Tabor Manor Care Center: Forced Medication Violation - IA
Federal inspectors cited Tabor Manor Care Center, a 43-bed nursing home at 209 Main Street, following a February 10, 2025 inspection that found the facility failed to treat at least one resident with dignity and respect.
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See the Derila PillowThe resident at the center of the finding, identified in inspection records only as Resident 15, had a severe cognitive decline score on standardized testing, meaning she could not reliably communicate or advocate for herself. Her diagnoses included non-Alzheimer's dementia, paralysis on one side of her body, a seizure disorder, and poor muscle coordination and balance following a stroke. She required total staff assistance for every activity of daily living, from bathing to eating to moving.
Someone noticed what was happening and wrote it down.
A nurse's progress note dated January 10, 2025, at 8:49 in the morning documented a concern that a staff member had held the resident's hands down and forced her medications. The note named no consequence, triggered no visible investigation, and sat in the clinical record until inspectors arrived weeks later.
The nurse who administered the medications was Staff A, a Licensed Practical Nurse with nine years of experience. When inspectors interviewed her on February 4, she confirmed she had held the resident's hands down. She said she did it to stop the resident from flinging her arms.
She also said something that inspectors recorded carefully: the resident had a history of refusing medications, but typically not for her. And she acknowledged that the right step, when a resident refuses, is to wait until the resident is willing to take them.
She knew. She held the hands down anyway.
The Director of Nursing, interviewed two days later on February 6, said her expectation was that staff document when a resident refuses medication. That is the policy she described. Whether anyone had enforced that expectation with the nurse in question, or whether any review of the January 10 incident had taken place before inspectors arrived, the inspection record does not say.
What the record does say is that the facility's own written protocol for medication administration, last updated in September 2014, contained no directions for staff to follow when a resident refused to take prescribed medications. The document that was supposed to guide nurses through exactly this situation said nothing about it.
Eleven years had passed since that policy was written. Resident 15's conditions, her dementia, her paralysis, her history of medication refusal, were not unusual in a long-term care setting. Residents who cannot communicate clearly and who resist care are among the most common and most vulnerable people in nursing homes. The gap between what the Director of Nursing said she expected and what the policy actually required left nurses to improvise.
One of them chose to use her hands.
Inspectors classified the violation as causing minimal harm or potential for actual harm, the lower end of the harm scale. The citation fell under the federal requirement that nursing homes treat residents with dignity and respect.
Resident 15 was totally dependent on staff. She could not move herself, could not reliably speak for herself, and scored in the severe range on cognitive testing. When a nurse held her hands down and put medication in her mouth, there was no one in the room to stop it, and no policy on the wall that said it was wrong.
The progress note from January 10 was the only record that something had happened at all.
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: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
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Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: November 14, 2026 · Our methodology
Tabor Manor Care Center in Tabor, IA was cited for violations during a health inspection on February 10, 2025.
She required total staff assistance for every activity of daily living, from bathing to eating to moving.
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.