A list of the most recent deficiencies for Twilight Acres. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-10-26 | 2023-10-26 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-10-26 | 2023-10-26 | N |
| Meet requirements for the use and maintenance of medical gas equipment. | Fire Safety | 2023-10-26 | 2023-10-26 | N |
| Assess the resident when there is a significant change in condition | Health | 2023-10-19 | 2023-10-20 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2023-10-19 | 2023-10-20 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-06 | 2022-09-07 | Y |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2022-08-02 | 2022-08-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-08-02 | 2022-08-19 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-08-02 | 2022-08-19 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-08-02 | 2022-08-19 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-08-04 | 2022-08-15 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-08-04 | 2022-08-15 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-08-04 | 2022-08-15 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-08-04 | 2022-08-11 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-08-04 | 2022-08-05 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-08-04 | 2022-08-05 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-08-04 | 2022-08-05 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2022-08-04 | 2022-08-04 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-08-12 | 2021-09-02 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2021-08-12 | 2021-09-02 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-08-12 | 2021-09-02 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-08-12 | 2021-09-02 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-08-19 | 2021-08-30 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2021-08-19 | 2021-08-30 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-08-19 | 2021-08-30 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-08-19 | 2021-08-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-08-19 | 2021-08-24 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-08-19 | 2021-08-23 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-08-19 | 2021-08-23 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-08-19 | 2021-08-23 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2021-08-19 | 2021-08-19 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-08-19 | 2021-08-19 | N |
