Twelve Oaks

Allegation investigated: Staff are verbally & physically aggressive towards residents, which can pose a risk to their health and safety. Staff do not provide the residents with privacy. Staff retaliate against residents by threatening to evict them if they complain. Staff do not provide adequate care & supervision for the residents by not meeting their incontinent needs. Staff mishandles the residents medications.

Licensing Program Analyst (LPA) Michael Cava conducted a complaint visit to the facility to investigate the above allegations. LPA met with the administrator, Denise Gotto, and advised her of the complaint. Today's investigation consisted of interviews with staff and residents, a physical plant inspection, and record review. Staff are verbally & physically aggressive towards residents, which can pose a risk to their health and safety: In regards to the allegation, it was reported that Staff 1 (S1) has been very aggressive towards residents, causing these residents to sustain an injury. At approximately 10:00am to 11:30am, LPA initiated interviews with staff and resident. In the process of these interveiws, a physical plant inspection was made to insure the health and safety of the residents in care. Interviews with staff deny the allegation of staff being verbally and physically aggressive towards residents. Interview with random residents, six of six, also deny the allegation. No residents or witnesses were identified to this allegation. Based on the information obtained through interviews, there was insufficient evidence to corroborate the above allegation. Therfore, the Unsubstantiated allegation is deemed Unsubstantiated at this time. Staff do not provide the residents with privacy: In regards to the allegation, it was reported that staff would disclose, or "gossip" about the health of residents and other staff. There were no staff or resident names identified to the allegation. According to the administrator, resident information are confidential. There hasn't been any staff caught, while on duty, providing, or causing gossip about any resident's or staff personal information. Interviews with staff deny the allegation. Interviews with residents also do not corroborate with the allegation. Based on the information obtained, there was insufficient evidence to prove that staff are disclosing personal information of residents and staff. Therefore, the allegation is deemed Unsubstantiated at this time. Staff retaliate against residents by threatening to evict them if they complain: In regards to the allegation, it was reported that if a resident complains about the administrator or staff, they would get wrongfully evicted. Interview with the administrator denies the allegation. The administrator stated there are currently no pending eviction notices that were issued. The administrator also stated that she hasn't had to issue an eviction within the last 30-60 days. Interviews with random residents also do not corroborate the allegation. Based on the information obtained, there was insufficient evidence to prove that staff retaliate against residents by threatening to evict them. Therefore the allegation is deemed Unsubstantiated at this time. Staff do not provide adequate care & supervision for the residents by not meeting their incontinent needs: In regards to the allegation, it was reported that staff would leave residents, who require diaper changes, wet for long hours. According to the administrator, approximately forty percent of the residents in care at her facility is incontinent. She stated each resident have their own assessment and care plan to address their incontinent care. The administrator denies the allegation of staff not meeting the resident's needs for incontinent care. At approximately 11:30am to 12:30pm, LPA, conducted a record review of random resident files to insure a care plan for incontinent care was in place. Furthermore, interviews with random residents, six of six, deny the allegation. Therefore, based on the information obtained, the allegation of staff not providing adequate care and supervision for the residents by not meeting their incontinent needs is deemed Unsubstantiated at this time. Staff mishandles the residents medications: In regards to the allegation, it was reported that staff do not prepare or give any medications to the residents. Interviews with random residents, six of six deny the allegation. LPA also interviewed medication staff, who also deny the allegation of staff not preparing or administering medications for the residents. Furthermore, between 11:30am to 12:30pm, LPA conducted a record review for medications and medication records and did not observe any discrepancies with any of the residents medications. Copies of these residents medication records were also obtained for record. Based on the information obtained, there was insufficient evidence to corroborate the allegation of staff mishandling the residents medications. Therefore, the allegation is deemed Unsubstantiated at this time.the state’s words, verbatim · CDSS document, Apr 3, 2023 · control 31-AS-20230329124852

Allegation investigated: Facility is not providing assistance in meeting resident's medical needs including transportation.

Licensing Program Analyst (LPA) Rosaura Valenzuela conducted an unannounced complaint investigation for the above noted allegation. LPA met with Denise Gotto, Executive Director. and discussed the purpose of the visit. It was reported that facility is not providing assistance in meeting resident's medical needs including transportation. To investigate this allegation, LPA Valenzuela conducted an unannounced visit on 04/21/2022 and between 1:45pm and 2:24pm initiated staff interviews. Staff interviews revealed that on 01/14/2022, facility E.D. sent a letter out to residents and their families indicating that complimentary transportation services would no longer be offered and that this would become effective 03/15/2022. The letter also stated that the facility can continue to arrange transportation services for the residents at the residents own expense. The facility also offered to provide a list of vendors to the residents. Continue- See 9099C Unsubstantiated At 2:32pm, LPA interviewed Resident #1 (R1). Interviews revealed that they came to the community last year. They chose the facility because E.D. told them that they provided transportation to medical appointments. E.D. informed R1 orally, but not in writing that transportation could be provided within a ten mile radius to go to medical appointments. Between 2:50pm and 3:30pm, LPA reviewed R1's admission agreement and physician's report. Documents revealed that R1 can take their own medication without assistance. R1 is also ambulatory and health status is listed as good. Review of R1's admission agreement revealed the basic service monthly fee and all other services provided. In regards to services provided as part of the monthly fee, it did not include transportation only mentioned arrangements for transportation to meet "health needs" ( i.e. doctors appointments) and planned activities within a ten mile radius could be provided. Based on the information obtained through interviews and record review this allegation is deemed to be UNSUBSTANTIATED at this time. Exit interview conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Apr 21, 2022 · control 31-AS-20220419142152

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Rosaura Valenzuela and conducted an unannounced Required 1 year infection control inspection to the facility. LPA met with the Executive Director The purpose of the visit was discussed. At 10:17am, with the assistance of the ED, LPA conducted a tour of the facility inside and out. There are two entrances being utilized at the facility, there are required posters posted at the main doors. Screening area is located immediately upon entrance. LPA was screened upon entry. The facility had submitted and approved Mitigation Plan. Signs to wear a mask and other COVID-19 prevention protocol signs were posted outside the door. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in the bathroom and all over the facility. The facility has a designated visitors' area in the patio. The facility has sufficient stock of PPE. See 809-C to continue The facility consists of 2 main buildings. One building named The Lodge houses the activity room, dinning room, and kitchen services. The assisted living is located on the top floor and the memory care unit is located on the bottom floor of Oaks Hall. The assisted living and memory care rooms have appropriate furniture. Common areas were observed to be neat and clean. The facility maintains a comfortable temperature at 78 degrees. The smoke detectors are hardwired and interconnected and observed to be operational. There are carbon monoxide detectors in the facility. Fire extinguishers are located throughout the facility and were last serviced in August of 2021. The bathrooms were checked for cleanliness and proper operation. LPA observed the appropriate grab bars in the showers and toilets. The hot water temperature was measured at 109.2 degrees F. Medications-LPA observed medications to be in the nurses station and it was locked and inaccessible to residents. There is one (01) complete first aid kit. Exit interview conducted. A copy of this report was issued and signature obtained. No deficiencies were issued at this timethe state’s words, verbatim · CDSS document, Mar 10, 2022