Inspection Reports for Twelve Oaks
1297 Galax Trail Mount Airy, NC 27030, Mount Airy, NC, 27030
Back to Facility ProfileDeficiencies (last 8 years)
Deficiencies (over 8 years)
7.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
42% worse than North Carolina average
North Carolina average: 5.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Annual Inspection
Census: 29
Deficiencies: 8
Date: Jul 17, 2025
Visit Reason
The Adult Care Licensure Section and the Surry County Department of Social Services conducted an annual survey and complaint investigation from 07/15/25 through 07/17/25.
Complaint Details
The inspection included a complaint investigation as noted in the initial comments section.
Findings
The facility was found deficient in multiple areas including housekeeping and furnishings, plumbing maintenance, health care follow-up, nutrition and food service, medication administration, self-administration of medications, and medication storage. Specific issues included unclean resident rooms, brown water from plumbing, failure to notify PCP of weight changes, incomplete meal service utensils, failure to serve therapeutic diets as ordered, medication administration errors, lack of physician orders for self-administration, and unsafe medication storage.
Deficiencies (8)
Facility failed to maintain a clean and uncluttered environment for 1 of 29 resident rooms related to a soiled shower curtain and a soiled bedside commode.
Facility failed to maintain all plumbing equipment in a safe and operating condition for 1 of 29 resident rooms due to brown water from a rusted hot water tank.
Facility failed to ensure referral and follow-up to meet health care needs for 1 of 7 sampled residents who had orders for PCP notification of weight gain but was not notified.
Facility failed to ensure residents were provided with non-disposable place settings including knives during meal service.
Facility failed to ensure therapeutic diets were served as ordered for 3 of 6 sampled residents, including failure to serve entire meal chopped or chopped meats as ordered.
Facility failed to administer medications as ordered for 4 of 7 sampled residents related to stool softener/laxative, basal insulin, depression medication, and sliding scale insulin documentation.
Facility failed to ensure 2 of 2 sampled residents had physician orders to self-administer medications including eye drops, topical cream, and nebulizer treatment.
Facility failed to ensure a resident's medication was stored safely and securely for a resident who required topical pain relief medication.
Report Facts
Resident rooms inspected: 29
Sampled residents: 7
Sampled residents: 6
Sampled residents: 7
Sampled residents: 2
Weight gain: 7.2
Medication doses missed: 41
Inspection Report
Follow-Up
Deficiencies: 0
Date: Apr 29, 2025
Visit Reason
The inspection was a Biennial Construction Follow Up Survey conducted to verify correction of previously identified deficiencies.
Findings
Deficiencies have been corrected. No further action is needed.
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Oct 30, 2024
Visit Reason
The purpose of the visit was an investigation of complaints regarding medication administration and personal care at the Twelve Oaks Adult Care Home.
Complaint Details
The investigation was triggered by complaints regarding medication administration errors and failure to provide adequate personal care to residents. The complaint was substantiated based on observations, record reviews, and interviews.
Findings
The facility failed to ensure the administration of medications in accordance with physicians' orders for 6 of 10 sampled residents and failed to provide personal care services to meet the needs of 1 of 10 sampled residents. These failures placed residents at substantial risk of physical harm and neglect, resulting in Type A2 and Type B violations.
Deficiencies (3)
Failure to ensure administration of medications in accordance with physicians' orders for 6 of 10 sampled residents.
Failure to ensure provision of personal care services to meet the needs of 1 of 10 sampled residents.
Failure to ensure provision of pharmaceutical services to meet the needs of 4 of 10 sampled residents.
Report Facts
Residents sampled with medication administration issues: 6
Residents sampled with pharmaceutical service issues: 4
Residents sampled with personal care service issues: 1
Correction date for A2 violation: Feb 6, 2025
Correction date for B violations: Feb 21, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nilda Aquino Rivera | Administrator/Designee | Signed receipt of the Corrective Action Report. |
Inspection Report
Annual Inspection
Capacity: 26
Deficiencies: 1
Date: Apr 23, 2024
Visit Reason
The Adult Care Licensure Section and the Surry County Department of Social Services conducted an annual survey on April 23-24, 2024, to assess compliance with regulations including hot water temperature requirements in the assisted living unit.
Findings
The facility failed to maintain hot water temperatures between 100 and 116 degrees Fahrenheit at 10 fixtures (9 sinks and 1 shower) in 9 residents' rooms in the assisted living unit, with temperatures observed as high as 130 degrees F. The issue was corrected during the survey by adjusting the mixing valve, and subsequent rechecks showed temperatures within the required range.
Deficiencies (1)
Failed to ensure hot water temperatures were maintained between 100 and 116 degrees Fahrenheit for 10 fixtures in residents' rooms in the assisted living unit.
Report Facts
Rooms in assisted living unit: 26
Fixtures with elevated hot water temperature: 10
Hot water temperature observed: 130
Hot water temperature recheck range: 104-112
Date of last documented hot water temperature check: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Informed about elevated hot water temperatures and responsible for contacting Corporate Regional Maintenance Director and ensuring signage placement | |
| Corporate Regional Maintenance Director (CRMD) | Assisted with adjusting hot water temperatures and monitoring the mixing valve | |
| Maintenance staff from sister facility | Discovered the mixing valve was incorrectly set to 130 degrees F and adjusted it | |
| Medication Aide (MA) | Reported no resident complaints or burns related to hot water | |
| Personal Care Aides (PCA) | Reported no recent complaints or burns due to hot water; provided bathing assistance |
Inspection Report
Follow-Up
Capacity: 112
Deficiencies: 1
Date: Apr 17, 2024
Visit Reason
This was a Construction Section Biennial Follow Up Survey conducted to verify compliance with building and safety regulations, specifically related to fire safety and equipment maintenance.
Findings
The facility was found to have deficiencies related to the fire sprinkler system, which was not maintained in a safe and operating condition due to leaks and had been taken out of service. A fire watch was implemented until repairs could be completed.
Deficiencies (1)
Fire sprinkler system was not maintained in a safe and operating condition due to leaks, affecting fire suppression capability.
Report Facts
Total licensed capacity: 112
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed regarding the fire sprinkler system condition |
Inspection Report
Capacity: 112
Deficiencies: 14
Date: Dec 7, 2023
Visit Reason
The report documents a Construction Section Biennial Survey conducted on December 7, 2023, to assess compliance with physical plant requirements, fire safety, housekeeping, electrical systems, and other regulatory standards for the adult care home.
Findings
The facility was found deficient in multiple areas including fire-resistance-rated construction, exit signage, housekeeping and maintenance, electrical safety, fire alarm and sprinkler systems, smoke resistant doors, plumbing, and exhaust ventilation. Numerous safety hazards and code violations were observed that could affect residents, staff, and visitors.
Deficiencies (14)
Failure to meet fire-resistance-rated construction requirements for rooms converted to storage with combustible items.
Lack of exit signs at required exit doors.
Walls, floors, and ceilings not kept clean and in good repair; microbial growth and organic matter observed in showers.
Building not maintained free of hazards; sharp edges and broken components present.
Bedrooms missing required individual clean towel and towel bars.
Electrical outlets in wet locations not equipped with ground fault interrupters.
Fire alarm system showing trouble signal due to duct detector problem; emergency lighting and exit signs not functioning on backup power.
Fire-resistance-rated enclosures and smoke resistant doors not maintained or blocked open, compromising fire containment.
Electrical system deficiencies including non-functioning GFCI receptacles, missing weatherproof covers, open breaker slots, and malfunctioning emergency release switches.
Fire safety equipment inspections not documented monthly as required.
Fire sprinkler heads obstructed or missing escutcheon plates, reducing effectiveness.
Plumbing fixtures not secure to the floor.
Fireplace glass enclosure hot to touch, posing burn hazard.
Exhaust ventilation systems running but not exhausting air in required spaces.
Report Facts
Total licensed capacity: 112
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Sep 23, 2022
Visit Reason
The Adult Care Licensure Section conducted an annual and follow-up survey from 09/21/22 to 09/23/22 to assess compliance with personal care, supervision, and use of restraints and alternatives.
Findings
The facility failed to provide adequate supervision for three residents resulting in multiple falls and injuries, failed to prevent elopement of a resident, and failed to ensure proper assessment and care planning for the use of bedrails as restraints for four residents. These failures resulted in serious physical harm and placed residents at risk of entanglement in bedrails.
Deficiencies (2)
Failed to provide supervision for 3 of 5 sampled residents related to falls, elopement, and injuries.
Failed to ensure documentation of assessment and care planning through a team process and attempted alternatives prior to use of restraints for 4 residents with half bedrails.
Report Facts
Residents with bedrails in Special Care Unit: 9
Residents with bedrails in Assisted Living: 21
Residents in bed with bedrails up in SCU: 2
Residents in bed with bedrails up in AL: 5
Residents in SCU: 25
Residents in AL: 30
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Oct 24, 2019
Visit Reason
The Adult Care Licensure Section conducted an annual survey on 10/23/19 through 10/24/19 to assess compliance with regulations related to care of diabetic residents and medication administration.
Findings
The facility failed to ensure that 3 of 4 staff administering insulin and obtaining blood sugars had completed required diabetic care training. Medication administration errors were identified involving incorrect or missed doses for multiple residents, including failure to administer clonazepam, incorrect vitamin D dosage, duplicate nasal spray orders, and crushing enteric coated aspirin.
Deficiencies (2)
Failed to assure 3 of 4 staff who administered insulin and obtained finger stick blood sugars completed training on care of diabetic residents prior to administration.
Failed to administer medications as ordered for multiple residents, including missed clonazepam dose, incorrect vitamin D dosage, duplicate nasal spray orders, and crushing enteric coated aspirin.
Report Facts
Medication error rate: 6
Staff sample: 4
Insulin administrations by Staff B: 4
Finger stick blood sugars by Staff B: 7
Insulin administrations by Staff E: 13
Insulin administrations by Staff F: 6
Vitamin D dosage error: 5000
Vitamin D ordered dosage: 1000
Aspirin EC dosage: 325
Aspirin chewable dosage: 81
Inspection Report
Capacity: 112
Deficiencies: 11
Date: May 16, 2018
Visit Reason
The report documents a Construction Section Biennial Survey conducted on May 16, 2018, to assess compliance with licensing rules and building codes for the facility.
Findings
Multiple deficiencies were cited including issues with housekeeping, maintenance hazards, fire safety rehearsals, building equipment safety, electrical system safety, ventilation system failures, and fire safety door malfunctions. These deficiencies require a Plan of Correction.
Deficiencies (11)
Building mechanical systems not kept clean and in good repair, including damaged gypsum walls and missing HVAC grille.
Building not maintained free of hazards due to sharp towel bar brackets, missing panic bar end cap, loose commode seat, and unsecured oxygen cylinder.
Facility failed to provide required individual towels and/or towel bars for each resident.
Fire drill rehearsals not performed regularly with at least one per shift for each quarter; no rehearsal during 3rd shift in 4th quarter of last 12 months.
Fire rated doors of hazardous or incidental areas not maintained in safe and operating condition; doors held open with permanent magnets and gaps around fire-resistance-rated assemblies.
Building emergency equipment not maintained in safe and operating condition; emergency lights dim and fire doors not closing or latching properly.
Building sprinkler system not maintained properly; dropped sprinkler escutcheon plate and abnormal pressure gauge reading.
Electrical system unsafe; use of extension cords for permanent wiring, missing breaker panel covers, missing light switch cover, and improper power tap connections.
Building not maintained to prevent insect, vermin, or weather intrusion; gate hitting slab and missing door handles.
Corridor doors not maintained in safe and operating condition; doors not latching, held open by rocks or wedges, or having gaps around handles.
Exhaust ventilation system failed to operate properly in multiple areas causing odors.
Report Facts
Licensed capacity: 112
Fire drill deficiency: 1
Fire sprinkler pressure gauge reading: 7
Inspection Report
Capacity: 112
Deficiencies: 14
Date: Apr 26, 2016
Visit Reason
Biennial Construction Survey conducted to assess compliance with the 1996 Rules for Licensing of Adult Care Homes and applicable building codes.
Findings
Multiple deficiencies were identified including fire alarm system failures, broken furniture handles, improper storage near fire sprinkler heads, unsafe handling of oxygen cylinders, malfunctioning emergency lights, fire door issues, compromised fire-rated walls and ceilings, dirty smoke detector sampling tubes, broken electrical conduit, and an exit door lock that was missing and posed a safety risk.
Deficiencies (14)
Fire alarm panel listed for recall and smoke detector failed to activate fire alarm system.
Broken or missing handles on chests of drawers in multiple resident rooms.
Improper storage too close to fire sprinkler heads in supply storage and activity office.
Portable medical oxygen cylinder stored without rack or container in room 44.
Shower wand hose in Beauty Salon lacked vacuum breaker, risking water contamination.
Corridor smoke detector near room 11 activated but failed to trigger fire alarm system.
Several battery powered emergency lights malfunctioned in dining and memory care areas.
Many corridor doors failed to close and latch properly, compromising fire and smoke barriers.
One-hour fire rated walls and ceilings compromised by holes, gaps, and damaged areas in multiple locations.
Missing or improperly fitting sprinkler escutcheons in fire rated ceilings.
Dirty sampling tubes for duct mounted smoke detectors in attic at units 6 and 14.
Broken flexible electrical conduit in attic near AHU 14 (corrected onsite).
Exterior portion of latch missing on exit door near room 60.
Exit door lock to smoking porch was locked, blocking safe egress; facility agreed to remove lock immediately.
Report Facts
Licensed capacity: 112
Rooms with broken or missing drawer handles: 7
Malfunctioning emergency lights: 3
Rooms with fire door latch issues: 7
Inches storage clearance from ceiling: 5
Inches storage clearance from ceiling: 4
Gap between smoke barrier doors: 0.375
Inspection Report
Follow-Up
Deficiencies: 1
Date: May 7, 2015
Visit Reason
The Adult Care Licensure Section and the Surry County Department of Social Services conducted a follow-up survey on May 6th and 7th, 2015 to verify correction of previous deficiencies related to therapeutic diets and supplements.
Findings
The facility failed to assure therapeutic diets and supplements were served as ordered by a licensed prescribing practitioner for 3 of 3 sampled residents with orders for no added salt (NAS) diets and 1 of 4 sampled residents with an order for a nutritional supplement. Salt packets were found on dining tables despite NAS diet orders, and a resident with an order for diabetic health shakes had not been offered or administered the supplement. The facility provided a plan of correction to remove salt packets and improve staff training.
Deficiencies (1)
Failed to assure therapeutic diets and supplements were served as ordered by a licensed prescribing practitioner for residents with NAS diets and nutritional supplements.
Report Facts
Residents with NAS diet orders not served properly: 3
Residents with nutritional supplement orders not served properly: 1
Weight measurements for Resident #4: 133.6
Weight measurements for Resident #4: 136
Weight measurements for Resident #4: 132
Salt packets observed on dining tables: 5
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Jan 6, 2015
Visit Reason
The Adult Care Licensure Section and the Surry County Department of Social Services conducted an annual survey and revisit on January 6-7, 2015.
Findings
The facility failed to assure therapeutic diets were served as ordered for 5 of 11 sampled residents and failed to implement infection control procedures consistent with CDC guidelines regarding the use of 'house' glucometers for multiple residents.
Deficiencies (2)
Failed to assure therapeutic diets of House Renal and No Concentrated Sweets (NCS) diet orders for 5 of 11 sampled residents were served as ordered.
Failed to implement infection control procedures consistent with CDC guidelines on infection control regarding the use of 'house' glucometers for multiple residents.
Report Facts
Number of sampled residents with diet deficiencies: 5
Number of glucometer readings on MCU house glucometer: 25
Milk ordered per week: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Interviewed regarding diet orders and milk supply | |
| Administrator | Interviewed regarding oversight of diet and infection control | |
| Memory Care Coordinator | Interviewed regarding glucometer cleaning procedures | |
| Resident Care Coordinator | Interviewed regarding glucometer use and cleaning | |
| Medication Aides | Interviewed regarding glucometer disinfection practices | |
| Personal Care Aides | Interviewed regarding meal service and beverage provision | |
| Dietary Aides/Cooks | Interviewed regarding meal preparation and diet compliance |
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