Inspection visit
Fire Safety inspection
Citations
19 citations recorded*CMS
This is a Fire Safety survey. CMS cites these findings under the Life Safety Code and Emergency Preparedness rules, a separate set from the health (F-tag) deficiencies. The codes and grading differ, so these do not link to the health violation pages.
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
- 0004GeneralS&S Fpotential for harm
Develop and maintain an Emergency Preparedness Program (EP).
- 0006GeneralS&S Fpotential for harm
Conduct risk assessment and an All-Hazards approach.
- 0007GeneralS&S Fpotential for harm
Address patient/client population and determine types of services needed.
- 0025GeneralS&S Fpotential for harm
Create arrangements with other facilities to receive patients.
- 0030GeneralS&S Fpotential for harm
List the names and contact information of those in the facility.
- 0039GeneralS&S Fpotential for harm
Conduct testing and exercise requirements.
- 0161GeneralS&S Fpotential for harm
Use approved construction type or materials.
- 0271GeneralS&S Fpotential for harm
Have exits that are accessible at all times.
- 0293GeneralS&S Fpotential for harm
Have properly located and lighted "Exit" signs.
- 0324GeneralS&S Fpotential for harm
Provide properly protected cooking facilities.
- 0345GeneralS&S Fpotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
- 0353GeneralS&S Fpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0355GeneralS&S Fpotential for harm
Properly select, install, inspect, or maintain portable fire extinguishes.
- 0363GeneralS&S Fpotential for harm
Install corridor and hallway doors that block smoke.
- 0712GeneralS&S Fpotential for harm
Have simulated fire drills held at unexpected times.
- 0920GeneralS&S Fpotential for harm
Ensure proper usage of power strips and extension cords.
- 0926GeneralS&S Fpotential for harm
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
- 0781GeneralS&S Fpotential for harm
Have restrictions on the use of portable space heaters.
- 0918GeneralS&S Fpotential for harm
Have generator or other power source capable of supplying service within 10 seconds.
FAQ · About this visit
Common questions about this visit
What happened during the December 18, 2025 survey of Twilight Acres?
This was a inspection survey of Twilight Acres on December 18, 2025. The surveyor cited 19 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at Twilight Acres on December 18, 2025?
Yes, 19 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Develop and maintain an Emergency Preparedness Program (EP)."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.