Twelve Oaks

The facility failed to ensure that medication aides had the required documentation for state-approved 5, 10, or 15-hour medication administration training. Specifically, 3 of 6 sampled staff members lacked required training documentation, and 1 of 6 sampled staff members lacked documentation of passing the state medication aide examination.

The facility failed to ensure that 3 of 6 sampled medication aides had the required documentation of the state-approved medication aide training course. Additionally, 1 of 6 sampled staff lacked documentation of successfully passing the state medication aide examination.

The facility failed to maintain a clean and uncluttered environment in a resident room on the special care unit. Specifically, a soiled shower curtain and a bedside commode with visible brown and yellow stains were observed in room #51.

The facility failed to maintain a clean environment in one of 29 resident rooms on the special care unit. Specifically, observations revealed multiple brown and yellow stains on a bedside toilet seat and brown stains on a shower curtain.

The facility failed to maintain all plumbing equipment in a safe and operating condition. This was evidenced by an issue identified in resident room #45 on the special care unit.

The facility failed to ensure that medication administration was in accordance with physicians' orders for 6 out of 10 sampled residents. Specifically, certain residents were not receiving prescribed medications for conditions such as bacterial infections, diabetes, thyroid disease, chronic pain, kidney disease, and heart disease.

The facility failed to ensure that medication administration was in accordance with physicians' orders for 6 out of 10 sampled residents. Specifically, residents did not receive prescribed medications for conditions including bacterial infections, diabetes, thyroid disease, chronic pain, kidney disease, and mental health. For one resident, a prescribed antibiotic was not administered because the facility failed to follow up on a prescription that was sent to the wrong pharmacy.

The facility failed to ensure that medication administration was in accordance with physicians' orders for 6 out of 10 sampled residents. Specifically, certain residents were not receiving prescribed medications for conditions such as bacterial infections, diabetes, thyroid disease, chronic pain, kidney disease, and heart disease.

The facility failed to maintain hot water temperatures between 100 and 116 degrees Fahrenheit for 10 different fixtures in 9 resident rooms. Specifically, observations showed temperatures as high as 126 degrees F in resident room #2 and 122 degrees F in resident room #12.