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Deficiency Records for Twilight Acres

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.

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

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