Tabor Manor Care Center

Survey Agencies and other support for advocacy in a form or manner accessible and understandable

Findings include: Surveyor's observations throughout the survey dates 2/3/25 - 2/6/25 revealed information posted in the common area by the nurses station on how to contact state agencies was above eye level and in small print flyers.

Information on Residents Rights was not posted. A framed flyer that read current state survey, fire marshall's report, medicaid and medicare information located in lobby bookcase did not have all listed information in the lobby's bookcase.

Another flyer read nondiscrimination policy and at the bottom of the flyer the contact for the facility was outdated.

During a facility tour on 2/4/25 at 3:00 pm with the Administrator Assistant, it was observed that the required postings with list of names, mailing and email addresses, and telephone numbers of all pertinent State regulatory and informational agencies and advocacy groups were not all displayed in the area easily visible or accessible to residents and some of the postings were outdated.

In an interview with the Administrator on 2/6/25 at 2:34 pm he stated that he will have to look at the area by the nurses desk to check for the information and ensure it is correct and present.

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Tabor Manor Care Center 209 Main Street Tabor, IA 51653

physician's signature to be faxed back to the facility.

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Tabor Manor Care Center 209 Main Street Tabor, IA 51653

The facility failed to provide written documentation with a signature by the resident or power of

On 2/10/25 at 9:55 AM the Assistant Administrator (AA) stated the Beneficiary Notice - Residents discharged Within the Last Six Months document completed upon entry did not have the correct resident names on it.

The document contained Medicare B residents, Medicaid Residents, Managed Care Residents, as well as Medicare A residents.

The AA indicated the Social Services Director completed the ABN notifications and he completed the pre-authorizations.

On 2/10/24 at 10:45 AM the AA indicated the documentation that was completed was submitted for review.

On 2/10/24 at 11:40 AM the Administrator acknowledged he had become aware of concerns regarding ABN completion.

The facility did not provide an Advanced Beneficiary Notice Policy.

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Tabor Manor Care Center 209 Main Street Tabor, IA 51653

breakfast, after breakfast, before lunch, and after lunch.

Staff N stated she had worked the morning

times a shift.

On 2/5/25 at 2:06 PM Staff D Certified Nurse Assistant (CNA)/Certified Medication Assistant (CMA) stated the toilet in room [ROOM NUMBER] was taped shut because Resident #20 flushed random things like washcloths, paper towels and other things.

Staff D stated the Administrator taped the toilet shut.

Staff D acknowledged Resident #20 used a commode for toileting.

Staff D stated the CNA's emptied Resident #20's commode.

Staff D stated Resident #20 would come out and tell the staff when the commode needs to be emptied.

Staff D stated would usually check around lunch time to see if the commode needed to be emptied.

Staff D stated she usually checked the commode before and after meals.

Staff D stated she arrived at work around 11:00 am and had not emptied the commode in room [ROOM NUMBER] all day.

Staff D stated the facility had never trained any expectation on care for the commode.

On 2/5/25 at 2:06 PM Staff O, CNA stated the toilet in room [ROOM NUMBER] was taped shut because Resident #20 flushed random things like washcloths, paper towels and other things.

Staff O stated the Administrator taped the toilet shut.

Staff O acknowledged Resident #20 used a commode for toileting.

Staff O stated the CNA's emptied Resident #20's commode.

Staff O stated Resident #20 would come out and tell the staff when the commode needs to be emptied.

Staff O stated would usually check around lunch time to see if the commode needed to be emptied.

Staff O stated she usually checked the commode before and after meals.

Staff O stated she arrived at work around 11:00 am and had not emptied the commode in room [ROOM NUMBER] all day.

Staff O stated the facility had never trained any expectation on care for the commode.

On 2/5/25 at 2:38 PM the Administrator acknowledged the toilet in room [ROOM NUMBER] was taped shut.

The Administrator stated there were multiple issues with her flushing washcloths and wipes The Administrator stated when Resident #20 was in the west hall Resident #20 had backed up the toilet 4 times.

The Administrator stated the facility had a plumber remove issues.

The Administrator stated a company from Omaha came down with a camera and had to jet the whole wing to open it up to get everything up and clear it.

The Administrator stated Resident #20 had moved to the south wing and there were washcloths and wipes and little bits of dolls in the plumbing.

The Administrator stated the first time cost $2500 and 2nd time cost $1200.

The Administrator stated he decided to have a commode put in Resident #20's room and had not had any problems since.

The Administrator acknowledged he did not know whether that was wrong or right.

The Administrator stated he would expect that the commode should be emptied several times a day.

The Administrator stated he expected the commode should be emptied after each use.

The Administrator stated he did not want the odor lingering.

The Administrator stated checks should have been completed every 2 hours and would expect it would be emptied or addressed at that time.

On 2/5/25 at 2:45 PM the DON stated she would expect that the commode would be emptied and would check it every 2 hours.

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Tabor Manor Care Center 209 Main Street Tabor, IA 51653

During an observation on 2/3/25 at 10:24 am of the common areas, no information was posted on how to file a complaint or a grievance, including a name of the grievance official.

In an interview with the Administrator on 2/3/25 at 3:00 pm he revealed the grievances forms and records were located in his office.

During the review of the Grievances records, only 1 record was located in the binder filed on 1/2/25 and the section 3 for follow up comments was left blank.

The Administrator confirmed the grievance was not followed up for a resolution.

In a follow up interview with the Administrator on 2/6/25 at 2:34 pm he stated his expectations was that the residents had access to file grievances and he was responsible to complete and follow up on grievances.

The Administrator provided a policy titled Grievance Policy revised 12/27/23 documented the following: It is the policy of this facility that resident or family concerns/grievances occurring during the resident's stay in the facility shall, whenever possible, be responded to by the designated Grievance officer or responsible Department Head closest to the cause of the concern/grievance.

Regardless of which supervisor/department head responds, the Administrator or his/her authorized representative shall review all complaints and agree with the actions taken towards resolution.

Actions taken to resolve the complaint shall be made within 72 hours from the time the Concern/Grievance was received.

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Tabor Manor Care Center 209 Main Street Tabor, IA 51653

Review of the document dated 2/4/25 titled, Employee Contact List documented Staff I, Certified Nurse Assistant (CNA) was hired 7/29/24.

Review of the document for Staff I titled, Single Contact License and Background Check documented background check was completed 7/25/22.

On 2/6/25 at 9:44 AM Staff E, Assistant Administrator acknowledged Staff I's background check was last completed 7/25/22.

Staff E stated he would expect that a background check would have been completed prior to being hired 7/29/24.

On 2/6/25 at 12:21 PM the Administrator stated the facility's expectation was that a background check would have been completed prior to Staff I's employment at the facility.

• A review of the Resident #15 Electronic Health Record (EHR) titled Progress Notes documented on

1/10/25 at 8:49 am a concern was brought to the Administrator and the Director of Nursing (DON) about a staff member holding resident's hands down and forcing medications.

In an interview on 2/4/25 at 3:13 pm with the alleged Staff A, Licensed Practical Nurse (LPN) confirmed putting her hands on top of Resident #15 hands during the medication administration and giving meds to the resident while the resident was refusing them.

Staff A, LPN stated the Administrator did not give her any written disciplinary actions after he was notified of the incident and he did not provide any additional training on Abuse Preventions.

She stated the Administrator kept her off work for 1 week and then she returned to work again and was actively providing cares to Resident #16 and to other residents.

A review of Staff A, LPN, personnel file documented a hire date of 10/26/16.

The file lacked documentation of annual abuse prevention training.

A review of the facility provided policy titled Abuse Prevention, Identification, Investigation, and Reporting Policy revised on 11-16 documented all employees shall receive annual training related to the reporting requirements of the Elder Justice Act.

In an interview with the Administrator on 2/6/25 at 2:34 pm confirmed the facility did not follow the policy to ensure all staff received annual abuse prevention training.

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Tabor Manor Care Center 209 Main Street Tabor, IA 51653

Reporting Policy revised 11-16, documented the procedure: Following completion of the facility

maintain a separation and have no contact with the resident alleged to have been abused, by

the accused employee and the resident alleged to have been abused.

This separation must be maintained until the Department concludes its investigation and issues the written results of its investigation.

Following investigation, the Administrator or designated agent will be responsible for forwarding the results of the investigation to the Department of Inspections & Appeals.

This written report shall be forwarded to the Department within five days of the initial report.

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Finding include: The Minimum Data Set (MDS) dated [DATE] for Resident #2 documented a Brief Interview for Mental Status (BIMS) score of 13 indicating no cognitive impairment.

Review of Resident #2's MDS dated [DATE] documented use of insulin therapy by Resident #2.

Review of Resident #2's Medication Administration Record (MAR) documented a physician's order for Ozempic 0.25 mg once a day every 7 days.

Review of Resident #2's MAR documented no physician order for insulin.

On 2/4/25 at 9:11 AM Staff P, Licensed Practical Nurse (LPN)/MDS Coordinator stated she had worked at the facility.

Staff P acknowledged the Ozempic was identified as an insulin on Resident #2's MDS and this was a coding error.

On 2/4/25 at 10:48 AM the DON acknowledged that Resident #2 was not on insulin.

The DON acknowledged Ozempic coded as insulin was a coding error.

The DON stated the facility's expectation was that the MDS would reflect an accurate assessment and would be coded correctly.

Review of policy dated 3/23/24 titled, MDS Policy documented the MDS is a data collection system that was a correlation of data painting an accurate picture of a resident's needs, care, goals, diagnosis and plan of care.

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Tabor Manor Care Center 209 Main Street Tabor, IA 51653

(F41.9) -5/22/24

3/18/24

On 2/4/25 at 2:21 PM the Director of Nursing (DON) reviewed the documentation of the PASRR and diagnoses in the EMR for Resident #3, and acknowledged there should have been a PASRR completed with the new diagnoses added in 2023.

On 2/10/25 at 11:40 AM the Administrator stated he had become aware of the PASRR concern during the survey and needed to put a process in place to ensure a PASRR was completed when new diagnoses were added by a physician.

The facility policy, PASRR Policy dated 1/23/23 revealed when there is a change in mental status or behaviors the resident will be assessed for submitting a Level II PASRR. It further revealed the MDS/Care Plan Team will monitor and the DON will submit concerns.

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pertinent information was considered for the development of the Care Plan.

The document revealed

ensuring the goal and interventions directly related to the identified focus area.

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from a ghost alarm to a pressure pad alarm.

attached to the call light system and probably would not work if the call lights didn't.

On 2/6/25 at 2:32 PM the DON concurred the ghost alarm was attached to the call light system, and if the call lights were not working the ghost alarm would not function properly.

The facility's policy, Resident Information to be Used for Care Plan, dated 1/24/23 revealed pertinent information to be utilized to generate the Care Plan.

Information to be utilized included fall history with interventions, access to incident report, resident information book, and behaviors.

The policy did not include procedures for when to update the Care Plan.

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Tabor Manor Care Center 209 Main Street Tabor, IA 51653

Review of the document dated 10/30/24 titled Physician's Order documented to place a mitt/glove on the right hand daily.

Remove for hygiene and range of motion at least twice daily.

Noted by Staff Q, Registered Nurse (RN) on 11/4/24 at 10:35 AM.

Review of the Treatment Administration Record for February 2025 revealed no physician's order entered for mitt/glove use.

Review of Resident #22's EHR titled, Progress Notes dated 11/4/24 at 10:33 AM by Staff Q, documented a signed order from Resident #22's primary care physician to place a mitt/glove on right hand daily.

Remove for hygiene and range of motion at least twice daily.

Mitts are to be supplied by the family.

Order entered into EHR, POA notified, and Director of Nursing (DON) updated.

Review of Resident #22's EHR titled, Progress Notes dated 11/4/24 at 10:33 AM by Nurse Staff R, Licensed Practical Nurse (LPN) documented Resident #22 does not like the mitt on his hand.

On 2/6/25 at 8:15 AM Staff P, MDS Coordinator stated the staff had put the mitt on him once that she could recall.

On 2/6/25 at 8:43 AM the DON acknowledged Resident #22 had worn the mitt/glove at least once.

The DON acknowledged the order for a mitt/glove for Resident #22 was not entered into the EHR.

The DON stated she would have expected the order to be entered into the EHR.

The DON acknowledged an assessment should have been completed twice a day and was not when Resident #22 had the glove on.

The DON stated that Resident #22's mother wanted him to have a glove to prevent him from pulling out his peg tube.

The DON stated Resident #22 hates the glove and will refuse the glove frequently.

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Tabor Manor Care Center 209 Main Street Tabor, IA 51653

/ or the facility feels a fall is imminent, the facility may implement the use of a restrictive device

Whenever the safety of a resident is determined to be at risk a screening shall be completed quarterly

will electronically sign that the resident's restraint had been released and the resident repositioned approximately every 2 hours while using the restraint.

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Tabor Manor Care Center 209 Main Street Tabor, IA 51653

CGA>SBA for standing and mobility using the FWW.

On 2/6/25 at 4:07 PM Staff AA, Physical Therapist Assistant (PTA)/Program Coordinator (PC),

the facility for skilled therapy services.

The staff stated treatment emphasized strengthening, leg exercises, walking, safety, balance, endurance.

Staff AA stated the resident was discussed at the weekly Medicare Meeting on 1/29/25.

The staff stated the Medicare Team, which is the clinical team, meets weekly to discuss the residents.

The staff stated during the Medicare Meeting on 1/29/25 the clinical team decided to discontinue the bed and chair alarms as they were not effective in preventing the resident from standing and moving around in the room.

Additionally Staff AA stated she had observed the resident exhibit signs of agitation with the alarms during therapy by punching the bed when the alarm sounded.

Staff AA stated CNAs were part of the team decision to trial no alarms in the room.

The staff stated the decision by the team was a 48 hour trial beginning on Wednesday the 29th, and there were no concerns raised during the 48 hour trial.

The staff stated the therapy department did not recommend the resident be independent in his room, but discontinue the alarm.

On 2/10/25 at 10:10 AM the MDS Coordinator stated the Baseline Care Plan should reflect the resident's ability to transfer within the ADLs portion of the Care Plan.

The staff stated the Care Plan should provide information for staff on the resident's assistance needs.

The MDS Coordinator stated during the Medicare Meeting it was discussed discontinuing the use of the alarms due to therapy stating it caused increased agitation, and the alarms did not stop the resident from standing or moving around in his room.

The MDS Coordinator stated the resident was considered contact guard at a minimum for transfers and ambulation.

The staff stated the resident had not been made independent for mobility and transfers.

On 2/10/25 at 10:12 AM the Certified Dietary Manager (CDM) stated the alarms for Resident #193 had been discontinued but the resident continued to require assistance for transfers and ambulation.

The facility's policy, Resident Information to be Used for Care Plan, dated 1/24/23 revealed sources for generating the Care Plan.

The document did not contain information regarding the updating the Care Plan, development of the Baseline Care Plan within 48 hours, or use of the MDS/Resident Assessment Instrument.

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Tabor Manor Care Center 209 Main Street Tabor, IA 51653

and the written and skills test.

Upon verification of licensed CNA's upon hiring process and

not showing up on the registry, the college would be contacted on the completion of this action.

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Tabor Manor Care Center 209 Main Street Tabor, IA 51653

Review of Resident #194's Care Plan revealed no focus, desired outcome, target behaviors or

The Physician Orders failed to include target behaviors for each psychotropic medication order.

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Tabor Manor Care Center 209 Main Street Tabor, IA 51653

administer with the sticker on the label.

The DON acknowledged that the facility did not have the

She stated the pharmacy was not able to provide new labels to the facility for medication changes per regulations.

She stated when the medication was changed the label should have a sticker that stated directions changed see MAR.

She stated a CMA would not be able to complete the 5 rights on their own if that sicker is on the medication label.

She stated the pharmacy did provide those stickers upon request.

The Consultant Pharmacist stated facility staff changing the label would not be acceptable practice.

She stated if the narcotic order was not a signed valid script from the provider and the medication would not be sent out until they had a signed valid script from the physician.

She stated she does see the continued use of narcotics with changes related to insurance purposes but would expect the facility to use the sticker that states direction change see MAR.

Review of undated policy titled Storage Policy documented that any items out of their original packaging could only be kept for 3 days after opening.

Frozen foods and produce are left in the original package.

Items remaining in their original packaging may be kept for 30 days after.

All items must have an open date after opening. If an item has no open date or improperly stored items must be discarded.

Items will be inspected daily by dietary staff, twice weekly on Mondays and Thursday by the CDM and the CDM assistant.

Additionally monthly by the Registered Dietitian.

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Tabor Manor Care Center 209 Main Street Tabor, IA 51653

Observation on 100 hallway on 2/4/25 from 7:50 am until 8:00 am revealed an unattended medication cart located near the exit door of the hallway.

The medication cart equipped with a built-in computer monitor on top of it displayed an Electronic Health Record of a current resident. It revealed personal identifiable information, including full name, room number, birthday, code status, and several medication/treatment orders.

One resident walked past the unlocked computer monitor.

Subsequent observations of the unlocked, unattended computer monitor with the EHR displaying residents' medical records:

• 02/05/25 07:32 AM computer screen unlocked
• 02/05/25 08:36 AM medication labels for refills stuck on the pill crusher
• 02/05/25 08:37 AM facility visitor in the hallway walked by
• 02/05/25 08:45 AM computer screen unlocked
• 02/05/25 09:19 AM computer screen unlocked, housekeeping staff present nearby

An anonymous staff member who walked past the medication cart confirmed the computer screen monitor was displaying resident identifiable information and it had to be locked.

This staff further stated when they are tasked with administering medications, they lock the monitor screen to protect residents' confidential information.

In an interview 2/6/25 at 02:34 pm, the Administrator confirmed that the computer monitor where EHR contained residents information had to be locked if the staff member in charge of the computer was not present.

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Tabor Manor Care Center 209 Main Street Tabor, IA 51653

Review of weekend staffing schedules for quarter 4 months of July, August, and September 2024 revealed equal staffing during the week and the weekend.

On 2/6/25 at 12:06 PM Staff E, Assistant Administrator acknowledged time sheets were not turned in for a traveling nurse in particular and was not appropriately being sent to the billing email.

Staff E acknowledged this was the reason for the inaccuracy in reporting staffing data.

On 2/6/25 at 12:02 PM the Administrator stated he had inaccuracies probably related to agency staff hours being reported.

Stated the facility's accountant takes all the staffing data information and submits it to CMS.

The Administrator acknowledged time sheets were not turned in appropriately for an agency nurse in particular and this was the reason for the inaccuracy when reporting staffing data.

The Administrator stated the facility's expectation was for accurate data to be sent when the facility reported the Payroll Based Journal (PBJ) report to CMS.

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Tabor Manor Care Center 209 Main Street Tabor, IA 51653

Enhanced Barrier Precautions (EBP) when it came out in 4/2024.

The Administrator stated going to be

of repeat deficiencies including PASRR, Advanced Directives, Minimum Data Set (MDS) accurate

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.

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Tabor Manor Care Center 209 Main Street Tabor, IA 51653

corrective plans of action.

written policies and procedures for the Quality Assurance and Performance Improvement (QAPI) plan.

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.

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Tabor Manor Care Center 209 Main Street Tabor, IA 51653

quarterly

records of Quality Assurance and Performance Improvement (QAPI) committee meetings 1 of the 3

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.

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Tabor Manor Care Center 209 Main Street Tabor, IA 51653

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

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Tabor Manor Care Center 209 Main Street Tabor, IA 51653

equipped to allow residents to call for staff assistance through a communication system which relays

prevents the entire call light system from working.

The facility reported a census of 43 residents.

Findings include:

• The Minimum Data Set (MDS) dated [DATE] 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.

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 the call light came to the facility and spoke about fixing it, but the software was determined to be outdated.

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.

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.

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Tabor Manor Care Center 209 Main Street Tabor, IA 51653

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.

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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.

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Tabor Manor Care Center 209 Main Street Tabor, IA 51653

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)

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.

165546

Form Approved OMB

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