Inspection Reports for Tabor Commons
703 Elizabeth St. Tabor City, NC 28463, Tabor City, NC, 28463
Back to Facility ProfileDeficiencies (last 7 years)
Deficiencies (over 7 years)
7.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
46% worse than North Carolina average
North Carolina average: 5.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Capacity: 80
Deficiencies: 11
Date: Feb 22, 2024
Visit Reason
The report documents a Construction Section Biennial Survey conducted to assess compliance with physical plant regulations, building codes, and safety requirements for the adult care home licensed for 80 beds.
Findings
Multiple deficiencies were cited related to physical plant and safety including lack of current sanitation and fire safety inspection reports, failure to submit construction plans for remodeling, missing wanderer alarms on exit doors, poor housekeeping and maintenance issues such as damaged walls, ceilings, furnishings, unsecured oxygen bottles, fire safety equipment not maintained or inspected, electrical hazards, non-functioning exhaust fans, and failure to maintain emergency lighting and fire alarm systems in safe operating condition.
Deficiencies (11)
Facility did not have current sanitation and fire and building safety inspection reports maintained in the home and available for review.
Facility did not submit plans to DHSR/Construction when changes or remodeling was conducted, including installation of a new fire alarm control panel without plan submission.
Facility did not equip each exit with a sounding device as required when there is at least one resident who is disoriented or a wanderer; exterior door alarm did not sound when opened.
Walls and ceilings were not kept clean and in good repair; paint bubbled and peeling, ceiling cracked and separating; furnishings not kept in good repair including cracked glass in back door.
Facility was not maintained free from hazards; unsecured oxygen bottles present in resident rooms.
Failure to maintain fire safety equipment in safe operating condition; fire doors did not close and latch properly; fire extinguishers and hood suppression system inspections overdue.
Fire resistant rated ceilings had unsealed cable and conduit penetrations and holes allowing potential spread of fire and smoke.
Electrical equipment not maintained in safe and operating condition; missing outlet covers, non-functioning outlets, and exterior outlets without protective covers.
Electrical emergency/safety lighting equipment not maintained; exit signs did not illuminate on test.
Failure to maintain emergency fire alarm system devices and equipment in safe operating condition; heat detector not secure to base.
Facility did not maintain exhaust ventilation in specified spaces; multiple exhaust fans not working in guest toilets, women's toilet, room bath, and housekeeping areas.
Report Facts
Total licensed capacity: 80
Deficiency count: 11
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Feb 9, 2023
Visit Reason
The Adult Care Licensure Section conducted an annual and follow-up survey on 02/08/23-02/09/23 at Tabor Commons.
Findings
The facility failed to ensure residents were provided non-disposable place settings including forks, knives, spoons, and cups at meal service. Observations and interviews revealed residents were served meals in styrofoam to-go plates and cups with plastic utensils instead of non-disposable place settings.
Deficiencies (1)
Facility failed to ensure residents were provided non-disposable place settings including forks, knives, spoons, and cups at meal service.
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Feb 4, 2020
Visit Reason
The Adult Care Licensure Section and the Columbus County Department of Social Services conducted an annual and follow-up survey from 02/04/20 to 02/06/20.
Findings
The facility failed to ensure food was stored to prevent contamination, including unlabeled and undated opened food packages, a cracked container lid, and improper thawing of meat without cold running water.
Deficiencies (1)
Food packages were not labeled or dated after opening, including an unsealed jar of mayonnaise without a date label, a cracked container lid on a bin holding sugar, flour, and cornmeal without an open date, and meat thawing in a sink without cold running water.
Inspection Report
Capacity: 80
Deficiencies: 15
Date: Feb 8, 2018
Visit Reason
The inspection was a Construction Section Biennial Survey conducted to assess compliance with the 1984 and applicable portions of the 2005 Rules for the Licensing of Adult Care Homes and the 1978 North Carolina State Building Code Section 409 institutional unrestrained occupancy.
Findings
Multiple deficiencies were cited including failure to maintain current sanitation and fire safety reports, unsafe physical environment hazards such as tripping hazards and unsecured oxygen cylinders, inadequate fire safety measures including blocked fire extinguishers and incomplete fire drill rehearsals, unsafe building equipment and fire safety systems, and the presence of prohibited portable electric heaters.
Deficiencies (15)
Facility failed to maintain current annual sanitation and fire safety inspection reports.
Floors not maintained smooth; tripping hazards present on sidewalks due to pipes, hoses, sand bags, and extension cords.
Ventilation system failed to properly exhaust odors.
Oxygen cylinders stored unsecured in multiple locations creating hazard.
Plumbing equipment not maintained safely; loose commode connections and seats.
Fire extinguishers improperly maintained; access blocked.
Fire drill rehearsals not performed regularly on all shifts and documentation incomplete.
Fire doors did not close and latch properly; loose latches and missing covers.
Egress impeded by gate latched with barrel bolt requiring special knowledge/tools.
Fire alarm panel showing memory signal indicating possible malfunction.
Combustible materials stored improperly in Bedroom 42 increasing fire load.
Fire safety compromised by unsealed holes in fire-resistance-rated walls and ceilings.
Smoke tight corridor doors not maintained; doors did not latch or were held open improperly.
Electrical system not maintained safely; loose receptacles and broken cover plates.
Portable electric heater found in Administrator Office, violating prohibition on unvented and portable electric heaters.
Report Facts
Total licensed capacity: 80
Fire extinguisher coverage requirement: 2500
Inspection Report
Follow-Up
Deficiencies: 2
Date: Feb 10, 2017
Visit Reason
The Adult Care Licensure Section conducted a follow-up survey from February 8, 2017 through February 10, 2017 to verify correction of previous deficiencies.
Findings
The facility failed to ensure proper medication orders and administration for residents, including failure to clarify sliding scale insulin orders for Resident #5 and failure to administer prescribed medications for Residents #4 and #5 as ordered by the prescribing practitioner.
Deficiencies (2)
Failed to ensure the Primary Care Provider was contacted for unclear and incomplete sliding scale insulin orders for Resident #5 and that contact was documented.
Failed to assure medications were administered as ordered for Residents #4 and #5, including diabetes medication, vitamin D supplement, and blood pressure medication.
Report Facts
FSBS results: 40
FSBS results >150: 19
FSBS refusals: 9
FSBS results >300: 35
FSBS results >300: 11
FSBS results >300: 25
Vitamin D lab result: 21.8
Vitamin D lab result: 17
Carvedilol doses held: 4
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Oct 26, 2016
Visit Reason
The Adult Care Licensure Section and the Columbus County Department of Social Services conducted an annual and follow up survey on 10/26/16, 10/27/16 and 10/28/16.
Findings
The facility failed to maintain cleanliness in common showers with black substance resembling mold observed. Additionally, the facility failed to ensure tuberculosis testing compliance for staff and residents, and did not administer Lantus insulin as ordered for one resident, resulting in multiple missed doses.
Deficiencies (5)
Facility failed to assure that 2 of 4 common showers were free of a black substance resembling mold.
Facility failed to assure 1 of 3 sampled staff completed Tuberculosis testing in accordance with control measures upon hire.
Facility failed to assure 1 of 5 sampled residents completed Tuberculosis testing in accordance with control measures upon admission.
Facility did not administer Lantus insulin as ordered by the primary care provider for 1 of 2 sampled residents resulting in 24 missed doses out of 57 opportunities.
Facility failed to ensure residents received care and services which were adequate, appropriate and in compliance with relevant laws related to infection prevention procedures, specifically related to medication administration.
Report Facts
Missed Lantus doses: 24
Lantus exceptions: 14
Lantus exceptions: 10
FSBS results documented: 118
FSBS results documented: 104
Inspection Report
Capacity: 80
Deficiencies: 16
Date: Nov 18, 2015
Visit Reason
Biennial Construction Survey conducted to assess compliance with the 1984 and applicable portions of the 2005 Rules for the Licensing of Adult Care Homes and the 1978 North Carolina State Building Code Section 409 institutional unrestrained occupancy.
Findings
Multiple physical plant deficiencies were identified including non-operable windows, inadequate closet hanging space, missing handrails, unclean and damaged furnishings, fire safety equipment issues, fire resistance rated components not maintained, unsafe electrical conditions, and ventilation system failures.
Deficiencies (16)
Facility failed to maintain operable windows and in good working order, affecting resident ventilation control.
Bedroom closets lacked minimum hanging space required by rule.
Building lacked stable handrails/guardrails at steps, porches, stoops, and ramps.
Walls, ceilings, floors, and furniture were not kept clean and in good repair.
HVAC ventilation grilles and dampers had excessive dust/lint accumulation; portable medical oxygen cylinders improperly stored.
Fire extinguishers and associated equipment were not properly maintained; monthly inspection documentation stopped; access to extinguisher blocked.
Fire evacuation plan maps were not properly posted or oriented.
Fire resistance rated components, including corridor doors and ceiling penetrations, were not maintained in safe and operating condition.
Egress from some areas was difficult due to gates and doors requiring special effort.
Fire protection equipment was in disrepair, including damaged fire alarm sensors and doors held open improperly.
Electrical power system unsafe due to improper use of extension cords and unapproved surge protectors.
Building access was restricted due to lack of keys for inspection.
Building components such as panic hardware and door gaps compromised fire and smoke containment.
Commercial kitchen hood fire extinguishing system lacked required inspections and documentation.
Normal fire load increased due to storage of combustible materials in resident rooms.
Exhaust ventilation system not maintained; laundry exhaust fan missing motor.
Report Facts
Total licensed capacity: 80
Fire extinguisher inspection lapse: 5
Fire extinguishers required: 1
Closet hanging space requirement: 48
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Jan 30, 2015
Visit Reason
The Adult Care Licensure Section conducted an annual survey on January 28, 29, and 30, 2015 to assess compliance with medication administration and staff training requirements at Tabor Commons.
Findings
The facility failed to assure proper medication administration for one resident during the medication pass, resulting in a 7% medication error rate. Additionally, one staff member performing medication aide duties did not meet state training and competency requirements.
Deficiencies (2)
Failed to assure medications were administered as ordered by the licensed prescribing practitioner for 1 of 8 residents, including errors with inhaler administration.
Failed to assure 1 of 4 staff performing medication aide duties met state training and competency requirements, including lack of documentation of passing the medication exam and required training hours.
Report Facts
Medication error rate: 7
Medication administration opportunities observed: 27
Number of residents observed during medication pass: 8
Dates staff B administered medications: 7
Dates staff B scheduled as supervisor: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Medication Aide | Failed to meet state training and competency requirements; administered medications without passing required exam or completing required training hours |
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