Twin Oaks Center
63 Locust Street · Danvers, MA · 01923 · 9787770011
101 certified beds For profit - Limited Liability company
Why this verdict
- Inspection record is far worse than the national median (deficiency count and severity).
- Inspection results are getting worse cycle over cycle, not better.
- 4 citations involved actual harm to residents.
The complete Safety Report — $19
Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
Red flags
RN staffing in the bottom 10% nationally
0.29 registered-nurse hours per resident per day, vs a 0.58 national median and 0.75 benchmark.
Total nurse staffing below 3.0 hours per resident-day
2.89 reported hours vs the 3.48 minimum CMS's own staffing study recommends.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 1 of 5 Inspections: 1 of 5 Staffing: 1 of 5 Quality measures: 2 of 5
| Total nurse hours / resident-day | 2.89 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.29 | 0.55–0.75 |
| Weekend hours / resident-day | 2.67 | ≈ weekday level |
| Nursing turnover / year | 47% | median 45% |
| Fines (3-yr window) | 1 · $2,186 |
Inspection citations (58 in the current record)
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Potential for harm · D June 18, 2025
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected July 24, 2025 · Resident Rights
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Potential for harm · D June 18, 2025
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected July 24, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D June 18, 2025
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected July 24, 2025 · Resident Assessment and Care Planning
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Potential for harm · D June 18, 2025
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected July 24, 2025 · Resident Assessment and Care Planning
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Potential for harm · D June 18, 2025
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected July 24, 2025 · Quality of Life and Care
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Potential for harm · D June 18, 2025
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.
Corrected July 24, 2025 · Quality of Life and Care
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Potential for harm · D June 18, 2025
Provide enough food/fluids to maintain a resident's health.
Corrected July 24, 2025 · Quality of Life and Care
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Potential for harm · D June 18, 2025
Provide care or services that was trauma informed and/or culturally competent.
Corrected July 24, 2025 · Quality of Life and Care
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Potential for harm · D June 18, 2025
Ensure medication error rates are not 5 percent or greater.
Corrected July 24, 2025 · Pharmacy Service
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Potential for harm · E June 18, 2025
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.
Corrected July 24, 2025 · Pharmacy Service
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Potential for harm · F June 18, 2025
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected July 24, 2025 · Administration
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Potential for harm · F June 18, 2025
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.
Corrected July 24, 2025 · Administration
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Potential for harm · D June 18, 2025
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected July 24, 2025 · Resident Assessment and Care Planning
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Potential for harm · F June 18, 2025
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected July 24, 2025 · Administration
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Potential for harm · F June 18, 2025
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected July 24, 2025 · Administration
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Potential for harm · F June 18, 2025
Provide and implement an infection prevention and control program.
Corrected July 24, 2025 · Infection Control
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Potential for harm · F June 18, 2025
Implement a program that monitors antibiotic use.
Corrected July 24, 2025 · Infection Control
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Potential for harm · D June 18, 2025
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected July 24, 2025 · Infection Control
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Potential for harm · D June 18, 2025
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.
Corrected July 24, 2025 · Infection Control
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Actual harm · G July 11, 2024
Provide enough food/fluids to maintain a resident's health.
Corrected July 11, 2024 · Quality of Life and Care
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Actual harm · G July 11, 2024
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Corrected July 11, 2024 · Administration
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Potential for harm · E July 11, 2024
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected July 11, 2024 · Resident Assessment and Care Planning
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Potential for harm · D December 12, 2023 · found via complaint
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Corrected January 15, 2024 · Resident Rights
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Actual harm · G May 3, 2023
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected May 4, 2023 · Quality of Life and Care
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Actual harm · H May 3, 2023
Ensure that residents are free from significant medication errors.
Corrected May 3, 2023 · Pharmacy Service
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| July 11, 2024 | Fine | $2,186 |
Family & resident reviews — a separate signal, never mixed into the score
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 225198 · certified since June 30, 1970. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.