F 0640
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Level of Harm - Minimal harm
or potential for actual harm
Based on interview and record review, the facility failed to ensure assessments were successfully
transmitted within 14 days of completion for 1 (R9) of 12 residents reviewed for assessments in the sample
of 22.
Residents Affected - Few
Findings Include:
R9's admission Record documented an initial admission date to the facility as 12/20/2018. Diagnoses
included, but were not limited to: unspecified dementia, dysphagia, type 2 diabetes mellitus, seizures,
macular degeneration, etc.
Review of R5's Minimum Data Set, dated (MDS) 7/29/23, documented the type of assessment as being a
reporting entry for death in facility. This same assessment documented the discharge date for R9 in section
A2000 as 07/29/2023.
On 01/03/24 at 02:40 PM, V5 (Medical Records) stated the death in facility MDS was completed on for R9
on 7/29/23. In reviewing the electronic record, V5 stated the MDS although complete, was inadvertently not
submitted. V5 stated she will get the document submitted today.
Review of CMS (Centers for Medicare & Medicaid Services) MDS NH (Nursing Home) Final Validation
Report documented completed submission of R9's 7/29/23 assessment on 1/3/24.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
146070
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
146070
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/05/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Twin Willows Nursing Center
1600 North Broadway
Salem, IL 62881
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0677
Provide care and assistance to perform activities of daily living for any resident who is unable.
Level of Harm - Minimal harm
or potential for actual harm
Based on interview and record review the facility failed to offer/provide showers for 2 of 12 (R136 and
R137) residents reviewed for showers in a sample of 22.
Residents Affected - Few
The Findings Include:
1. R137's admission record documents an admission date of 12/28/23 with diagnoses including heart
failure and unspecified osteoarthritis.
R137 does not yet have a completed Minimum Data Set, but R137 was alert to person, place, and time
during the interview on 1/3/24 at 10:00 AM.
R137's baseline care plan dated 12/28/23 documents she is dependent for showers.
On 1/3/24 at 10:00 AM, R137 stated she has not had a shower since admission, and they changed her out
of her pajamas at 4AM and put her clothes on from the previous day. R137 stated at this time she would
like to have clean clothes on daily and to not get too close because she likely smells. R137 stated she has
not asked for a shower, but assumes it is in the plan soon.
On 1/3/24 at 2:41 PM, R137 stated she has never received a bed bath. R137 stated she recalls receiving a
washcloth one time and that is what she used to wash her hands since admission.
2. R136's admission record documents 12/21/23 as an admission date with a principle diagnosis of fracture
of unspecified part of the scapula, left shoulder and other diagnoses including: anemia, dementia,
depressive disorder, anxiety, and rheumatoid arthritis. R136 does not have a Minimum Data Set completed
due to being a new admission, thus no Brief Interview of Mental Status is completed. R136 was alert to
person and place at the time of the interview on 1/3/24.
On 01/03/24 at 12:38 PM, R136 stated she has not had a shower since she got here.
On 01/03/24 at 2:29 PM, V1 (Administrator) stated all residents start at a base of 1 shower a week and then
per preference or situation they can get more. The current shower sheets documents Saturdays are shower
day for R136, and she refused a shower on 12/30/23. The next scheduled shower day is 1/6/24.
R136's baseline care plan dated 12/21/23 documents CNA's (Certified Nursing Assistant's) are to shower
R136.
On 1/3/24 at 2:27 PM, V3 (Certified Nurse Assistant) (CNA) stated R137 is not yet on the shower sheet
because she is a new admission. V3 stated she would have V1 (Administrator) add R137's name to the
schedule and she will be getting a shower tomorrow because she is getting her hair fixed in the beauty
shop. V3 stated R136, per the shower record, refused her shower on 12/30/23 and is not due for her next
one until 1/6/24. V3 stated residents should get a bed bath after breakfast daily but is not documented.
On 1/3/24 at 3:03PM, V2 (Registered Nurse) stated R136 and R137 would both be dependent for activities
of daily living including showers, toileting, and transfers.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146070
If continuation sheet
Page 2 of 2
