Tabor Manor Care Center: Medication Safety Failures - IA
Federal inspectors cited the facility following a complaint inspection completed August 20, 2025. The violation centered on medication administration, specifically on what staff were and were not doing before documenting that a drug could not be given.
The facility uses a Cubex system, an automated medication dispensing cabinet, to store and track medications on the floor. When a medication appeared unavailable, the correct process required staff to check the Cubex before recording anything on the medication administration record. Staff were not doing that. They were documenting medications as "NA," meaning not available, without first confirming whether the drug was actually in the cabinet.
The process did not stop there. If a medication genuinely was not in the Cubex, staff were supposed to contact the director of nursing or whoever was on call, and then reach out to the pharmacy. That chain of notification was not happening either.
A staff member told inspectors she had not been notified the previous day that a medication shortage existed for Resident 5. The director of nursing said she found out the morning of the inspection, not when the problem occurred. She said she receives alerts when medications are documented as NA on the medication administration and treatment record, which is how she learned about it at all.
The director of nursing told inspectors she would look into why the medication had not been available. That investigation had not yet happened when inspectors were on site.
The administrator learned of the problem on August 19, 2025, at 4:30 in the afternoon. He told inspectors he expected staff to check the Cubex and follow the established process for both administering and ordering medications. He was aware the process had not been followed.
The facility's own protocol for medication administration, last updated September 3, 2014, states that medications must be given within one hour before or one hour after the scheduled administration time. That same protocol contains no instructions about the Cubex system at all, meaning the dispensing cabinet the facility relies on daily is not addressed anywhere in the written guidance staff are expected to follow.
The gap matters. When a protocol does not account for a core piece of the medication workflow, staff have no written standard to fall back on. What inspectors found was not a single employee making a judgment call in an ambiguous situation. It was a pattern of staff skipping a verification step, a gap in written policy that left that step unaddressed, and a director of nursing who was not in the loop until alerts surfaced the following morning.
Inspectors rated the violation at a level of minimal harm or potential for actual harm, with some residents affected. The citation fell under F0658, which covers professional standards for medication administration.
Resident 5 is identified in the inspection record only by number. What the record does not say is whether that resident received their medication late, received it at all, or experienced any consequence from the missed doses. The inspection documents the process failure. What happened to the person waiting for the medication is not in the record.
The administrator said he expected staff to follow the process. The director of nursing said she would investigate. The protocol on paper has not been updated in more than a decade and does not mention the system staff use every day to dispense drugs.
Resident 5 was still a patient at Tabor Manor when inspectors arrived.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Tabor Manor Care Center from 2025-08-20 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: October 14, 2026 · Our methodology
Tabor Manor Care Center in Tabor, IA was cited for violations during a health inspection on August 20, 2025.
Federal inspectors cited the facility following a complaint inspection completed August 20, 2025.
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.