarding notification and tube management were found deficient.
Deficiencies (2)
Failed to notify Resident #1's primary care provider of refusal of scheduled breathing treatments.
Failed to replace Resident #1's leaking PEG tube timely and used Foley catheter without proper physician orders for medication and feeding administration.
Report Facts
Census: 39
Scheduled nebulizer treatments: 3
Foley catheter size: 16
Foley catheter inflation volume: 3
Feeding order volume: 240
Water flush volume: 360
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse | Administered medications via Foley catheter and placed Foley catheter in PEG tube site |
| Director of Nursing | Provided statements regarding notification policies and tube replacement |
Inspection Report
Complaint Investigation
Census: 39
Deficiencies: 2
Date: Aug 7, 2024
Visit Reason
Investigation of complaints #120896-C and #121847-C regarding failure to notify the primary care provider (PCP) of a resident's refusal of scheduled breathing treatments and failure to properly manage a leaking PEG tube.
Complaint Details
Complaints #120896-C and #121847-C were substantiated based on clinical record review, staff and PCP interviews, and policy review.
Findings
The facility failed to notify the PCP of Resident #1 refusing scheduled breathing treatments and failed to replace a leaking PEG tube timely, instead using a Foley catheter without proper physician orders for medication and feeding administration.
Deficiencies (2)
Failure to notify the PCP of Resident #1 refusing scheduled breathing treatments.
Failure to replace leaking PEG tube and failure to obtain physician orders for administering medications and feedings via Foley catheter.
Report Facts
Census: 39
Deficiencies cited: 2
Dates of refusal: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse | Administered medications via Foley catheter and reported to PCP about leaking PEG tube |
| Director of Nursing | Director of Nursing | Provided statements regarding notification policies and PEG tube management |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: May 4, 2024
Visit Reason
The document serves as a statement of deficiencies and plan of correction following a survey completed on May 4, 2024, related to facility certification compliance.
Findings
The facility was found to be in substantial compliance based on the credible allegation and plan of correction, resulting in certification effective May 4, 2024.
Inspection Report
Annual Inspection
Census: 42
Deficiencies: 7
Date: Apr 4, 2024
Visit Reason
The inspection was conducted as an annual recertification survey combined with a complaint investigation (#118145-C).
Complaint Details
Complaint #118145-C was investigated and found not substantiated.
Findings
The facility was found deficient in multiple areas including accuracy of assessments, coordination of PASARR and assessments, care plan timing and revision, tube feeding management, medication administration errors, infection prevention and control, and influenza and pneumococcal immunizations.
Deficiencies (7)
Failure to accurately reflect resident status in Minimum Data Set (MDS) assessments, including incorrect use of chair alarms and bed rails.
Failure to refer a resident with newly evident serious mental disorder for Level II PASRR evaluation.
Failure to review and revise care plans to include goals for residents.
Failure to ensure tube feeding was administered per physician orders, including a transcribing error in tube feeding formula concentration.
Failure to prevent significant medication errors, including administration of discontinued medication.
Failure to maintain an infection prevention and control program that was reviewed annually.
Failure to document influenza immunization status or medical contraindications for residents.
Report Facts
Residents reviewed: 16
Residents reviewed for PASARR: 1
Residents reviewed for tube feeding: 2
Residents observed for medication pass: 3
Medication doses administered in error: 11
Tube feeding volume: 240
Tube feeding volume administered: 237
Facility census: 42
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | CNA/CMA | Provided information about Resident #25's use of chair pad alarm. |
| Staff B | CNA | Provided information about Resident #25's mobility and alarm use. |
| Director of Nursing | Registered Nurse | Provided multiple statements regarding alarm use, PASARR expectations, care plan revisions, medication administration, and infection control. |
| Staff E | Licensed Practical Nurse, MDS Coordinator | Commented on MDS coding error for bed rails. |
| Staff D | Registered Nurse, former MDS Coordinator | Commented on MDS coding error and PASARR documentation. |
| Staff G | Registered Nurse | Observed administering tube feeding to Resident #20. |
| Staff F | Licensed Practical Nurse | Observed administering medication to Resident #5 including discontinued medication. |
| Staff C | Provided expectation for PASRR completion when new diagnoses are listed. |
Inspection Report
Routine
Census: 42
Deficiencies: 7
Date: Apr 4, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident assessments, care planning, PASRR referrals, tube feeding, medication administration, infection control, and vaccination documentation at Tabor Manor Care Center.
Findings
The facility failed to accurately document Minimum Data Set (MDS) assessments for some residents, failed to refer a resident for PASRR Level II evaluation, did not include goals in care plans for a resident, administered tube feeding inconsistent with physician orders, committed a significant medication error by administering discontinued medication, lacked annual review documentation for infection control policy, and failed to document influenza vaccination status for a resident.
Deficiencies (7)
Failed to document the Minimum Data Set (MDS) Assessment accurately for 2 of 16 residents reviewed.
Failed to refer 1 resident with a negative Level I PASRR result for Level II evaluation as required.
Failed to review and revise the care plan to include a goal for 1 of 16 residents reviewed.
Failed to ensure residents reliant on tube feeding received feeding per physician orders for 1 of 2 residents reviewed.
Failed to prevent a significant medication error by administering discontinued medication to 1 of 3 residents observed.
Failed to maintain an infection prevention and control program that was reviewed annually.
Failed to document influenza immunization or medical contraindication for 1 of 5 residents reviewed.
Report Facts
Residents reviewed: 16
Residents reviewed: 42
Tube feeding volume: 240
Medication dose: 200
Medication doses administered: 8
Medication doses administered: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff E | Licensed Practical Nurse, MDS Coordinator | Commented on MDS coding error for Resident #1 |
| Staff D | Registered Nurse, former MDS Coordinator | Acknowledged MDS coding error and plan to modify MDS |
| Director of Nursing | Registered Nurse | Provided multiple statements regarding MDS, care plans, PASRR expectations, and medication administration |
| Staff A | CNA/CMA | Provided information about chair pad alarm use for Resident #25 |
| Staff B | CNA | Provided information about Resident #25's mobility and chair pad alarm use |
| Staff C | Discussed PASRR expectations | |
| Staff G | Registered Nurse | Observed administering tube feeding inconsistent with physician order |
| Staff F | Licensed Practical Nurse | Observed administering discontinued medication to Resident #5 |
| Staff D | MDS Coordinator | Documented verbal consent for influenza vaccine for Resident #7 |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jan 22, 2024
Visit Reason
The document is a Plan of Correction submitted following a survey to address deficiencies and certify the facility in compliance.
Findings
The facility was found to be in substantial compliance based on the credible allegation and Plan of Correction, resulting in certification effective January 22, 2024.
Inspection Report
Complaint Investigation
Census: 42
Deficiencies: 1
Date: Dec 22, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to adequately plan and document the transfer of Resident #4.
Complaint Details
The complaint investigation focused on Resident #4's transfer planning and discharge process. The facility was found to have failed in adequately planning the transfer and providing necessary documentation. The Administrator acknowledged the difficulty with the resident and the refusal to accept him back until manageable, resulting in the deficiency.
Findings
The facility failed to meet a resident's need related to adequately planned transfer for Resident #4, including lack of discharge planning and absence of a discharge summary. The resident was sent to the emergency room for psychiatric evaluation and had multiple refusals from other facilities due to behaviors.
Deficiencies (1)
Failure to adequately plan and document transfer for Resident #4, including lack of discharge planning and discharge summary.
Report Facts
Residents Affected: 3
Residents Affected: 42
Facilities Refusing Resident: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Administrator provided statements regarding Resident #4's psychiatric evaluations and transfer difficulties |
Inspection Report
Complaint Investigation
Census: 42
Deficiencies: 1
Date: Dec 22, 2023
Visit Reason
The inspection was conducted as a result of investigations into multiple complaints and facility reported incidents regarding resident care and transfer/discharge procedures.
Complaint Details
The investigation involved complaints #112722-C, #113083-C, #113086-C, #114560-C, #115625-C and facility reported incidents #112741-I and #114363-I. Complaints #113083-C and #113086-C were substantiated with no deficiencies. Complaint #114560-C was substantiated.
Findings
The facility failed to meet the needs related to adequately planned transfer for one resident (Resident #4) who exhibited difficult behaviors and required psychiatric evaluation. The resident's care plan lacked discharge planning and the clinical record lacked a discharge summary. The Administrator acknowledged safety concerns and refusal to readmit the resident until manageable.
Deficiencies (1)
Failure to meet a resident's need related to adequately planned transfer and discharge procedures, including lack of discharge summary and discharge planning for Resident #4.
Report Facts
Resident census: 42
Complaints investigated: 5
Facility reported incidents investigated: 2
BIMS score: 7
Completion date: Jan 22, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mitchell Worcester | Administrator | Named in relation to the finding about Resident #4's transfer and discharge issues and facility safety concerns. |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Mar 8, 2023
Visit Reason
A revisit of the annual recertification survey was conducted in conjunction with an investigation of facility-reported incident 111263-I from February 28 to March 8, 2023.
Complaint Details
Facility-reported incident 111263-I was investigated and found to be not substantiated.
Findings
Facility-reported incident 111263-I was not substantiated. The facility was found to be in compliance with the Code of Federal Regulations (42CFR) Part 482, Subpart B-C.
Inspection Report
Deficiencies: 0
Date: Mar 8, 2023
Visit Reason
An investigation of facility self-report 111263-I was conducted from February 28 to March 8, 2023.
Findings
The facility was found to be in compliance with the Code of Federal Regulations (42CFR) Part 482, Subpart B-C.
Inspection Report
Annual Inspection
Census: 39
Deficiencies: 13
Date: Dec 20, 2022
Visit Reason
The inspection was conducted as the facility's annual recertification survey and included investigation of complaints 104050-C, 105419-C, and 104880-C.
Complaint Details
Complaint 104050-C was substantiated. Complaints 105419-C and 104880-C were not substantiated.
Findings
The facility was found to have multiple deficiencies including failure to notify the Long-Term Care Ombudsman before resident transfers, failure to provide bed hold notices, inadequate coordination of PASARR assessments, incomplete comprehensive care plans, failure to provide restorative therapy, incomplete medication regimen reviews, inadequate infection prevention and control measures, and failure to ensure staff met health requirements such as TB screening. The complaint 104050-C was substantiated while the others were not.
Deficiencies (13)
Failure to notify the Long-Term Care Ombudsman before resident transfers or discharges.
Failure to provide bed hold notices before resident transfers or hospitalizations.
Failure to coordinate PASARR assessments and reviews for residents with mental disorders or developmental disabilities.
Failure to develop and implement comprehensive care plans including measurable objectives and timely revisions.
Failure to provide restorative therapy as planned for residents.
Failure to complete monthly medication regimen reviews for all residents.
Failure to ensure infection prevention and control program was fully implemented including staff training and surveillance.
Failure to ensure staff received required health screenings and examinations prior to employment.
Failure to provide adequate supervision and safety measures to prevent resident elopement.
Failure to ensure proper hand hygiene and infection control practices when assisting residents.
Failure to maintain sanitary kitchen and food safety standards.
Failure to ensure all residents received COVID-19 vaccinations or proper exemptions.
Failure to ensure Director of Nursing was employed and registered nurse coverage was adequate.
Report Facts
Residents reviewed: 39
Residents reviewed for restorative therapy: 3
Residents reviewed for medication regimen review: 5
Residents reviewed for TB screening: 5
Residents reviewed for nursing supervision: 1
Residents reviewed for elopement risk: 1
Residents reviewed for hand hygiene assistance: 2
Residents reviewed for dining assistance: 2
Residents reviewed for COVID-19 vaccination: 39
Days lacking RN coverage: 15
Inspection Report
Annual Inspection
Census: 39
Deficiencies: 18
Date: Dec 20, 2022
Visit Reason
The inspection was conducted as an annual survey to assess compliance with federal and state regulations for nursing home care.
Findings
The facility was found deficient in multiple areas including failure to notify the Long Term Care Ombudsman of hospital transfers, failure to provide bed hold notices, incomplete PASRR Level II screenings, inadequate care planning, failure to provide restorative therapy as planned, inadequate assessment of residents with health changes, inadequate supervision leading to resident elopement, lack of a full-time Director of Nursing and sufficient RN coverage, failure to complete monthly medication regimen reviews, failure to document medication indications, failure to implement gradual dose reductions for psychotropic medications, unsanitary kitchen conditions, failure to meet employee health screening requirements, failure to hold timely QAPI meetings, inadequate infection prevention practices, lack of a designated infection preventionist, and failure to ensure COVID-19 vaccination compliance among staff.
Deficiencies (18)
Failed to notify the Long Term Care Ombudsman when residents transferred to the hospital.
Failed to provide bed hold notices to residents or responsible parties when residents transferred to the hospital.
Failed to submit a Level II PASRR when a resident exhibited significant change in treatment needs due to disruptive behaviors.
Failed to develop and implement complete care plans addressing residents' needs and changes.
Failed to provide restorative therapy as planned for residents.
Failed to assess resident when changes in health status occurred.
Failed to provide adequate nursing supervision and assistance devices to prevent accidents leading to resident elopement.
Failed to assure a Director of Nursing employment and registered nurse on duty for 8 hours daily, 7 days per week.
Failed to complete Medication Regimen Review for multiple residents.
Failed to document diagnosis or indication for use of medication for a resident.
Failed to implement gradual dose reductions and non-pharmacological interventions for psychotropic medications.
Failed to maintain a sanitary kitchen and properly date opened foods.
Failed to ensure new employees met all health requirements prior to employment.
Failed to hold quarterly Quality Assurance and Performance Improvement meetings as required.
Failed to perform hand hygiene when providing help and moving between residents requiring assistance with dining.
Failed to document oxygen tubing changes and maintain proper documentation.
Failed to designate a qualified infection preventionist responsible for the infection prevention and control program.
Failed to provide COVID-19 vaccination status of employees and ensure all employees received vaccination or met exemption requirements.
Report Facts
Residents affected: 2
Residents affected: 3
Residents affected: 2
Residents affected: 12
Residents affected: 3
Residents affected: 1
Residents affected: 1
Residents affected: 39
Days without RN coverage 8 hours: 26
Residents affected: 4
Residents affected: 5
Months between QAPI meetings: 4
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff E | Social Services | Reviewed ombudsman notifications and confirmed lack of notifications |
| Staff F | Certified Nurse Assistant | Reported resident complaints and directed care related to swollen feet |
| Staff D | Certified Nurse Assistant | Reported inability to assist with restorative therapy due to staffing |
| Staff H | Administrative Assistant | Found resident outside after elopement |
| Staff I | Registered Nurse | Reported resident elopement and confusion |
| Staff B | Certified Nursing Assistant | Observed failing hand hygiene during dining assistance |
| Staff O | Licensed Practical Nurse | Reported documentation practices for oxygen tubing changes |
| Staff N | Dietary Aide | Reported not receiving COVID-19 vaccination |
| Administrator | Provided multiple interviews confirming deficiencies and staffing issues | |
| Assistant Administrator | Reported on medication regimen review and oxygen tubing documentation |
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 3
Date: Feb 10, 2022
Visit Reason
The inspection was conducted as a result of complaints #102007 and #102065, both of which were substantiated. The investigation focused on notification of changes to residents and family, bathing care for dependent residents, and infection prevention and control.
Complaint Details
Complaint #102007-C and Complaint #102065-C were both substantiated.
Findings
The facility failed to notify family members of significant changes and hospital transfers for residents, failed to provide adequate bathing opportunities for dependent residents, and did not maintain proper infection control practices including mask usage among staff. Documentation and communication deficiencies were noted, and the facility was in outbreak status with staffing shortages due to COVID-19.
Deficiencies (3)
Failure to notify family member of resident's hospital transfer and change in condition.
Failure to provide adequate bathing opportunities for dependent residents.
Failure to maintain infection prevention and control program including proper mask usage by staff.
Report Facts
Census: 35
Number of residents reviewed: 3
Dates of survey completion: Feb 10, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Named in findings related to notification failures and infection control observations. |
| Administrator | Administrator | Mentioned in infection control observations and plan of correction monitoring. |
| Staff A | Licensed Practical Nurse (LPN) | Provided statements regarding bathing practices. |
| Staff B | Certified Medication Aide (CMA) | Provided statements regarding bathing practices. |
| Staff C | Certified Nursing Assistant (CNA) | Provided statements regarding bathing practices. |
| Staff D | Certified Nursing Assistant (CNA) | Provided statements regarding bathing practices. |
| Staff E | Certified Medication Aide/Certified Nursing Assistant (CMA/CNA) | Provided statements regarding bathing practices. |
Inspection Report
Complaint Investigation
Census: 46
Deficiencies: 8
Date: Jun 14, 2021
Visit Reason
The Iowa Department of Inspections and Appeals conducted a Medicare Recertification Survey and Investigation of complaints and facility reported incidents. The facility was found to be not in compliance.
Complaint Details
Complaint and Facility Reported Incident numbers reviewed included #86452-I (substantiated), #86902-I (not substantiated), #90662-C (not substantiated), #97701-C (not substantiated), and #97702-I (not substantiated).
Findings
The facility failed to notify the physician in a timely manner following continued pain and a significant change in a resident's mobility after a fall. Additional findings included failure to properly complete Medicare Liability Notices and Beneficiary Appeals for residents, failure to evaluate the use of physical restraints, failure to ensure infection prevention and control, and failure to maintain accurate assessments and care plans for residents.
Deficiencies (8)
Failure to notify the physician in a timely manner following continued pain and significant change in resident's mobility after a fall.
Failure to properly complete Medicare Liability Notices and Beneficiary Appeals for residents.
Failure to evaluate the use of physical restraints for residents.
Failure to ensure infection prevention and control practices.
Failure to maintain accurate assessments and care plans for residents.
Failure to ensure proper labeling, storage, and handling of drugs and biologicals.
Failure to provide proper notification before transfer or discharge of residents.
Failure to provide influenza and pneumococcal immunizations and education to residents and their representatives.
Report Facts
Total residents: 46
Residents reviewed for notification failure: 15
Residents reviewed for restraint use: 7
Residents reviewed for Medicare Liability Notices: 3
Residents reviewed for immunization consent: 4
Residents reviewed for care plan accuracy: 12
Residents reviewed for medication administration: 5
Residents reviewed for restraint use quarterly review: 15
Residents reviewed for fall risk: 15
Residents reviewed for bed hold policy: 1
Inspection Report
Abbreviated Survey
Census: 45
Deficiencies: 0
Date: Jun 22, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection and Appeals on 6/22/20 to assess the facility's compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
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