Inspection Reports for Tabor Manor Care Center
209 Main Street, IA, 516532061
Back to Facility ProfileInspection Report Summary
The most recent inspection on January 13, 2026, found the facility to be in substantial compliance with no deficiencies cited. Earlier inspections showed a pattern of deficiencies related primarily to medication administration, notification of primary care physicians and families about resident changes, infection prevention and control, and care planning. Several complaint investigations substantiated issues such as failure to follow physician orders, inadequate abuse prevention policies, and incomplete discharge planning, but enforcement actions like fines or license suspensions were not listed in the available reports. Most complaints were substantiated, though some investigations found the facility in substantial compliance or unsubstantiated. The inspection history shows some improvement over time, with recent plans of correction accepted and the latest survey confirming compliance.
Deficiencies (last 7 years)
Deficiencies (over 7 years)
9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
105% worse than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
24
18
12
6
0
Census
Latest occupancy rate
19 residents
Based on a November 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census 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: 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 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
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
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
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
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 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
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.
Report
Nov 13, 2025
Report
Aug 20, 2025
Report
Feb 10, 2025
Report
Feb 10, 2025
Report
Aug 7, 2024
Report
Apr 4, 2024
Report
Dec 22, 2023
Report
Dec 20, 2022
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