Cycle 1
Health 2025-01-16 · Fire 2025-01-16
12 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Salem, IL
Twin Willows Nursing Center
3-star overall rating with 4-star inspections with 12 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
1600 North Broadway, Salem, IL
(618) 548-0542
Overall
3 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
72
Certified beds
Average residents
24
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2004-10-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.53
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.88
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.64
Nurse aide staffing · state 2.13 · national 2.35
Total nurse hours
4.05
All reported nurse hours · state 3.49 · national 3.89
Licensed hours
1.41
RN + LPN hours · state 1.36 · national 1.54
Weekend hours
3.76
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.35
Weekend registered nurse coverage · state 0.56 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.62
CMS adjusted RN staffing hours
Adjusted total hours
4.74
CMS adjusted total nurse staffing hours
Case-mix index
1.17
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
39%
Annual nurse turnover · state 46% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,208
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
45.48
Composite VBP score used to determine payment impact.
Payment multiplier
0.9987
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
6.41
Baseline 13.79% · Performance 37.50% · Measure score 6.41 · Achievement 6.41 · Improvement 0
Adjusted total nurse staffing
2.69
Baseline 4.14 hours · Performance 3.84 hours · Measure score 2.69 · Achievement 2.69 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.1% |
10.72%
0.6 pts better
|
No Different than the National Rate · Eligible stays 33 · Observed rate 6.06% · Lower 95% interval 6.52% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 23 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 0.99 |
1.02
About the same
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 1 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 16 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 4.17% |
8.2%
4 pts worse
|
Numerator 2 · Denominator 48 |
| Staff flu vaccination coverage | 27.08% |
42%
14.9 pts worse
|
Numerator 13 · Denominator 48 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.5 |
2.0
0.5 pts better
|
1.9
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.6 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.9 |
2.3
0.6 pts worse
|
1.8
1.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.9 · Observed 3.3 · Expected 1.9 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
89.6%
10.4 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 92.9% |
91.6%
1.3 pts better
|
95.5%
2.6 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 92.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
3.3%
3.3 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 8.5% |
50.3%
41.8 pts better
|
11.4%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 4.5% · Q3 16.7% · Q4 9.1% · 4Q avg 8.5% |
| Percentage of long-stay residents who lose too much weight | 0.0% |
6.5%
6.5 pts better
|
5.4%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 24.4% |
18.5%
5.9 pts worse
|
19.6%
4.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.3% · Q2 21.7% · Q3 14.3% · Q4 27.3% · 4Q avg 24.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 14.3% |
22.8%
8.5 pts better
|
16.7%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 20.0% · 4Q avg 14.3% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 37.6% |
17.2%
20.4 pts worse
|
16.3%
21.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 37.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 24.4% |
15.0%
9.4 pts worse
|
14.9%
9.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.8% · Q2 23.8% · 4Q avg 24.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.0% |
1.1%
1.9 pts worse
|
1.0%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 0.0% · Q3 4.7% · Q4 2.3% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 5.8% |
1.7%
4.1 pts worse
|
1.7%
4.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 0.0% · Q3 7.7% · Q4 12.0% · 4Q avg 5.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 13.5% |
21.3%
7.8 pts better
|
19.8%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.6% · Q2 12.4% · Q3 7.1% · Q4 18.9% · 4Q avg 13.5% |
| Percentage of long-stay residents with pressure ulcers | 6.4% |
5.2%
1.2 pts worse
|
5.1%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.0% · Q2 0.0% · Q3 6.1% · Q4 6.7% · 4Q avg 6.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.2% |
68.8%
27.4 pts better
|
81.7%
14.5 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 96.2% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-05 · Fire 2024-01-05
3 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
8 fire-safety deficiencies
Top issue: Emergency Preparedness (4 deficiencies)
Cycle 3
Health 2022-12-15 · Fire 2022-12-15
2 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
4 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-01-16
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2025-01-14
F · Potential for more than minimal harm
2025-01-16
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2025-01-14
F · Potential for more than minimal harm
2025-01-16
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-02-13
F · Potential for more than minimal harm
2025-01-16
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2025-01-13
F · Potential for more than minimal harm
2025-01-16
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-02-17
F · Potential for more than minimal harm
2025-01-16
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2025-01-13
F · Potential for more than minimal harm
2025-01-16
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2025-01-13
E · Potential for more than minimal harm
2025-01-16
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-01-20
F · Potential for more than minimal harm
2024-01-05
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2024-03-22
F · Potential for more than minimal harm
2024-01-05
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2024-03-22
F · Potential for more than minimal harm
2024-01-05
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-03-22
F · Potential for more than minimal harm
2024-01-05
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2024-03-22
F · Potential for more than minimal harm
2024-01-05
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2024-03-22
F · Potential for more than minimal harm
2024-01-05
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2024-03-22
E · Potential for more than minimal harm
2024-01-05
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-03-22
E · Potential for more than minimal harm
2024-01-05
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-03-22
F · Potential for more than minimal harm
2022-12-15
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-02-28
F · Potential for more than minimal harm
2022-12-15
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-01-27
F · Potential for more than minimal harm
2022-12-15
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2023-01-27
F · Potential for more than minimal harm
2022-12-15
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2023-01-27
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-01-16
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-02-13
F · Potential for more than minimal harm
2025-01-16
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2025-02-13
E · Potential for more than minimal harm
2025-01-16
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-02-13
D · Potential for more than minimal harm
2025-01-16
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-02-05
D · Potential for more than minimal harm
2025-01-16
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-02-06
D · Potential for more than minimal harm
2025-01-16
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-02-07
D · Potential for more than minimal harm
2025-01-16
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-02-06
D · Potential for more than minimal harm
2025-01-16
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-02-06
D · Potential for more than minimal harm
2025-01-16
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2025-01-31
D · Potential for more than minimal harm
2025-01-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-07
D · Potential for more than minimal harm
2025-01-16
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2025-02-13
C · Minimal harm
2025-01-16
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2025-01-18
F · Potential for more than minimal harm
2024-07-08
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-07-09
D · Potential for more than minimal harm
2024-01-05
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2024-01-24
D · Potential for more than minimal harm
2024-01-05
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-01-24
D · Potential for more than minimal harm
2022-12-15
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-02-28
D · Potential for more than minimal harm
2022-12-15
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-02-28
Penalties and ownership
What sits behind the stars
Ownership
Woodruff, Helen
5% Or Greater Direct Ownership Interest · Individual
Woodruff, Jeffrey
5% Or Greater Direct Ownership Interest · Individual
Woodruff, Jeffrey
Corporate Director · Individual
Woodruff, Jeffrey
Corporate Officer · Individual
Woodruff, Todd
Operational/Managerial Control · Individual
Woodruff, Todd
Corporate Director · Individual
Woodruff, Todd
Corporate Officer · Individual
Nearby options
Other facilities in reach
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Doctors Nursing & Rehab Center
Salem, IL
1-star overall rating with 3-star inspections with $67,088 in total fines with 6 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Odin Health And Rehab Center
Odin, IL
1-star overall rating with 1-star inspections with abuse icon flag with $176,517 in total fines with 22 recent health deficiencies with 22 fire-safety deficiencies in the latest cycle
#3
Centralia Manor
Centralia, IL
2-star overall rating with 2-star inspections with $98,011 in total fines with 15 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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