A list of the most recent deficiencies for Tabor Manor Care Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2023-12-22 | 2024-01-22 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-12-20 | 2023-01-27 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2022-12-20 | 2023-01-27 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2022-12-20 | 2023-01-27 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-12-20 | 2023-01-27 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-12-20 | 2023-01-27 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2022-12-20 | 2023-01-27 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-12-20 | 2023-01-27 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-12-20 | 2023-01-27 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2022-12-20 | 2023-01-27 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-12-20 | 2023-01-27 | N |
| Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. | Health | 2022-12-20 | 2023-01-27 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2022-12-20 | 2023-01-27 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-12-20 | 2023-01-27 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2022-12-20 | 2023-01-27 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2022-12-20 | 2023-01-27 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2022-12-20 | 2023-01-27 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-12-20 | 2023-01-27 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-12-20 | 2023-01-27 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-12-06 | 2023-01-06 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-12-06 | 2023-01-06 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-12-06 | 2023-01-06 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-12-06 | 2023-01-06 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-12-06 | 2023-01-06 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-12-06 | 2023-01-06 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-02-10 | 2022-03-10 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-02-10 | 2022-03-10 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-02-10 | 2022-03-10 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2021-06-14 | 2021-07-14 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2021-06-14 | 2021-07-14 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-06-14 | 2021-07-14 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2021-06-14 | 2021-07-14 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-06-14 | 2021-07-14 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-06-14 | 2021-07-14 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2021-06-14 | 2021-07-14 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2021-06-14 | 2021-07-14 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-06-14 | 2021-07-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-06-14 | 2021-07-14 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2021-06-14 | 2021-07-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-06-14 | 2021-07-14 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-06-14 | 2021-07-14 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-06-14 | 2021-07-14 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-06-14 | 2021-07-14 | Y |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2021-06-10 | 2021-07-10 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2021-06-10 | 2021-07-10 | N |
| Have an externally vented heating system. | Fire Safety | 2021-06-10 | 2021-07-10 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-06-10 | 2021-07-10 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-06-10 | 2021-07-10 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-06-12 | 2019-07-12 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2019-06-12 | 2019-07-12 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2019-06-12 | 2019-07-12 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-06-12 | 2019-07-12 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2019-06-12 | 2019-07-12 | N |
| Meet requirements for the use and maintenance of medical gas equipment. | Fire Safety | 2019-06-12 | 2019-07-12 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2019-06-05 | 2019-07-05 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2019-06-05 | 2019-07-05 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-06-05 | 2019-07-05 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-06-05 | 2019-07-05 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2019-06-05 | 2019-07-05 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2019-06-05 | 2019-07-05 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-06-05 | 2019-07-05 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-06-05 | 2019-07-05 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2019-06-12 | 2019-06-26 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-06-12 | 2019-06-14 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-06-12 | 2019-06-12 | N |
