Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Twilight Acres during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, hip fracture, and malnutrition was identified as at risk for pressure sores, but when the Braden score declined from low to moderate risk, the facility did not document additional targeted interventions to prevent pressure ulcers. The care plan contained only general skin care measures, and the clinical record lacked evidence of timely, risk-based prevention despite the increased risk level. The resident subsequently developed a left heel pressure area that progressed to an unstageable ulcer with black eschar and increasing size. The DON later stated there was no established procedure for pressure ulcer prevention and treatment during this period, contrary to NPIAP guidance on structured risk assessment and pressure offloading, including for the heels.
Inconsistent Code Status Documentation: The facility failed to keep resident code status aligned between the IPOST and EHR for multiple residents. For one resident, the care plan and EHR were blank despite DNR orders and an IPOST showing DNR; for two other residents, the IPOST showed DNR but the EHR care plan and/or physician orders did not consistently reflect it. Staff interviews showed uncertainty about who was responsible for entering code status, while the DON stated it was the nurse’s responsibility.
Failure to Offer Pneumococcal Vaccinations: The facility failed to offer pneumococcal vaccination for 5 residents reviewed. Chart review showed each resident had an older pneumococcal immunization documented, while MDS assessments reflected varying cognition, including severe impaired cognition for several residents. The facility policy required vaccination history review on admission and scheduling of missing or overdue vaccines, but the IP stated no pneumococcal clinic had been done and residents or their representatives had not been offered the updated immunizations.
PRN psychotropic orders were not limited to 14 days or documented with the required rationale and duration. A resident with dementia received PRN lorazepam for agitation across multiple months without proper order extension documentation, and another resident with dementia and anxiety had PRN alprazolam renewed without end dates in the record after staff and the consultant pharmacist requested review.
The facility failed to promptly assess and isolate two residents with respiratory symptoms. One resident with severe cognitive impairment and COPD was not isolated until hours after symptoms were noted. Another resident with a history of COVID reported symptoms but was not assessed further or isolated, and vital signs were not recorded for several days. Facility policy required immediate isolation for unexplained respiratory symptoms, which was not followed.
Failure to Escalate Pressure Ulcer Prevention After Increased Risk
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer prevention and care consistent with professional standards for one resident. The resident had severe cognitive impairment, required staff assistance for mobility and transfers, and had diagnoses including hip fracture and malnutrition. An MDS assessment documented that the resident was at risk for pressure sores but had none at that time, and the care plan identified fragile skin and the need for assistance with activities of daily living, with general interventions such as encouraging nutrition and hydration, keeping skin clean and dry, using lotion on dry skin, and monitoring/documenting skin injuries. A Braden Scale completed later showed the resident’s score had declined from 19 (low risk) to 14 (moderate risk), but the clinical record did not show that the facility identified or implemented additional interventions to address the increased pressure ulcer risk. Subsequently, progress notes documented the development of a new pressure area on the resident’s left heel, initially described as a 2 by 2 cm pressure area with black edges and a white center. Later documentation by the ARNP identified the left heel as having an unstageable pressure area with black eschar, and subsequent measurements showed the wound increasing in size to 3 by 3 cm and then 3.2 by 3 cm. Throughout this period, the record shows that the facility relied on existing care plan elements and did not document timely, risk-based preventive interventions in response to the declining Braden score. The DON reported not knowing when interventions to prevent pressure ulcers were started and stated that they did not really have a procedure to prevent or treat pressure ulcers until recently. The NPIAP guidance cited in the report emphasizes structured risk assessment and development of a plan of care based on identified risk areas, including repositioning and ensuring heels are free from pressure, which contrasts with the lack of documented, timely preventive measures in this case.
Inconsistent Code Status Documentation
Penalty
Summary
The facility failed to keep resident code status consistent between the Iowa Physician's for Scope of Treatment (IPOST) and the Electronic Health Record (EHR) for 3 of 12 residents reviewed for advance directives. Resident #23’s care plan did not indicate DNR status even though the clinical physician orders included a DNR order and the IPOST reflected DNR status. During interview, an LPN stated the code status list could not be found, the EHR was blank for that resident, and the issue may have been missed during administration changes. The LPNs interviewed stated they would look in the EHR if they needed to find a resident’s code status, and the Administrator/DON stated it was the nurse’s responsibility to enter the code status into the EHR. Resident #18’s IPOST reflected DNR status, but the clinical physician orders, base information in the EHR, and care plan lacked identification of the resident’s code status. Resident #26’s IPOST also reflected DNR status, but the clinical care plan lacked code status identification, and the clinical physician orders did not add DNR until later. An RN stated the resident code status list was printed from PCC and entered into the EHR, and the outgoing DON stated that if staff knew where to look, it could be found. The facility policy stated resident resuscitation preferences must be documented in the medical record and communicated to the physician, and that staff are responsible for ensuring these preferences are clearly visible and accessible in both the resident’s chart and care plan.
Failure to Offer Pneumococcal Vaccinations
Penalty
Summary
The facility failed to offer pneumococcal vaccination for 5 of 5 residents reviewed, identified as Residents #2, #3, #10, #11, and #24. Clinical record review showed each of these residents had documentation of a prior pneumococcal immunization, with the last recorded vaccine listed as PVC 13 on 5/16/16, 7/18/16, 4/23/15, 3/8/18, and 6/3/15, respectively. The Minimum Data Set assessments showed varying cognitive status, including severe impaired cognition for Residents #2, #10, #11, and #24, and intact cognition for Resident #3. The facility policy titled Infection Control and Prevention Plan stated that residents are to be encouraged to receive routine vaccinations, that vaccination history is to be reviewed and documented on admission, and that missing or overdue vaccinations are to be identified and scheduled. During interview, the Infection Preventionist stated the facility completed a chart audit to determine residents’ immunization status, but acknowledged that no pneumococcal clinic had been done and that residents or their representatives had not been offered or given the updated immunizations.
PRN psychotropic orders were continued without required 14-day limits
Penalty
Summary
The facility failed to ensure PRN psychotropic medication orders were limited to 14 days unless the attending physician or prescribing practitioner documented that an extension beyond 14 days was appropriate and stated the duration of the order. For Resident #7, who had severe cognitive impairment and a diagnosis of non-Alzheimer's dementia, a fax to the physician reported increased behaviors and requested a PRN medication. Lorazepam 0.5 mg every 6 hours PRN for agitation was ordered, added to the MAR, and continued through October with doses given on multiple dates without reconsideration by the provider. The record also showed outpatient psychiatric follow-up notes in November renewing the PRN lorazepam for 14-day periods, and the MAR documented additional doses in December without an extension of the order. The DON confirmed there were no additional orders related to the PRN lorazepam before it was discontinued. For Resident #24, who had severe cognitive impairment, non-Alzheimer's dementia, and an anxiety disorder, a fax to the physician reported increased anxiety and exit-seeking behaviors and asked whether something PRN would be helpful. The physician ordered Alprazolam 0.25 mg by mouth every 8 hours as needed, with one repeat dose allowed after one hour if symptoms did not improve. Later, a consultant pharmacist faxed the physician stating the alprazolam order needed review every 2 weeks for continuation and asked if it could be renewed; the physician responded to renew it. Review of the resident's medical record did not find end dates for the alprazolam orders associated with the two faxes.
Failure to Implement Timely Isolation for Respiratory Symptoms
Penalty
Summary
The facility failed to assess and provide timely interventions for two residents displaying respiratory symptoms. Resident #1, with severe cognitive impairment and diagnoses including COPD and heart failure, exhibited congestion and coughing. Despite these symptoms, isolation precautions were not initiated until the next shift, several hours after the symptoms were first noted. Staff interviews confirmed that isolation should have been implemented immediately upon recognizing the symptoms. Resident #16, with moderate cognitive impairment and a history of COVID, reported coughing, a hoarse voice, and a sore throat. Although a COVID test was negative and cough medicine was administered, the facility did not document further assessments or initiate isolation precautions. Additionally, vital signs were not recorded from the onset of symptoms until several days later. The facility's policy required immediate isolation for residents with unexplained respiratory symptoms, but this was not followed in these cases.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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How nearby facilities compare on the same public inspection record.
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| Blackhawk Life Care Center | 3 mi | — | 3 | 1 |
| Odebolt Specialty Care | 7.9 mi | ★★★★★ | 3 | 0 |
| Park View Rehabilitation Center | 11.8 mi | ★★★★★ | 12 | 0 |
| Accura Healthcare Of Carroll | 17.6 mi | ★★★★★ | 18 | 0 |
| Accura Healthcare Of Lake City, Llc | 17.6 mi | ★★★★★ | 8 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.