Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
TWIN WILLOWS NURSING CENTER
SALEM, IL · 72 certified beds · Last Life Safety survey January 16, 2025
CMS Certification Number 146070 · first certified October 2004
Ownership
Independently operated (no chain recorded by CMS) · For profit - Corporation
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within IL
20 citations — more than 64% of the 666 certified nursing homes in IL. Compared within IL rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 8 citations; the earlier surveys in the window averaged 6. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
Well past the typical window (December 2025 to February 2026), and past the point by which nine in ten IL facilities have been surveyed. This facility’s last Life Safety survey was January 2025. Facilities in IL are typically surveyed 11–13 months after the last one (median 12), measured over 759 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
Get an email about TWIN WILLOWS NURSING CENTER
One email when it happens. No account; stop it any time with one click.
1 inspection-and-testing tag has been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
10 of the 20 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
7 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 20 Life Safety citations above. The Physical Environment Index
- F-0584 Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F-0880 Provide and implement an infection prevention and control program.
- F-0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
How that compares
Compared with the median facility in IL, and nationally. Surveyors differ markedly between states, so the IL figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 20 |
| Median facility in IL | 15 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| December 15, 2022 | 4 |
| January 5, 2024 | 8 |
| January 16, 2025 | 8 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| E-0039 | Conduct testing and exercise requirements. | 3 | 2025-01-16 |
| K-0354 | Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | 3 | 2025-01-16 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 2 | 2025-01-16 |
| K-0346 | Follow proper procedures when the fire alarm was out of service for more than 4 hours. | 2 | 2025-01-16 |
| E-0015 | Address subsistence needs for staff and patients. | 2 | 2025-01-16 |
| K-0363 | Install corridor and hallway doors that block smoke. | 1 | 2025-01-16 |
| E-0006 | Conduct risk assessment and an All-Hazards approach. | 1 | 2024-01-05 |
| E-0026 | Establish roles under a Waiver declared by secretary. | 1 | 2024-01-05 |
What the citations cover
- Emergency Preparedness Deficiencies 10
- Smoke Deficiencies 9
- Miscellaneous Deficiencies 1
| Category | Citations |
|---|---|
| Emergency Preparedness Deficiencies | 10 |
| Smoke Deficiencies | 9 |
| Miscellaneous Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
January 16, 2025 — 8 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0015 | Address subsistence needs for staff and patients. | Deficient, Provider has date of correction (January 14, 2025) |
| E-0037 | Establish staff and initial training requirements. | Deficient, Provider has date of correction (January 14, 2025) |
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (February 13, 2025) |
| K-0346 | Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Deficient, Provider has date of correction (January 13, 2025) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (February 17, 2025) |
| K-0354 | Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Deficient, Provider has date of correction (January 13, 2025) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (January 20, 2025) |
| K-0711 | Provide a written emergency evacuation plan. | Deficient, Provider has date of correction (January 13, 2025) |
January 5, 2024 — 8 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0006 | Conduct risk assessment and an All-Hazards approach. | Deficient, Provider has date of correction (March 22, 2024) |
| E-0015 | Address subsistence needs for staff and patients. | Deficient, Provider has date of correction (March 22, 2024) |
| E-0026 | Establish roles under a Waiver declared by secretary. | Deficient, Provider has date of correction (March 22, 2024) |
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (March 22, 2024) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (March 22, 2024) |
| K-0346 | Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Deficient, Provider has date of correction (March 22, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (March 22, 2024) |
| K-0354 | Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Deficient, Provider has date of correction (March 22, 2024) |
December 15, 2022 — 4 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (January 27, 2023) |
| E-0007 | Address patient/client population and determine types of services needed. | Deficient, Provider has date of correction (January 27, 2023) |
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (February 28, 2023) |
| K-0354 | Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Deficient, Provider has date of correction (January 27, 2023) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.