Inspection Reports for Tre’ More Manor ALF
6016 Pine Town Road Oxford, NC 27565, Oxford, NC, 27565
Back to Facility ProfileDeficiencies (last 8 years)
Deficiencies (over 8 years)
8.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
65% worse than North Carolina average
North Carolina average: 5.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Mar 19, 2025
Visit Reason
The Adult Care Licensure Section conducted an annual survey on 03/18/25 and 03/19/25 to assess compliance with medication administration, documentation, infection control, and medication storage regulations.
Findings
The facility failed to ensure medications were administered as ordered for some residents, failed to document medication administration immediately after administration, failed to implement proper infection control measures during medication administration, and failed to secure medications properly as medication carts, medication rooms, and offices were found unlocked and unattended.
Deficiencies (4)
Failed to ensure medications were administered as ordered for 1 of 3 sampled residents (#1) regarding Mirtazapine dosage.
Failed to ensure staff documented medication administration on the electronic medication administration record (eMAR) immediately following administration for multiple residents (#3, #6, #7).
Failed to implement infection control measures during medication administration as a medication aide did not sanitize hands or change gloves between administering eye drops and sublingual drops to Resident #7.
Failed to ensure medications were stored securely; medication cart, medication room, and office were found unlocked and unattended with medications accessible.
Report Facts
Medication tablets unaccounted for: 19
Medication administration pass time: 8
Medication administration pass time: 9
Medication bottle tablets: 30
Medication punch card tablets: 30
Inspection Report
Follow-Up
Deficiencies: 1
Date: Oct 30, 2024
Visit Reason
The visit was a Biennial Follow Up Construction Survey to verify correction of previous deficiencies related to facility construction and physical environment.
Findings
The facility does not meet the bathroom requirements as it lacks a bathtub accessible on at least two sides due to recent renovations where the bathtub was removed and replaced with a shower. One deficiency from the Biennial Construction Survey remains uncorrected.
Deficiencies (1)
Facility does not have a bathtub accessible on at least two sides as required.
Inspection Report
Capacity: 31
Deficiencies: 8
Date: Dec 7, 2023
Visit Reason
The inspection was a Biennial Construction Section Survey conducted to assess conformance with the 2005 Rules for Licensing of Adult Care Homes of Seven or More Beds and applicable portions of the North Carolina Building Code and licensing rules in effect at the time of re-licensure.
Findings
Multiple deficiencies were cited including lack of current fire and building safety inspection reports, failure to meet bathroom requirements due to removal of bathtub, unsafe and unclean outside premises, walls and furnishings not in good repair, failure to conduct quarterly fire rehearsals on each shift, and failure to maintain fire safety equipment and building systems in safe and operating condition.
Deficiencies (8)
Facility did not have current fire and building safety inspection reports maintained in the home and available for review.
Facility does not meet bathroom requirements by not having a bathtub accessible on at least two sides; bathtub was removed and replaced with a shower.
Outside premises were not maintained in a clean and safe condition; broken spindles on back ramp and pest entry through hole in mesh soffit vent.
Walls are not in good repair; veneer on men's main bathroom door delaminating and door frame deteriorating leaving a small hole.
Facility was not conducting quarterly fire rehearsals on each shift; specifically, no fire rehearsal on second shift for third quarter of 2023.
Failure to maintain fire safety equipment in safe operating condition; cross corridor doors and dining room door did not close and latch properly.
Holes or gaps at penetrations through fire resistant rated ceilings or walls could allow fire and smoke to spread beyond the area of origin; multiple holes and cracks noted in various locations including basement stair, med room, laundry, and bathrooms.
Fire safety equipment not maintained in operating condition; heat detectors in laundry, bathroom by room 25, and room 20 not attached or secure to ceiling.
Report Facts
Total licensed capacity: 31
Inspection Report
Annual Inspection
Deficiencies: 8
Date: Mar 24, 2022
Visit Reason
The Adult Care Licensure Section conducted an annual survey on March 23-24, 2022 to assess compliance with adult care home regulations.
Findings
The facility was found deficient in multiple areas including failure to ensure tuberculosis testing for staff and residents, lack of weekly and therapeutic diet menus, failure to serve therapeutic diets and nutritional supplements as ordered, inaccurate medication administration records, failure to ensure staff completed required medication aide training, and inadequate infection prevention and control practices related to COVID-19 including improper mask use and lack of screening.
Deficiencies (8)
Failure to ensure 1 of 3 sampled staff were tested for tuberculosis disease upon hire.
Failure to ensure 1 of 3 sampled residents had completed two-step tuberculosis testing upon admission.
Failure to ensure weekly menus with serving quantities specified were available for food service staff.
Failure to have matching therapeutic diet menus for physician-ordered therapeutic diets for 3 of 4 sampled residents.
Failure to serve therapeutic diets as ordered by the primary care provider for 2 of 4 sampled residents.
Failure to assure electronic Medication Administration Records were accurate to include initials of the Medication Aide who administered medications for 3 of 3 sampled residents.
Failure to ensure 2 of 3 staff who administered medications had completed mandated medication aide training and competency validation.
Failure to ensure implementation of CDC and NCDHHS infection prevention and control guidance related to COVID-19 including proper use of face masks by staff and screening of staff and residents.
Report Facts
Residents sampled: 4
Staff sampled: 3
Medication administration records reviewed: 3
Dates of survey: 2022-03-23 to 2022-03-24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Personal Care Aide | Named in tuberculosis testing deficiency and medication aide training deficiency |
| Staff C | Personal Care Aide | Named in medication aide training deficiency |
| Resident Care Coordinator | Named in medication administration and infection control findings | |
| Administrator | Named in tuberculosis testing, medication aide training, and infection control findings |
Inspection Report
Follow-Up
Deficiencies: 1
Date: May 16, 2019
Visit Reason
The visit was a Biennial Follow Up Construction Survey to assess the status of previously cited deficiencies related to building maintenance and safety.
Findings
The building was found not to be maintained in a safe and operating condition due to standing water in the basement causing damage to walls and doors around water heaters. Repairs had been quoted but not yet started.
Deficiencies (1)
The basement has standing water causing damage to the door and walls around two water heaters, indicating the building is not maintained in a safe and operating condition.
Inspection Report
Follow-Up
Deficiencies: 1
Date: Mar 14, 2019
Visit Reason
The Adult Care Licensure Section conducted a follow-up survey on March 14, 2019 to verify correction of previous deficiencies related to the use of physical restraints and alternatives.
Findings
The facility failed to assure physical restraints were used only after assessment, care and team planning, and use of alternatives were tried and documented for one sampled resident who had full bed rails attached to both sides of her bed without proper documentation or prior use of alternatives.
Deficiencies (1)
Failure to assure physical restraints were used only after assessment, care and team planning, and use of alternatives were tried and documented for Resident #1 who had full bed rails attached to both sides of her bed without a physician's order initially and no documentation of alternatives.
Report Facts
Resident admission date: Jul 24, 2018
Assessment and care plan date: Jun 19, 2018
Licensed Health Professional Support review date: Aug 13, 2018
Physician's order date: Feb 7, 2019
Physician's order date: Mar 14, 2019
Observation date: Mar 13, 2019
Employees mentioned
| Name | Title | Context |
|---|---|---|
| supervisor-in-charge (SIC)/medication aide (MA) | Interviewed regarding bedrails use and alternatives for Resident #1 | |
| Owner/Supervisor | Interviewed regarding bedrails use and alternatives for Resident #1 | |
| physician's nurse | Telephone interview regarding Resident #1's bedrails order |
Inspection Report
Capacity: 31
Deficiencies: 9
Date: Feb 27, 2019
Visit Reason
The facility was surveyed for conformance with the 2005 Rules for Licensing of Adult Care Homes of Seven or More Beds and applicable portions of the North Carolina Building Code and Rules for Licensing of Adult Care Homes in effect at the time of initial licensure.
Findings
The inspection identified multiple deficiencies related to physical plant conditions including lack of current fire and building safety inspection reports, outside premises not maintained in a clean and safe condition, walls, ceilings, and furnishings not kept in good repair, facility not maintained free of hazards, failure to maintain fire safety systems and equipment in safe and operating condition, and standing water causing damage in the basement.
Deficiencies (9)
Facility did not have current fire and building safety inspection reports maintained in the home.
Outside premises were not maintained in a clean and safe condition, including damaged gutters, broken furniture, broken porch light with glass hazards, and bird nest creating fire hazard.
Walls and furnishings were not kept in good repair, including loose door hardware and damaged door veneer.
Ceilings were not kept in good repair, including cracked and separating ceiling finish in men's bath.
Facility was not maintained free of hazards, including multiple loose or missing handrails and loose toilet seat.
Failure to maintain building's fire safety systems in a safe condition, including gaps and holes in fire resistant ceilings and walls.
Resident room doors had gaps between door and frame, compromising smoke resistance.
Mechanical equipment not maintained in operating condition, including grease-coated kitchen hood filters.
Building not maintained in safe and operating condition, including standing water and damage in basement around water heaters.
Report Facts
Licensed capacity: 31
Inspection Report
Annual Inspection
Deficiencies: 9
Date: Nov 29, 2018
Visit Reason
The Adult Care Licensure Section conducted an annual survey on November 28-29, 2018.
Findings
The facility failed to maintain resident bathrooms and furnishings in good repair, ensure tuberculosis testing and pharmacy reviews were up to date, provide required controlled substance screenings for staff, serve milk twice daily, and properly use physical restraints with physician orders and care planning.
Deficiencies (9)
Facility failed to assure 4 of 4 resident bathrooms and a hallway ventilation fan were kept clean and in good repair, including rust, stains, cracked paint, and dusty residue.
Facility failed to assure 5 upholstered chairs in resident rooms and 2 chairs in the Common Room were clean and in good repair.
Facility failed to assure 1 of 4 sampled staff did not complete a two-step tuberculosis test as required.
Facility failed to assure 1 of 4 sampled staff had no substantiated findings on the North Carolina Health Care Personnel Registry.
Facility failed to assure 2 of 3 sampled residents completed the two-step tuberculosis test in compliance with control measures.
Facility failed to assure 8 ounces of milk was served to residents twice a day.
Facility failed to assure pharmacy reviews for 2 of 3 sampled residents were completed quarterly.
Facility failed to assure physical restraints were used only after assessment, care planning, use of alternatives, and a written physician order for 1 sampled resident with bed rails.
Facility failed to assure examination and screening for controlled substances was performed for 2 of 4 sampled staff hired after 10/01/13.
Report Facts
Deficiencies cited: 9
Resident rooms with deficient chairs: 3
Residents sampled: 4
Residents sampled for TB test deficiency: 2
Staff sampled for controlled substance screening deficiency: 2
Residents sampled for pharmacy review deficiency: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Medication Aide | Named in controlled substance screening deficiency |
| Staff B | Administrator | Named in tuberculosis testing deficiency |
| Staff C | Housekeeper | Named in personnel registry and controlled substance screening deficiencies |
| Owner/Supervisor | Named in multiple findings including housekeeping, TB testing, pharmacy reviews, and restraint use | |
| Medication Aide | Named in multiple interviews related to pharmacy reviews, housekeeping, and TB testing | |
| LHPS RN | Licensed Health Professional Supervisor Registered Nurse | Named in restraint use assessment |
Inspection Report
Follow-Up
Deficiencies: 4
Date: May 25, 2017
Visit Reason
This was a Follow Up Construction Survey conducted to verify correction of deficiencies identified in the Biennial Construction Survey conducted on 2017-03-31.
Findings
The facility exterior was found not to be maintained in a safe and clean condition, with issues including separated wood ramp railings, a separated galvanized pipe grab rail, rotten wood fascia trim boards, and peeling paint on window trim, brick moldings, soffits, and fascia boards.
Deficiencies (4)
Wood railing for the ramp has separated at a joint leaving a large gap in the top and bottom rails and the vertical balusters.
Galvanized pipe grab rail above the wood railing has separated at a threaded coupling leaving a gap in the grab rail.
Pattern of rotten wood fascia trim boards on building exterior.
Pattern of peeling paint on window trim, brick moldings, soffits, and fascia boards.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Billy S. Bryant | Conducted the Follow Up Construction Survey. |
Inspection Report
Capacity: 31
Deficiencies: 8
Date: Mar 31, 2017
Visit Reason
The facility was surveyed for conformance with the 2005 Rules for Licensing of Adult Care Homes of Seven or More Beds and applicable portions of the North Carolina Building Code and licensing rules, as part of a Biennial Construction Survey.
Findings
The inspection found multiple deficiencies including unsafe and unclean exterior premises, deteriorated building components such as wood ramp railings and peeling paint, walls not kept in good repair with exposed holes in shower walls, and failure to maintain fire safety systems due to gaps in fire resistant rated ceilings.
Deficiencies (8)
Exterior wood ramp railing separated at a joint leaving large gaps.
Galvanized pipe grab rail separated at a threaded coupling leaving a gap.
Rotten wood fascia trim boards on building exterior.
Peeling paint on window trim, brick mouldings, soffits, and fascia boards.
Facility entrance door facing is delaminating and does not freely close and latch.
Walls not kept in good repair; shower piping escutcheons detached exposing holes.
Gap between wall tile and GFCI outlet at the sink.
Failure to maintain fire safety systems due to penetrations or gaps in fire resistant rated ceilings.
Report Facts
Licensed bed capacity: 31
Inspection Report
Capacity: 31
Deficiencies: 16
Date: Feb 18, 2015
Visit Reason
Biennial Construction Survey conducted to assess physical plant compliance with applicable adult care home rules and building codes.
Findings
Multiple physical plant deficiencies were identified including lack of current sanitation and fire safety reports, unstable handrails and guardrails, unsanitary conditions, improper fire safety evacuation plans and rehearsals, unsafe building equipment and fire protection systems, presence of prohibited portable electric heaters, and inadequate exhaust ventilation in certain areas.
Deficiencies (16)
Facility failed to provide current sanitation and fire safety inspection reports.
Unstable handrails in corridors affecting safety and maneuverability.
Unstable handrails/guardrails at steps, porches, stoops, and ramps.
HVAC/ventilation grilles and radiation dampers not maintained, with excessive dust/lint accumulation.
Commode not flushing and faucet handles not functioning properly in Bath A14.
Evacuation diagrams improperly oriented in corridors.
Fire safety rehearsals not documented; fire rehearsal log not provided.
Building egress requires special knowledge or effort to open some doors.
Breaches in fire-resistance-rated construction compromising integrity.
Fire alarm system heat detector dangling from ceiling.
Emergency lighting not working properly or providing adequate illumination.
Exit signs not working on normal or backup power.
Corridor doors not latching properly to resist passage of smoke.
Improper wiring method creating potential fire hazard.
Portable electric heater found in Executive Director Office, prohibited by rule.
Lack of proper exhaust ventilation in linen closet and janitor closet.
Report Facts
Licensed capacity: 31
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ed Miller | Surveyor | Conducted the Biennial Construction Survey on February 18, 2015. |
| Executive Director | Interviewed regarding missing reports and fire rehearsal log; named in multiple findings. |
Viewing
Loading inspection reports...
