Tabor Manor Care Center: Call Light System Failures - IA
TABOR, IA. Resident #194 pressed her call light and waited 30 minutes for help that never came, trapped by a communication system that staff knew was broken but hadn't fixed.
The 43-bed Tabor Manor Care Center has struggled with a failing call light system since mid-December, federal inspectors found during a February visit. When the wireless system crashes, residents across the facility lose the ability to summon staff assistance.
"Every staff member knows that her call light does not work appropriately," Resident #194 told inspectors on February 3. She described waiting half an hour for help just minutes before the interview, with staff eventually having to unplug her call light at the wall to reset it.
The resident had experienced the same problem in her previous room on the facility's west side. Staff confirmed her account.
Certified nursing assistant Staff G acknowledged that Resident #194 had complained about the malfunctioning call light before. Another CNA, Staff H, explained the scope of the problem: "The call light system goes down at times and needs to be reset. When that happens none of the call lights work."
Administrator acknowledged the system-wide failures began around December 12 or 15, 2024. The company that manufactured the call light system determined the software was outdated during a repair visit, but no permanent fix was implemented.
"Residents had to tell the staff the call light system was not working," the administrator told inspectors. Staff would enter rooms to find residents who said their call lights had been on "for a while," only to learn the signals weren't reaching staff radios.
The south wing bore the brunt of the problems. Two rooms there had completely lost connection to the wireless system, requiring the call light company to remote in for repairs or facility staff to reboot the entire network.
The administrator described a cascading series of technical failures. The system would become "overwhelmed" and require archiving. IP addresses would randomly disconnect. Sometimes isolated rooms would lose connectivity, other times the entire facility's call light network would crash simultaneously.
Residents and family members complained about delayed response times caused by the system failures, the administrator confirmed. Yet the facility had done nothing to provide alternative communication methods for the 43 residents who depended on the system.
The administrator revealed that 40 backup bells sat unused in storage. These emergency communication devices could have been distributed to residents when the electronic system failed, but none were currently in use anywhere in the facility.
"There are bells for the residents that were purchased, but they were currently in storage and not handed out to the residents," the administrator told inspectors. The bells would only be deployed "if the system crashed," despite the system's documented pattern of regular failures.
The call light breakdown represented just one symptom of broader management failures at Tabor Manor Care Center. Federal inspectors found the facility had essentially abandoned its quality improvement responsibilities during a Chapter 11 bankruptcy reorganization.
The administrator couldn't produce any current Performance Improvement Plans when inspectors asked on February 10. He admitted the facility hadn't created systematic approaches to address recurring problems like infection control violations, medication errors, or care plan deficiencies.
"If we get tagged, it's a tag," the administrator said when asked about repeat violations. He expected staff to "stand on their own 2 feet and do their jobs correctly" without institutional support systems.
The last Performance Improvement Plan the facility had completed addressed Enhanced Barrier Precautions in April 2024. The administrator acknowledged that quality improvement discussions happened informally during daily "standup meetings" but weren't documented or tracked systematically.
"The facility reorganization of Chapter 11 Section 5 took a toll on myself and Assistant Administrator, and some areas may not have been a high focus as if the facility did not reorganize the facility would have to close," the administrator explained.
Staff training had also deteriorated. Two certified nursing assistants, Staff I and Staff M, had no documentation of required dependent adult abuse training despite facility policy requiring completion within six months of employment.
The Assistant Administrator sent an email requesting Staff M's training certificate during the inspection, acknowledging that neither employee had completed the mandatory education. The facility's own policy required two hours of abuse identification and reporting training initially, with additional training every five years.
Certified nursing assistant Staff D, employed for about a year and a half, told inspectors she had received only online mandatory reporter training. She confirmed getting no regular education on resident rights, dementia care, infection control, or behavioral health despite federal requirements for 12 hours of annual training.
The Director of Nursing admitted no yearly training was currently being conducted. "Not having CNA yearly training has been identified as a concern and brought to the Administrator's attention," she told inspectors.
The administrator acknowledged the training violations when confronted. "The yearly training/in-services related to resident rights, dementia care, infection control or behavioral health that was required was not completed for CNAs per the regulation."
Quality assurance committee meetings had become sporadic. The facility provided documentation for only two quarterly meetings in the past year, dated July 10, 2024, and December 5, 2024. Required committee members, including the infection preventionist, weren't consistently included in planning documents.
The facility's quality assurance policy lacked basic procedural requirements. It didn't describe how to collect and monitor data across departments, track adverse events, develop system-level corrections, or monitor improvement plan effectiveness.
"The facility did not utilize QAPI to its highest potential and abilities," the administrator admitted repeatedly during the inspection.
Meanwhile, Resident #194 continued dealing with her broken call light. The facility's outdated software and wireless connectivity issues meant she and other residents remained vulnerable to extended waits for assistance, dependent on a communication system that staff knew was unreliable.
The 40 emergency bells remained in storage.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Tabor Manor Care Center from 2025-02-10 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 15, 2026 · Our methodology
Tabor Manor Care Center in Tabor, IA was cited for violations during a health inspection on February 10, 2025.
The 43-bed Tabor Manor Care Center has struggled with a failing call light system since mid-December, federal inspectors found during a February visit.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.
Frequently Asked Questions
- What happened at Tabor Manor Care Center?
- The 43-bed Tabor Manor Care Center has struggled with a failing call light system since mid-December, federal inspectors found during a February visit.
- How serious are these violations?
- Violation severity varies from minor documentation issues to serious safety concerns. Review the inspection report for specific deficiency codes and scope. All violations must be corrected within required timeframes and are subject to follow-up verification inspections.
- What should families do?
- Families should: (1) Ask facility administration about specific corrective actions taken, (2) Request to see the follow-up inspection report verifying corrections, (3) Check if this represents a pattern by reviewing prior inspection reports, (4) Compare this facility's ratings with other nursing homes in Tabor, IA, (5) Report any new concerns directly to state authorities.
- Where can I see the full inspection report?
- The complete inspection report is available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request a copy directly from Tabor Manor Care Center or from the state Department of Health. The report includes specific deficiency codes, facility responses, and correction timelines. This facility's federal provider number is 165546.
- Has this facility had violations before?
- To check Tabor Manor Care Center's history, visit Medicare.gov's Care Compare and review their inspection history, quality ratings, and staffing levels. Look for patterns of repeated violations, especially in critical areas like abuse prevention, medication management, infection control, and resident safety.