Twilight Acres

In the surveyor’s words

From the most serious findings on record at Twilight Acres, in the surveyor’s own words.

• Immediate jeopardy, widespreadF880Aug 2, 2022

  Based on observations, interviews and record review the facility failed to implement adequate infection control strategies and practices to mitigate the transfer of viruses for 7 of 29 residents reviewed. In a series of observations on 7/25/22 and 7/26/22 it was discovered that residents that tested positive and negative for novel Coronavirus 2019 (COVID) remained in the same hallway, and many times had their bedroom doors left open. An observation showed staff not wearing full Personal Protective Equipment (PPE) when administering a nasal COVID test to a symptomatic resident, staff wore surgical masks improperly, and a symptomatic resident did not have isolation precautions and later tested positive for COVID. The facility reported a census of 28 residents. […]

• Actual harm, isolatedF689Sep 6, 2022

  Based on observations, clinical record reviews, facility policy review, and staff interviews the facility failed to adequately supervise and implement interventions to prevent falls for 1 of 3 residents (Resident #1) reviewed. On 8/24/22 staff found Resident #1 on the floor in the resident's room with increased complaints of right hip pain. Resident #1 required a transfer to the hospital and surgical repair of a right hip fracture. The facility reported a census of 28 residents. Findings include: The Minimum Data Set (MDS) assessment for Resident #1 dated 8/29/22, identified a Brief Interview for Mental Status (BIMS) score of 2, indicating severe cognitive impairment. […]

• Actual harm, isolatedF689Feb 11, 2021

  Based on observation, record review, and staff interview, the facility failed to assure they implemented appropriate safety measures during transfer with a mechanical lift for 1 of 3 residents reviewed (Resident #1) resulting in a fall with a major injury. The facility reported a census of 29 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #1 scored 0 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. The resident depended on staff for activities of daily living (ADL's) including bed mobility, transfer, toilet use, personal hygiene and dressing. […]

• No harm, potential for more than minimal, patternF578Dec 18, 2025

  Based on clinical record review and staff interview, the facility failed to ensure a consistent code status between the IowaPhysician's for Scope of Treatment (IPOST), and the Electronic Health Record (EHR) for 3 of 12 resident reviewed for advanceddirectives (Resident #18, #23 and #26). The facility reported a census of 26 residents. Findings include: 1.The Care Plan initiated date of [DATE] failed to indicate Resident #23 desired to be a do not resuscitate (DNR) per his IPOST. The Clinical Physician Orders reviewed on [DATE] included an order dated [DATE] for Resident #23 to be DNR. Review of Resident #23's IPOST dated [DATE] reflected she desired a DNR status. Interview on [DATE] at 4:00 p.m. […]

• No harm, potential for more than minimal, patternF883Dec 18, 2025

  Based on clinical record review, staff interviews and policy review, the facility failed to offer to provide pneumococcal vaccine for 5 of 5 residents reviewed for Resident #2, #3, #10, #11, and #24. The facility reported a census of 26 residents. Findings include: 1)The Minimum Data Set (MDS) dated for 10/23/25, Resident #2 had a Brief Interview for Mental Status (BIMS) score not completed noting severe impaired cognition. Review of the immunization tab in the electronic health record revealed the last Pneumococcal Immunization was the PVC 13 on 5/16/16. 2) The Minimum Data Set (MDS) dated for 9/18/25, Resident #3 had a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. […]