Tabor Manor Care Center

F-F582 Medicaid/Medicare Coverage/Liability Notice (2021, 2025)

F-F623 Notice Requirements Before Transfer/Discharge (2021, 2022)

F-F625 Notice of Bed Hold Policy Before/Upon Transfer (2019, 2021, 2022)

F-F644 Coordination of Pre-Admission Screening and Resident Review (PASRR) and Assessments (2019, 2022, 2024, 2025)

F-F656 Development/Implement Comprehensive Care Plan (2022, 2025)

F-F657 Care Plan Timing and Revision (2021, 2022, 2024, 2025)

F-F689 Free of Accident Hazards/Supervision/Devices (2019, 2021, 2022, 2025)

F-F693 Tube Feeding Management/Restore Eating Skills (2019, 2024)

F-F758 Free from Unnecessary Psychotropic Medications/PRN Use (2019, 2021, 2022, 2025)

F-F760 Residents are Free of Significant Med Error (2024, 2025)

F-F812 Food Procurement, Store/Prepare/Serve Sanitary (2019, 2021, 2022, 2025)

F-F880 Infection Prevention and Control (2021, 2022, 2024)

F-F883 Influenza and Pneumococcal Immunizations (2021, 2024)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of 46 165546 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 165546 B. Wing 02/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Tabor Manor Care Center 209 Main Street Tabor, IA 51653

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0865 On 2/10/25 at 11:40 AM the Administrator stated the facility was not able to provide any current Performance Improvement Plans (PIPs), tracking mechanisms for PIPs, or what staff developed the PIP and took Level of Harm - Minimal harm or responsibility for it. The Administrator stated the last PIP the facility addressed was Enhanced Barrier potential for actual harm Precautions (EBP) when it came out in 4/2024. The Administrator stated going to be honest trying to take something like Infection Control, do all the paperwork and root cause analysis through the assistance of a Residents Affected - Many subsidiary of CMS was difficult. The Administrator stated he was aware of repeat deficiencies including PASRR, Advanced Directives, Minimum Data Set (MDS) accurate completions, and Care Plans. The Administrator stated he would not expect repeat deficiencies but with a small facility and staff turnover there might be some. When asked about concerns with repeat deficiencies the Administrator replied if we get tagged, it's a tag. The Administrator stated the facility did complete Plans of Corrections (POCs), but did not necessarily create a PIP to mitigate repeat deficiencies. The staff stated the POC would shore up the deficiency via personnel changes or audits, but expected the staff to stand on their own 2 feet and do their jobs correctly. The Administrator stated the QAPI team discussed the same concerns that were raised in the Standup Meetings regarding infection control, falls, insufficient intakes and fluids. The Administrator revealed

during the past year the facility reorganization of Chapter 11 Section 5 took a toll on himself 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 acknowledged the facility was not using QAPI to its fullest extent.

The facility policy, QAPI Policy and Protocol not dated, revealed PIPs would be used to identify problems and concerns within the facility. The document revealed through the Quality Assurance process data based concerns would be identified and would use staff huddles to collaborate on interventions and root cause analysis.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 40 of 46 165546 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 165546 B. Wing 02/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Tabor Manor Care Center 209 Main Street Tabor, IA 51653

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0867 Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Level of Harm - Minimal harm or potential for actual harm 49628

Residents Affected - Many Based on staff interview, and policy review the facility failed to properly establish and implement written policies and procedures for the Quality Assurance and Performance Improvement (QAPI) plan. The facility reported a census of 43 residents.

Findings include:

The facility policy, QAPI Policy and Protocol, revealed no effective procedures to identify, collect, use and monitor data for all departments, and utilize the Facility's Assessment. The document did not identify how the facility would report, track, investigate and analyze adverse events and/or problem prone concerns. The facility policy did not describe how the facility developed corrective actions to effect change at the systems level to prevent quality of care, quality of life and safety problems. The document did not contain how the facility monitored the effectiveness of its Performance Improvement Plans (PIPs) to ensure improvements were sustained. The facility did not contain the required committee members.

On 2/10/25 at 11:40 AM the Administrator stated the facility was unable to provide any on-going QAPI programs, implementations, and activities in either paper or electronic format for review. The Administrator indicated he would have to look for that, but did not provide further details. The Administrator stated the last PIP was related to Enhanced Barrier Precautions (EBP) in April 2024, and how the facility customized it to meet its needs. The Administrator stated the committee would use concerns brought up during the Standup Meeting including infection control, falls, upper respiratory infections, urinary tract infections and insufficient intakes. The Administrator stated everyone submits paperwork on falls, infection control, and intakes but was unable to provide the documentation or details of PIPs developed from the paperwork submitted. The Administrator stated the QAPI is managed in the same manner as the daily Standup Meeting. The Administrator acknowledged the policy should be updated yearly. The Administrator stated the facility did not utilize QAPI to its highest potential and abilities.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 41 of 46 165546 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 165546 B. Wing 02/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Tabor Manor Care Center 209 Main Street Tabor, IA 51653

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

Level of Harm - Minimal harm or 49628 potential for actual harm Based on facility record review, staff interview, and policy review the facility failed to maintain records of Residents Affected - Many Quality Assurance and Performance Improvement (QAPI) committee meetings 1 of the 3 quarters reviewed and the required attendees. The facility reported a census of 43 residents.

Findings include:

The facility provided documents titled, Q.A. Meeting, dated 7/10/24 and 12/5/24 revealed all the required members were in attendance. No further quarterly documentation was provided for the previous 3 quarters.

The facility policy, QAPI Policy and Protocol undated, revealed the members did not include the Infection Preventionist and Medical Director as required. The document further revealed the team would meet monthly and as needed.

The facility document, QAA Committee, revealed the members included the Administrator, Director of Nursing (DON), Minimum Data Set (MDS) Coordinator, Dietary Manager, Activities Director, Social Services, Medical Director, and Pharmacy. The document did not include Infection Preventionist.

On 2/10/25 at 11:40 PM the Administrator stated the core members of the QAPI committee were the Administrator, DON, MDS/Care Plan Coordinator, Social Services/Housekeeping/Laundry, and Dietary Supervisor as per policy. When asked about the difference between the QAPI Policy and Protocol, and the QAA Committee document, the Administrator stated the documents should match and the policy must be old. The Administrator acknowledged the policy should be updated yearly. The Administrator stated he expected social services, nursing, MDS Coordinator, Administrator, Assistant Administrator, and the Medical Director present, as well as a floor nurse and Certified Nurse Assistant (CNA) depending upon the concern in

the building at the meetings. The Administrator stated in general the Medical Director should be present, and

the facility attempts to have QAPI meetings when he is present for rounds. The Administrator stated meetings were held once a quarter, but may have them more frequently if needed and may be without the Medical Director. The Administrator stated there should be 4 attendance sheets since the previous survey.

The Administrator stated he could not provide any additional documentation as the Social Services personnel manages that. The Administrator expected as many team members to be present for QAPI meetings, and there was no excuse for not having people at the meetings. The Administrator stated there had been QAPI plans developed related to meeting frequencies or attendance. The Administrator stated the facility did not utilize QAPI to its highest potential and abilities.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 42 of 46 165546 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 165546 B. Wing 02/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Tabor Manor Care Center 209 Main Street Tabor, IA 51653

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0919 Make sure that a working call system is available in each resident's bathroom and bathing area.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47673 potential for actual harm Based on clinical record review, resident interview, and staff interview the facility failed to be adequately Residents Affected - Some equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or centralized work area by the system having a known issue that prevents the entire call light system from working. The facility reported a census of 43 residents.

Findings include:

1. The Minimum Data Set (MDS) dated [DATE REDACTED] for Resident #194 documented a Brief Interview for Mental Status (BIMS) of 11 indicating no cognitive impairment. The MDS documented diagnoses of acute respiratory failure with hypoxia and unspecified asthma with acute exacerbation.

On 2/3/25 at 12:55 PM Resident #194 stated every staff member knows that her call light does not work appropriately. Resident #194 stated she used to live in a room on the west side and it did not work appropriately. Resident #194 stated she had just had her call light on for the last 30 minutes a couple minutes ago and it was not working. Resident #194 stated the staff had to unplug the call light at the wall to reset the call light.

On 2/3/25 at 1:00 PM Staff G, Certified Nurse Assistant (CNA) stated Resident #194 had mentioned to her that the call light was not working appropriately once before.

On 2/3/25 at 1:07 PM Staff H, CNA Stated Resident #194's light did not work appropriately when she was in room [ROOM NUMBER]. Staff H stated the call light system goes down at times and needs to be reset. Staff H stated when that happens none of the call lights work.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 43 of 46 165546 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 165546 B. Wing 02/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Tabor Manor Care Center 209 Main Street Tabor, IA 51653

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0919 On 2/4/25 at 8:26 AM the Administrator stated the call light system had to archive, and was something the facility has had to deal with since 12/12/24 or 12/15/24. The Administrator stated that the company that made Level of Harm - Minimal harm or the call light came to the facility and spoke about fixing it, but the software was determined to be outdated. potential for actual harm The Administrator stated residents had to tell the staff the call light system was not working. The Administrator revealed when the staff entered a room the resident said the call light had been on for a while. Residents Affected - Some The Administrator further revealed this is when the staff told the resident that the call lights were not coming across the radio. The Administrator stated the call lights not working appropriately happened more on the south wing and there were 2 rooms on south hall that had lost the link to the wireless call light system. The Administrator stated the call light company would remote in and fix that or they would have to reboot the system. The Administrator stated the facility had to archive the call lights and/or the call light system would become overwhelmed. The Administrator acknowledged occasionally he had to ask the staff to check rooms.

The Administrator stated there are bells for the residents that were purchased, but they were currently in storage and not handed out to the residents. The Administrator stated there are 40 bells that would be utilized if the system crashed. The Administrator acknowledged there had been complaints from residents and family members about the time it takes to answer the call lights related to the system failure. The Administrator stated it was random rooms and that sometimes when it is an archive situation it is all the call lights. The Administrator stated there were isolated incidents where the IP address was lost. The Administrator stated currently there were no residents that had bells in their room.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 44 of 46 165546 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 165546 B. Wing 02/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Tabor Manor Care Center 209 Main Street Tabor, IA 51653

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0943 Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. Level of Harm - Minimal harm or potential for actual harm 47673

Residents Affected - Some Based on facility document review, staff interviews and policy review the facility failed to provide training to their staff that at a minimum educates staff on activities that constitute abuse, neglect, exploitation, and misappropriation of resident property and procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property. The facility reported a census of 43 residents.

Findings include:

A request for documentation from the Administrator and Staff E, Assistant Administrator of training for Staff I, Certified Nurse Assistant (CNA) in Dependent Adult Abuse / Mandatory Reporter revealed no documentation of completion or certificate of completion.

A request for documentation from the Administrator and Staff E of training for Staff M, CNA in Dependent Adult Abuse/Mandatory Reporter revealed no documentation of completion or certificate of completion.

On 2/6/25 at 9:44 AM Staff E, Assistant Administrator stated he just sent an email to Staff M that requested a copy of her Dependent Adult Abuse/Mandatory Reporter certificate. Staff E stated Staff M was not on the list

the facility had that needed a Dependent Adult Abuse/Mandatory Reporter update. Staff E stated Staff I was

on the list and had asked her to complete the Dependent Adult Abuse training and should have completed

the training. Staff E acknowledged no documentation of completed training or certificate of completion for either staff.

On 2/6/25 at 12:21 PM the Administrator stated the facility's expectation was that Dependent Adult Abuse/Mandatory Reporter training would be completed in the first 6 months of employment at the facility for each staff member.

Review of undated policy titled, Abuse Prevention, Identification, Investigation, and Reporting Policy documented each employee shall be required to complete 2 hours of training related to the identification and reporting of dependent adult abuse within six months of initial employment and at least 2 hours of additional dependent adult abuse identification and reporting training every 5 years.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 45 of 46 165546 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 165546 B. Wing 02/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Tabor Manor Care Center 209 Main Street Tabor, IA 51653

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0947 Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Level of Harm - Minimal harm or potential for actual harm 47673

Residents Affected - Some Based on employee file review and staff interview the facility failed to complete required in-service training for nurse aides to ensure continued competence no less than 12 hours per year. The facility reported a census of 43 residents.

Findings include:

On 2/5/25 at 3:34 PM Staff D, Certified Nurse Assistant (CNA) stated she had worked at the facility for about

a year and a half. Staff D stated the facility provided online in-services for mandatory reporters. Staff D stated she had not gotten regular in-service training related to resident rights, dementia care, infection control or behavioral health.

Review of Staff D's employee file revealed no documents of yearly in-service training related to resident rights, dementia care, infection control or behavioral health.

On 2/5/25 at 3:47 PM the Director of Nursing (DON) stated there was not currently any training being conducted as the annual training. The DON acknowledged there was no yearly in-services related to resident rights, dementia care, infection control or behavioral health that had been completed. The DON stated not having an CNA yearly training has been identified as a concern and brought to the Administrator's attention.

On 2/6/25 at 10:55 AM the Administrator acknowledged that the yearly training/in-services related to resident rights, dementia care, infection control or behavioral health that was required was not completed for CNA's per the regulation.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 46 of 46 165546