Tabor Manor Care Center: Wound Documentation Failures - IA
That detail emerged during a November 2025 complaint inspection at the facility. When inspectors asked the director of nursing about wound assessment records, she told them the gaps had surfaced during an internal mock survey the facility conducted between November 3 and November 7, roughly a week before inspectors arrived on November 12. The DON said she would have expected "more documentation in the Progress Notes with wound size and description." The facility had identified the problem itself. The documentation still hadn't been fixed.
What inspectors found was a pattern of wound assessments that lacked the basic information nurses are trained to record: measurements and written descriptions of the wound. A registered nurse identified in the report as Staff C told inspectors on November 13 that skin assessments are supposed to be completed weekly, and that each assessment should include measurements and a description of the wound. The facility's own policy, dated February 28, 2024, said the same thing, requiring nurses to obtain weekly measurements and reflect them in each resident's electronic medication administration record, alongside a description of any skin concern and documentation of physician notification.
The measurements weren't there. The descriptions weren't there.
Inspectors classified the violation under F0686, which covers the prevention and treatment of pressure ulcers and skin integrity. The level of harm was listed as minimal harm or potential for actual harm, with few residents affected.
That classification sits at the lower end of the federal scale, but it obscures something worth examining. A wound that isn't measured weekly is a wound that isn't being tracked. Without serial measurements, a nurse reading a patient's chart the following week has no baseline. There's no way to tell whether a wound is healing, holding steady, or quietly getting worse. The measurement isn't paperwork for its own sake. It's the mechanism by which anyone caring for that resident the next day, or the next shift, knows what they're dealing with.
The DON's acknowledgment that documentation "could have been better" is the kind of careful institutional language that tends to appear in these situations. What it describes, translated plainly, is that nurses were completing assessments, or something recorded as assessments, without capturing the information those assessments exist to capture.
The mock survey the facility conducted in early November was presumably designed to catch exactly this kind of gap before regulators found it. It did catch it. The inspectors arrived six days after that internal review concluded and found the problem unresolved.
Tabor Manor's policy requiring weekly wound measurements has been in place since at least February 2024. Staff C confirmed on the day of inspection that the expectation for weekly measurements and wound descriptions was understood. The gap, then, was not a matter of staff being unaware of the requirement. The assessments simply weren't being completed the way the policy described.
Inspectors did not detail in the publicly available portion of this report how many residents were affected or how long the documentation gaps had been occurring. The report covers four pages, and the narrative provided reflects the findings on the final page.
What the record shows is a facility that identified a wound documentation problem during its own internal review, told inspectors it knew the records should have been more complete, and was still out of compliance when the complaint inspection took place. The residents whose wounds went unmeasured during that window had caregivers who were working without the full picture.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Tabor Manor Care Center from 2025-11-13 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.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 4, 2026 · Our methodology
Tabor Manor Care Center in Tabor, IA was cited for violations during a health inspection on November 13, 2025.
That detail emerged during a November 2025 complaint inspection at the facility.
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.