Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Twin Willows Nursing Center during CMS and state inspections, most recent first.
The facility failed to prevent cross-contamination during meal service, as CNAs delivered drinks by the rims of glasses after touching various surfaces without hand hygiene. Drinks were also served uncovered, contrary to proper protocols, affecting all 24 residents.
The facility failed to maintain a clean and accessible environment, with observations of dirt, mildew, and blocked access in shower rooms and hall bathrooms. Housekeeping staff acknowledged persistent cleanliness issues, and the DON was unaware of an environmental cleaning policy. These deficiencies potentially affect all 24 residents.
The facility failed to ensure call lights were within reach for several residents, including those with cognitive impairments and histories of falls. Observations revealed call lights were often placed out of reach, compromising residents' ability to request assistance. Staff interviews confirmed the expectation for call lights to be accessible, yet this was not consistently achieved.
A resident with severe cognitive impairment and significant assistance needs was left to eat without immediate help, leading her to use her fingers to eat. Despite the care plan requiring substantial assistance, staff interviews confirmed the resident's meal tray should not have been placed in front of her without someone available to assist, compromising her dignity.
A facility failed to investigate a bruise of unknown origin on a cognitively impaired resident with progressive supranuclear ophthalmoplegia. The resident had a dark purple bruise on the right buttocks, with no pain or discomfort reported. Despite notifying the POA and doctor, no investigation was conducted, contrary to the facility's policy requiring prompt investigation of such injuries.
A resident with multiple health conditions, including diabetes and obesity, was at risk of developing pressure ulcers. Despite a care plan requiring zinc oxide application to the left hip, there was no documentation of treatment in January. Observations showed confusion among staff about treatment responsibilities, leading to inconsistent care and worsening of the resident's condition.
The facility failed to implement effective fall prevention measures for three residents with cognitive impairments, leading to multiple falls and injuries. Care plans were not consistently updated with new interventions, and call lights were often out of reach, contributing to the risk of falls.
A resident with multiple diagnoses, including Parkinsonism and Alzheimer's, experienced significant weight loss, dropping from 178 to 158 pounds. The facility failed to follow its policy for managing weight loss, as there was no referral to a dietician or implementation of nutritional supplements. The dietary manager did not receive weight loss information, and the LPN confirmed the facility's inaction in addressing the resident's weight loss.
A resident with dementia frequently wandered into other residents' rooms, causing distress, without a care plan addressing this behavior. Staff removed the resident multiple times, but the facility lacked behavior tracking for wandering, as confirmed by the DON.
A resident with a history of incontinence and other medical conditions received improper incontinent care from CNAs who failed to follow infection control protocols. The CNAs did not perform hand hygiene before donning gloves, did not change gloves appropriately, and touched the resident's skin and linens with contaminated gloves. The DON observed the incident and instructed the CNAs, but hand hygiene was still not performed as required by the facility's policy.
A resident with a history of multiple health issues was prescribed a Z-pak for bronchitis without proper diagnostic confirmation, such as a culture or x-ray. The facility's documentation was insufficient, with no notes on respiratory symptoms between late December and early January, and the care plan lacked a section for respiratory concerns. The DON admitted to the absence of necessary follow-up documentation after antibiotic administration, leading to a deficiency in antibiotic stewardship.
The facility failed to post current daily nurse staffing data, affecting all 24 residents. On several occasions, the postings were outdated or incorrect, with one instance showing a future date and another showing a past date. A staff member acknowledged the oversight, indicating it was likely missed. The facility's form confirmed 24 residents were present.
The facility failed to store food according to professional standards after their freezer malfunctioned, affecting all 29 residents. The Director of Nurses moved the food to her house, but could not provide evidence of proper temperature maintenance. The facility's policy requires off-site storage in a Public Health Certified area, which was not followed.
Cross-Contamination of Drinking Glasses During Meal Service
Penalty
Summary
The facility failed to prevent cross-contamination of drinking glasses during meal service, affecting all 24 residents. On multiple occasions, a Certified Nurse Aide (CNA) delivered drinks to residents by holding the rims of the glasses, which is where residents drink from. This occurred after the CNA had touched various surfaces, including the kitchen door, drink cart handle, her jeans, and wheelchair handles, without performing any hand hygiene. Additionally, drinks were delivered uncovered from a cart, further increasing the risk of contamination. The Dietary Manager and a dietary staff member acknowledged that drinks should not be handled by the rims and should be covered when transported. Despite this understanding, the drinks were not covered, and the improper handling continued over several days. The lack of adherence to proper food handling protocols was observed and confirmed through interviews with staff, highlighting a systemic issue in the facility's meal service procedures.
Facility Fails to Maintain Clean and Accessible Environment
Penalty
Summary
The facility failed to maintain a safe, sanitary, and clean environment for its residents, as evidenced by multiple observations of unclean and obstructed areas. In the shower rooms on the 200 and 400 halls, there was a significant accumulation of dirt, mildew, and a black substance along the edges between the floor and walls, as well as missing tiles. Toilets in these areas had visible dirt and black rings, and access to handwashing sinks was blocked by large linen barrels and trash cans. Additionally, a resident's handwashing sink was found to drain extremely slowly, taking nearly nine minutes to empty, which the resident had previously reported to the facility. Housekeeping staff acknowledged the persistent issues with cleanliness, stating that the shower rooms always appear dirty despite cleaning efforts, and that there is no housekeeping staff available in the evenings. The Director of Nursing was unaware of the existence of an environmental cleaning policy, indicating a lack of structured procedures for maintaining cleanliness. These deficiencies have the potential to affect all 24 residents living in the facility, as the shower rooms and hall bathrooms are shared by multiple residents.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that call lights were within reach for six out of seven residents reviewed for call lights. This deficiency was observed through multiple instances where residents with varying degrees of cognitive and physical impairments were unable to access their call lights. For example, Resident 19, who has severe cognitive impairment and a history of falls, was found with call lights out of reach on multiple occasions, leading her to express concerns about having to crawl to the bathroom without assistance. Similarly, Resident 5, with moderate cognitive impairment and a history of falls, was observed with call lights under the bed covers and wrapped around a wall light, both out of reach. Resident 21, who has severe cognitive impairment and a history of falls, was also found with call lights on the floor behind a recliner, not accessible to him. These observations indicate a pattern of neglect in ensuring that residents have access to call lights, which are crucial for their safety and ability to request assistance. Additional residents, including Resident 24, who has Parkinsonism and Alzheimer's disease, and Resident 11, with Parkinson's disease, were also found without call lights within reach. Resident 1, who is cognitively intact but has physical limitations, was observed with a call light five feet away on the floor, leading her to express that reaching it would be challenging. Interviews with staff, including the Director of Nursing and Certified Nurse Assistants, confirmed that call lights should be within reach of all residents, yet this standard was not consistently met, as evidenced by the observations and resident statements.
Failure to Assist Resident with Eating Compromises Dignity
Penalty
Summary
The facility failed to promote dignity for a resident with severe cognitive impairment and significant assistance needs during meal times. The resident, diagnosed with unspecified dementia and other conditions, was observed attempting to eat with her fingers after her meal tray was placed in front of her without immediate assistance. Despite the care plan indicating that the resident requires substantial to maximal assistance with eating, the tray was left unattended, leading the resident to use her hands to eat, which compromised her dignity. Staff interviews confirmed that the resident should not have been left to eat without assistance, as she is dependent on staff for eating. The Director of Nursing and a Certified Nurse Assistant both acknowledged that the resident's food should not have been placed in front of her without someone available to assist, highlighting a lapse in following the care plan and ensuring the resident's dignity during meals.
Failure to Investigate Bruise of Unknown Origin
Penalty
Summary
The facility failed to investigate a bruise of unknown origin for a resident diagnosed with progressive supranuclear ophthalmoplegia, who was severely cognitively impaired with a BIMS score of 2. The resident's nurse's note documented a dark purple bruise on the right buttocks, measuring 5.5 cm by 4.5 cm, with no open areas or edema, and the resident denied any pain or discomfort. Despite notifying the power of attorney and the doctor, no new orders were given. The Director of Nursing acknowledged the lack of further information or investigation into the injury, despite it being mentioned in a meeting. The facility's policy mandates that all injuries of unknown source be promptly and thoroughly investigated, which was not adhered to in this case.
Failure to Prevent Worsening of Pressure Ulcers
Penalty
Summary
The facility failed to provide necessary services consistent with professional standards to prevent the worsening of pressure ulcers for a resident identified as R4. R4 was admitted with diagnoses including Type 2 diabetes mellitus, morbid obesity, and venous insufficiency, and was at risk of developing pressure ulcers. Despite having a care plan that included the application of zinc oxide to the left hip three times a day and as needed, there was no documentation of this treatment being administered throughout January. Observations revealed that the treatment was not consistently performed by the nursing staff, and there was confusion among staff regarding who was responsible for applying the treatment. On January 14, 2025, a registered nurse (V12) was observed not performing the treatment, mistakenly believing that CNAs were responsible for it. The Director of Nursing (V2) clarified that the nursing staff should apply all treatments. When the treatment was eventually performed, the left hip area was observed to have open and scabbed areas, indicating a lack of consistent care. The Director of Nursing acknowledged the lack of documentation and expressed uncertainty about the specific treatment being administered, highlighting a failure in communication and adherence to the prescribed care plan.
Inadequate Fall Prevention and Supervision
Penalty
Summary
The facility failed to implement effective and appropriate interventions to prevent falls for three residents, R5, R19, and R21, who were reviewed for falls. R5, who has moderate cognitive impairment and a history of falls, experienced multiple falls resulting in injuries such as bruises and hematomas. Despite these incidents, the care plan was not consistently updated with new interventions. Observations revealed that R5's call light was often out of reach, and the alarm pad was not used correctly, contributing to the risk of falls. R21, with severe cognitive impairment, also experienced several falls, some resulting in injuries. The care plan for R21 included interventions such as visual checks and reminders to use the call light, but these were not effectively implemented. Observations showed that R21's call light was frequently out of reach, and there was a lack of documentation regarding physician notification after falls, indicating inadequate follow-up and intervention. R19, who has severe cognitive impairment and a history of falls, experienced falls resulting in injuries such as lacerations and hematomas. The care plan included interventions like visual checks and ensuring the call light was within reach, but these were not consistently followed. Observations indicated that R19's call light was often inaccessible, and there was a lack of timely assistance, contributing to the risk of falls. The facility's failure to update care plans and implement effective interventions for these residents highlights deficiencies in fall prevention and supervision.
Failure to Address Resident's Weight Loss
Penalty
Summary
The facility failed to adhere to its policy for managing weight loss in a resident, identified as R24, who was part of a sample of 23 residents. R24, who has diagnoses including Parkinsonism, anemia, Alzheimer's disease, and cerebral infarction, was noted to have a potential for excessive weight loss due to cognitive issues and being a picky eater. Despite documented interventions in R24's care plan, such as monitoring meal intake and offering food substitutes, the facility did not implement these measures effectively. R24 experienced significant weight loss, dropping from 178 pounds to 158 pounds over a few months, which exceeded the facility's threshold for notifying a physician and dietician. However, there was no evidence of a referral to a registered dietician or the provision of nutritional supplements to address the weight loss. The facility's documentation was inconsistent, with different weights recorded on various forms, and the correct weights were not communicated to the dietary manager. The dietary manager, V15, stated that she did not receive information about residents' weight loss or calculate weight loss, relying on nursing staff to provide this information. V16, an LPN, confirmed that the facility did not follow through with R24's weight loss management, including failing to notify the registered dietician or implement supplements. The facility's policy required notifying the physician and dietary supervisor of significant weight changes, but this was not done, contributing to the deficiency in care for R24.
Failure to Address Wandering Behavior in Dementia Resident
Penalty
Summary
The facility failed to provide necessary person-centered care and services for a resident diagnosed with dementia, specifically in addressing wandering behavior. The resident, identified as R14, was admitted with diagnoses including dementia without behavioral disturbance and altered mental status. The Minimum Data Set for R14 indicated that no brief interview of mental status was performed due to the resident being rarely or never understood. Despite these conditions, R14's current care plan did not address the issue of wandering into other residents' rooms. Multiple incidents were observed where R14 entered other residents' rooms, causing distress to those residents. On several occasions, residents were heard calling for help to have R14 removed from their rooms. Staff members, including a Certified Nurse Aide and Housekeeping personnel, were involved in removing R14 from these rooms. The Director of Nursing confirmed that there was no behavior tracking for R14's wandering, and the care plan provided to the surveyor was the entirety of R14's care plan, which lacked any problem areas related to wandering.
Infection Control Breach During Incontinent Care
Penalty
Summary
The facility failed to adhere to proper infection control techniques during the provision of incontinent care for a resident, identified as R4, who was observed to be totally incontinent of bowel and bladder. R4's medical history includes Type 2 diabetes mellitus, morbid obesity, venous insufficiency, muscle weakness, and a need for assistance with personal care. During an observation, a CNA, identified as V10, did not perform hand hygiene before donning gloves and proceeded to clean R4's buttocks and rectum area, which had a moderate amount of stool. After removing the soiled gloves, V10 failed to perform hand hygiene before putting on a new pair of gloves and continued to clean R4's groin area. Additionally, V10 did not remove gloves when touching R4's skin and clothing, and along with other CNAs, touched R4's bed linens with contaminated gloves. The Director of Nursing (DON), identified as V2, was present during the incident and instructed the CNAs to remove their gloves when touching linens. However, the CNAs did not perform hand hygiene after removing their gloves. Interviews with the DON and other CNAs confirmed that the staff should have changed gloves and performed hand hygiene after cleaning stool and before continuing care. The facility's handwashing policy, which aligns with CDC guidelines, emphasizes the importance of handwashing before and after situations likely to cause microbial contamination, including contact with body fluids, even when gloves are worn.
Deficiency in Antibiotic Stewardship for Resident with Bronchitis
Penalty
Summary
The facility failed to adhere to standards of practice for antibiotic use for a resident diagnosed with bronchitis. The resident, who had a history of anxiety disorder, cerebral infarction, chronic kidney disease, gastroesophageal reflux disease, and adult failure to thrive, was prescribed a Z-pak antibiotic on January 8, 2025, without a documented culture or x-ray to confirm the diagnosis. The resident's nurse's notes did not document any symptoms of respiratory distress or infection between December 23, 2024, and January 8, 2025, when the antibiotic was ordered. The care plan also lacked a section addressing respiratory problems or concerns. The Director of Nursing acknowledged that the resident had symptoms of clear phlegm as early as November 10, 2024, but no further documentation was made until the antibiotic was prescribed. The resident was observed coughing and spitting clear phlegm into tissues, but no diagnostic tests were conducted to justify the antibiotic use. The facility's infection control log noted the infection as nosocomial, yet there was no follow-up documentation for 72 hours after the antibiotic administration, as required. This lack of documentation and diagnostic confirmation led to the deficiency in antibiotic stewardship practices.
Failure to Post Current Nurse Staffing Data
Penalty
Summary
The facility failed to post daily nurse staffing data for both licensed and unlicensed staff responsible for resident care, which has the potential to affect all 24 residents residing at the facility. On multiple occasions, the staff postings were either outdated or incorrect. On January 13, 2024, the staff posting displayed a future date of February 26, 2024, with a census of 32 residents. On January 14, 2025, the posting was updated to reflect the correct date and a census of 24 residents. However, on January 15 and 16, 2025, the postings still showed the date as January 14, 2025. During an interview on January 15, 2025, a staff member acknowledged that the daily staff posting was not current and suggested it was likely missed that day. The Long-Term Care Facility Application for Medicare and Medicaid form 671, dated January 14, 2025, confirmed there were 24 residents living in the facility.
Improper Off-Site Food Storage Due to Freezer Malfunction
Penalty
Summary
The facility failed to store food in accordance with professional standards for food service safety, which has the potential to affect all 29 residents currently residing at the facility. The deficiency was identified when the facility's freezer malfunctioned, and the Director of Nurses (V2) moved all the food off-premises to a dedicated freezer at her house. However, V2 was unable to provide reproducible evidence that the temperature of the freezer/food was maintained per current standards of practice. The Cook (V4) and Dietary Aid/Cook (V5) confirmed that the freezer had been non-functional for about two weeks, and V2 was responsible for transporting the food daily from her house to the facility. The Dietary Manager (V6) and Maintenance Director (V3) corroborated the situation, stating that the freezer had been repaired temporarily but failed again. They mentioned that a part had been ordered to fix the freezer, expected to arrive soon. The facility's Food Storage policy from 2009 requires that freezers maintain a temperature that ensures products remain frozen, and an addendum added to the policy on 7/8/24 specifies that food stored off-site must be transferred to a Public Health Certified area. This policy was not followed, as the food was stored at V2's house, which does not meet the specified requirements.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 64 citations issued within 25 miles in the last 12 months — including the 3 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Salem
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Doctors Nursing & Rehab Center | 0.9 mi | — | 25 | 1 |
| Odin Health And Rehab Center | 6 mi | — | 2 | 1 |
| Centralia Manor | 12.9 mi | — | 12 | 1 |
| Fireside House Of Centralia | 12.9 mi | — | 0 | 0 |
| Axiom Healthcare Of Mount Vernon | 22.3 mi | — | 5 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Twin Willows Nursing Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.