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Health Inspection Summary
Twin Oaks Center
63 Locust Street
Danvers, MA 01923
(978) 777-0011

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Deficiency Category
Inspection Date:
7/11/24
Complaint Reporting Period:
3/1/24 - 2/28/25
Inspection Date:
5/3/23
Complaint Reporting Period:
3/1/23 - 2/29/24
Inspection Date:
3/10/22
Complaint Reporting Period:
3/1/22 - 2/28/23
Freedom from Abuse, Neglect, and Exploitation Deficiencies023
Quality of Life and Care Deficiencies1105
Infection Control Deficiencies010
Resident Assessment and Care Planning Deficiencies160
Nursing and Physician Services Deficiencies041
Resident Rights Deficiencies041
Nutrition and Dietary Deficiencies022
Pharmacy Service Deficiencies031
Environmental Deficiencies010
Administration Deficiencies130

Detailed result for inspection on 7/11/24
Date of last standard health inspection:7/11/24Read the full report (PDF)
Date(s) of complaint inspection(s) between 3/1/24 - 2/28/25
No complaint inspections
Date(s) of infection control inspection(s) between 3/1/24 - 2/28/25
No infection control inspections
Total number of Health Deficiencies for this nursing home:3
Average number of Health Deficiencies in Massachusetts:10
Average number of Health Deficiencies in the United States:9.6
Freedom from Abuse, Neglect, and Exploitation Deficiencies
No Freedom from Abuse, Neglect, and Exploitation Deficiencies were found during this inspection period.
Quality of Life and Care Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Provide enough food/fluids to maintain a resident's health.

7/11/247/11/24
3 - Actual harm
Few
Infection Control Deficiencies
No Infection Control Deficiencies were found during this inspection period.
Resident Assessment and Care Planning Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Ensure services provided by the nursing facility meet professional standards of quality.

7/11/247/11/24
2 - Minimal harm or potential for actual harm
Some
Nursing and Physician Services Deficiencies
No Nursing and Physician Services Deficiencies were found during this inspection period.
Resident Rights Deficiencies
No Resident Rights Deficiencies were found during this inspection period.
Nutrition and Dietary Deficiencies
No Nutrition and Dietary Deficiencies were found during this inspection period.
Pharmacy Service Deficiencies
No Pharmacy Service Deficiencies were found during this inspection period.
Environmental Deficiencies
No Environmental Deficiencies were found during this inspection period.
Administration Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.

7/11/247/11/24
3 - Actual harm
Few

Detailed result for inspection on 5/3/23
Date of last standard health inspection:5/3/23Read the full report (PDF)
Date(s) of complaint inspection(s) between 3/1/23 - 2/29/24
Date(s) of infection control inspection(s) between 3/1/23 - 2/29/24
No infection control inspections
Total number of Health Deficiencies for this nursing home:36
Average number of Health Deficiencies in Massachusetts:12.2
Average number of Health Deficiencies in the United States:9.4
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Respond appropriately to all alleged violations.

5/3/236/9/23
2 - Minimal harm or potential for actual harm
Few

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

5/3/236/9/23
2 - Minimal harm or potential for actual harm
Few
Quality of Life and Care Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

5/3/236/9/23
2 - Minimal harm or potential for actual harm
Few

Provide or obtain dental services for each resident.

5/3/236/9/23
2 - Minimal harm or potential for actual harm
Few

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

5/3/236/9/23
2 - Minimal harm or potential for actual harm
Few

Provide activities to meet all resident's needs.

5/3/236/9/23
2 - Minimal harm or potential for actual harm
Some

Provide appropriate foot care.

5/3/236/9/23
2 - Minimal harm or potential for actual harm
Few

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

5/3/235/4/23
3 - Actual harm
Few

Provide care and assistance to perform activities of daily living for any resident who is unable.

5/3/236/9/23
2 - Minimal harm or potential for actual harm
Few

Provide safe and appropriate respiratory care for a resident when needed.

5/3/236/9/23
2 - Minimal harm or potential for actual harm
Few

Provide safe, appropriate dialysis care/services for a resident who requires such services.

5/3/236/9/23
2 - Minimal harm or potential for actual harm
Few

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.

5/3/235/3/23
2 - Minimal harm or potential for actual harm
Few
Infection Control Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Implement a program that monitors antibiotic use.

5/3/235/5/23
2 - Minimal harm or potential for actual harm
Few
Resident Assessment and Care Planning Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Ensure services provided by the nursing facility meet professional standards of quality.

5/3/236/9/23
2 - Minimal harm or potential for actual harm
Few

Assure that each resident’s assessment is updated at least once every 3 months.

5/3/236/9/23
2 - Minimal harm or potential for actual harm
Few

Ensure each resident receives an accurate assessment.

5/3/236/9/23
2 - Minimal harm or potential for actual harm
Few

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

5/3/236/27/23
2 - Minimal harm or potential for actual harm
Some

Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

5/3/236/9/23
2 - Minimal harm or potential for actual harm
Many

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

5/3/236/9/23
2 - Minimal harm or potential for actual harm
Some
Nursing and Physician Services Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Observe each nurse aide's job performance and give regular training.

5/3/236/16/23
2 - Minimal harm or potential for actual harm
Many

Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

5/3/236/9/23
2 - Minimal harm or potential for actual harm
Few

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

5/3/236/12/23
2 - Minimal harm or potential for actual harm
Few

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.

5/3/236/16/23
2 - Minimal harm or potential for actual harm
Few
Resident Rights Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.

12/12/231/15/24
2 - Minimal harm or potential for actual harm
Few

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.

5/3/236/9/23
2 - Minimal harm or potential for actual harm
Few

Ensure that residents are fully informed and understand their health status, care and treatments.

5/3/236/16/23
2 - Minimal harm or potential for actual harm
Few

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.

5/3/235/8/23
2 - Minimal harm or potential for actual harm
Many
Nutrition and Dietary Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

5/3/236/2/23
2 - Minimal harm or potential for actual harm
Some

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

5/3/235/29/23
2 - Minimal harm or potential for actual harm
Some
Pharmacy Service Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Ensure that residents are free from significant medication errors.

5/3/235/3/23
3 - Actual harm
Some

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.

5/3/236/27/23
2 - Minimal harm or potential for actual harm
Many

Ensure medication error rates are not 5 percent or greater.

5/3/236/16/23
2 - Minimal harm or potential for actual harm
Some
Environmental Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

5/3/235/15/23
2 - Minimal harm or potential for actual harm
Many
Administration Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

5/3/235/9/23
2 - Minimal harm or potential for actual harm
Many

Have a plan that describes the process for conducting QAPI and QAA activities.

5/3/236/2/23
2 - Minimal harm or potential for actual harm
Many

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

5/3/236/2/23
2 - Minimal harm or potential for actual harm
Many

Detailed result for inspection on 3/10/22
Date of last standard health inspection:3/10/22Read the full report (PDF)
Date(s) of complaint inspection(s) between 3/1/22 - 2/28/23
Date(s) of infection control inspection(s) between 3/1/22 - 2/28/23
No infection control inspections
Total number of Health Deficiencies for this nursing home:13
Average number of Health Deficiencies in Massachusetts:10.8
Average number of Health Deficiencies in the United States:8.7
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Respond appropriately to all alleged violations.

3/10/224/8/22
2 - Minimal harm or potential for actual harm
Few

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

3/10/224/8/22
2 - Minimal harm or potential for actual harm
Few

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

2/1/232/22/23
2 - Minimal harm or potential for actual harm
Few
Quality of Life and Care Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

3/10/224/8/22
2 - Minimal harm or potential for actual harm
Few

Provide enough food/fluids to maintain a resident's health.

3/10/224/8/22
2 - Minimal harm or potential for actual harm
Few

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

3/10/224/8/22
2 - Minimal harm or potential for actual harm
Few

Provide care and assistance to perform activities of daily living for any resident who is unable.

3/10/224/8/22
2 - Minimal harm or potential for actual harm
Few

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.

3/10/224/8/22
2 - Minimal harm or potential for actual harm
Few
Infection Control Deficiencies
No Infection Control Deficiencies were found during this inspection period.
Resident Assessment and Care Planning Deficiencies
No Resident Assessment and Care Planning Deficiencies were found during this inspection period.
Nursing and Physician Services Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.

3/10/224/8/22
2 - Minimal harm or potential for actual harm
Few
Resident Rights Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Give the resident's representative the ability to exercise the resident's rights.

3/10/224/8/22
2 - Minimal harm or potential for actual harm
Few
Nutrition and Dietary Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

3/10/224/8/22
2 - Minimal harm or potential for actual harm
Few

Dispose of garbage and refuse properly.

3/10/224/8/22
2 - Minimal harm or potential for actual harm
Few
Pharmacy Service Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

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.

3/10/224/8/22
2 - Minimal harm or potential for actual harm
Few
Environmental Deficiencies
No Environmental Deficiencies were found during this inspection period.
Administration Deficiencies
No Administration Deficiencies were found during this inspection period.
Complaints and facility-reported incidents in the past 3 years
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.

12/12/231/15/24
2 - Minimal harm or potential for actual harm
Few

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

2/1/232/22/23
2 - Minimal harm or potential for actual harm
Few
Infection control inspection deficiencies in the past 3 years
This nursing home has not had any infection control inspections in the past 3 years.
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