Public Record
Twin Oaks Center
From CMS
Facility profile
- CMS overall rating
- 1 / 5
- Certified beds
- 101
- Avg. residents per day
- 76.7
*CMS Five-Star
*CMS
*CMS
Inspection record
On record from CMS
- Citations on record
- 81
- Inspections on file
- 7
- Last inspection
- 2025-06-18
*CMS
*CMS
*CMS
Citations
81 citations on record
Each deficiency cited on a CMS health inspection of this facility, sourced from the federal record. Open a report for the raw CMS Scope and Severity grade on each finding.
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
- 0550Generalpotential for harm
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- 0609Generalpotential for harm
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- 0656Generalpotential for harm
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- 0658Generalpotential for harm
Ensure services provided by the nursing facility meet professional standards of quality.
- 0684Generalpotential for harm
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- 0688Generalpotential for harm
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
- 0692Generalpotential for harm
Provide enough food/fluids to maintain a resident's health.
- 0699Generalpotential for harm
Provide care or services that was trauma informed and/or culturally competent.
- 0759Generalpotential for harm
Ensure medication error rates are not 5 percent or greater.
- 0761Generalpotential for harm
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
- 0835Generalpotential for harm
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
- 0837Generalpotential for harm
Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.
- 0842Generalpotential for harm
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
- 0865Generalpotential for harm
Have a plan that describes the process for conducting QAPI and QAA activities.
- 0867Generalpotential for harm
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
- 0880Generalpotential for harm
Provide and implement an infection prevention and control program.
- 0881Generalpotential for harm
Implement a program that monitors antibiotic use.
- 0883Generalpotential for harm
Develop and implement policies and procedures for flu and pneumonia vaccinations.
- 0887Generalpotential for harm
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
- 0004Generalpotential for harm
Develop and maintain an Emergency Preparedness Program (EP).
- 0013Generalpotential for harm
Develop Emergency Preparedness policies and procedures.
- 0029Generalpotential for harm
Develop a communication plan.
- 0036Generalpotential for harm
Establish emergency prep training and testing.
- 0211Generalpotential for harm
Keep aisles, corridors, and exits free of obstruction in case of emergency.
- 0222Generalpotential for harm
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
- 0324Generalpotential for harm
Provide properly protected cooking facilities.
- 0345Generalpotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
- 0353Generalpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0521Generalpotential for harm
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
- 0531Generalpotential for harm
Have elevators that firefighters can control in the event of a fire.
- 0712Generalpotential for harm
Have simulated fire drills held at unexpected times.
- 0914Generalpotential for harm
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
- 0918Generalpotential for harm
Have generator or other power source capable of supplying service within 10 seconds.
- 0773Seriousactual harm
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
- 0353Generalpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0015Generalpotential for harm
Address subsistence needs for staff and patients.
- 0026Generalpotential for harm
Establish roles under a Waiver declared by secretary.
- 0036Generalpotential for harm
Establish emergency prep training and testing.
- 0037Generalpotential for harm
Establish staff and initial training requirements.
- 0324Generalpotential for harm
Provide properly protected cooking facilities.
- 0351Generalpotential for harm
Install an approved automatic sprinkler system.
- 0658Generalpotential for harm
Ensure services provided by the nursing facility meet professional standards of quality.
- 0692Seriousactual harm
Provide enough food/fluids to maintain a resident's health.
- 0568Generalpotential for harm
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
- 0730Generalpotential for harm
Observe each nurse aide's job performance and give regular training.
- 0759Generalpotential for harm
Ensure medication error rates are not 5 percent or greater.
- 0760Seriousactual harm
Ensure that residents are free from significant medication errors.
- 0761Generalpotential for harm
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
- 0791Generalpotential for harm
Provide or obtain dental services for each resident.
- 0804Generalpotential for harm
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
- 0812Generalpotential for harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- 0835Generalpotential for harm
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
- 0842Generalpotential for harm
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
- 0865Generalpotential for harm
Have a plan that describes the process for conducting QAPI and QAA activities.
- 0867Generalpotential for harm
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
- 0881Generalpotential for harm
Implement a program that monitors antibiotic use.
- 0925Generalpotential for harm
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
- 0947Generalpotential for harm
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
- 0291Generalpotential for harm
Install emergency lighting that can last at least 1 1/2 hours.
- 0712Generalpotential for harm
Have simulated fire drills held at unexpected times.
- 0552Generalpotential for harm
Ensure that residents are fully informed and understand their health status, care and treatments.
- 0584Generalpotential for harm
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.
- 0585Generalpotential for harm
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
- 0609Generalpotential for harm
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- 0610Generalpotential for harm
Respond appropriately to all alleged violations.
- 0636Generalpotential for harm
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
- 0638Generalpotential for harm
Assure that each resident’s assessment is updated at least once every 3 months.
- 0641Generalpotential for harm
Ensure each resident receives an accurate assessment.
- 0656Generalpotential for harm
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- 0676Generalpotential for harm
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
- 0658Generalpotential for harm
Ensure services provided by the nursing facility meet professional standards of quality.
- 0677Generalpotential for harm
Provide care and assistance to perform activities of daily living for any resident who is unable.
- 0679Generalpotential for harm
Provide activities to meet all resident's needs.
- 0684Generalpotential for harm
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- 0687Generalpotential for harm
Provide appropriate foot care.
- 0689Seriousactual harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- 0693Generalpotential for harm
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
- 0695Generalpotential for harm
Provide safe and appropriate respiratory care for a resident when needed.
- 0698Generalpotential for harm
Provide safe, appropriate dialysis care/services for a resident who requires such services.
- 0725Generalpotential for harm
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
- 0726Generalpotential for harm
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
FAQ
Questions and answers
- What is Twin Oaks Center?
- Twin Oaks Center is a Medicare- and Medicaid-certified nursing home in Danvers, MA, tracked by the Centers for Medicare & Medicaid Services (CMS). Its CMS Certification Number (CCN) is 225198.
- What is the CMS rating for Twin Oaks Center?
- Twin Oaks Center has a CMS overall rating of 1 out of 5 stars. CMS rates nursing homes on health inspections, staffing, and quality measures.
- How many beds does Twin Oaks Center have?
- Twin Oaks Center is certified for 101 beds. It serves an average of 76.7 residents per day.
- How many citations does Twin Oaks Center have?
- Twin Oaks Center has 81 citations on record from CMS health inspections, each tied to a federal deficiency tag.
- When was Twin Oaks Center last inspected?
- Twin Oaks Center was last inspected on June 18, 2025. CMS surveys nursing homes about once a year and after complaints.
- What can I do if I have concerns about care at this facility?
- Start by raising the concern with the facility administrator or director of nursing. Every state also runs a free long-term care ombudsman program that advocates for residents and families; the federal Eldercare Locator at eldercare.acl.gov can connect you with yours. Complaints about quality of care can also be filed with your state survey agency.
*Sourced from the Centers for Medicare & Medicaid Services (CMS). See the official record on CMS Care Compare. If you believe any information is inaccurate, report it here.
/nursing-home/225198-twin-oaks-center