Inspection·July 8, 2024

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation interview and record review the facility failed to store food in accordance with professional standards for food service safety. This failure has the potential to affect all 29 residents currently residing at the facility. Findings Include: The facility Wing Group Assignments provided to this surveyor on 7/6/24 documents 29 residents currently reside at the facility. On 7/6/24 at 9:26 AM, V2 (Director of Nurses) stated the facility freezer went down and they moved all of the food off premises to a dedicated freezer in a secure place at V2's house. V2 stated they maintain the temperature of the freezer. V2 was unable to provide this surveyor with reproducible evidence the temperature of the freezer/food was maintained per current standards of practice. On 7/6/24 at 10:06 AM, V4 (Cook) stated they don't have a working freezer at the facility. V4 stated the unit went down about two weeks ago. V5(Dietary Aid/Cook) stated V2 is taking the food to her house to store in a freezer and she brings the food they need to the facility each day. V4 stated they check the temperatures every AM and the food is frozen when it gets to the facility from V2's house. On 7/6/24 at 10:08 AM, V5 stated the freezer went out a couple of weeks ago. V5 stated the temperature started going up so they called V2 (DON) and she took the food to her house. V5 stated the food in the freezer did not thaw out before it was transported to V2's house. V5 stated V2 brings them what they need each day and the food is frozen when it gets to the facility. On 7/6/24 at 10:13 AM, V6 (Dietary Manager) stated the freezer went out and they had someone come in and look at it. V6 stated it worked for a couple of days then went out again. V6 stated they checked the food temperature and it remained frozen. V6 stated V2 took the food to her house to store until they can get it fixed. V6 stated she gives V2 a list of what she needs each day and V2 brings it to the facility. On 7/8/24 at 12:26 PM, V3 (Maintenance Director) stated the freezer went out and he called in a local repairmen to look at it. V3 stated they have ordered the part to fix it and it should be here on Wednesday, 7/10/24. The facility Food Storage (Dry/Refrigerated/Frozen) policy dated 2009 documents under Frozen storage guidelines to be followed: Keep freezer at a temperature that ensures products will remain frozen (continued on next page) 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 07/08/2024 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)