| Twin Oaks Center | |
| 63 Locust Street, Danvers, Massachusetts 01923 | |
| (978) 777-0011 | |
| Name | Twin Oaks Center |
|---|---|
| Location | 63 Locust Street, Danvers, Massachusetts |
| Certified By | Medicare and Medicaid |
| No. of Certified Beds | 101 |
| Occupancy Rate | 74.26% |
| Medicare ID (CCN) | 225198 |
| Legal Business Name | Locust Street Operations LLC |
| Ownership Type | For Profit - Limited Liability Company |
| NPI Number | 1154339943 |
| Match | Possible same name, address or phone number |
| Organization Name | Harborside Massachusetts Limited Partnership |
| Doing Business As | Twin Oaks Care and Rehabilitation Center |
| Address | 63 Locust St, Danvers, MA 01923 |
| Phone Number | 978-777-0011 |
| NPI Number | 1487240891 |
| Match | Possible same name, address or phone number |
| Organization Name | Oc Twin Oaks Center, LLC |
| Doing Business As | Twin Oaks Center |
| Address | 63 Locust St, Danvers, MA 01923 |
| Phone Number | 978-777-0011 |
| NPI Number | 1588497226 |
| Match | Possible same name, address or phone number |
| Organization Name | Locust Street Operations LLC |
| Doing Business As | Twin Oaks Rehabilitation and Nursing |
| Address | 63 Locust St, Danvers, MA 01923 |
| Phone Number | 978-777-0011 |
| NPI Number | 1659879740 |
| Match | Possible same name, address or phone number |
| Organization Name | Twin Oaks Opco LLC |
| Address | 63 Locust St, Danvers, MA 01923 |
| Phone Number | 978-777-0011 |
| Ratings from Surveys (Inspections): | |
| Ratings from Quality Measures: | |
| Ratings from Staffing Data: | |
| Overall Rating: |
|---|
| Staffing Measure | Provider | National Avg. |
|---|---|---|
| Total nurse staff hours per resident per day | 3.02 | 3.86 |
| Registered nurse (RN) hours per resident per day | 0.24 | 0.69 |
| Licensed practical nurse (LPN) hours per resident per day | 0.9 | 0.86 |
| Nurse aide hours per resident per day | 1.88 | 2.32 |
| Total nurse staff hours per resident per day on the weekend | 2.84 | 3.42 |
| RN hours per resident per day on the weekend | 0.15 | 0.48 |
| Physical therapist hours per resident per day | 0 | 0.07 |
| Total nursing staff turnover | 44.3% | 45.8% |
| Registered nurse turnover | 66.7% | 42.9% |
| Number of administrators who have left the nursing home | 1 | 0.5 |
| Cited for abuse, neglect or exploitation of residents (Care Compare abuse icon) | No |
| Number of Fines | 1 |
| Total Amount of Fines in Dollars | $2,186 |
| Number of Payment Denials | 0 |
| Total Number of Penalties | 1 |
| Date | Deficiency | Harm Level | Status |
|---|---|---|---|
| Jun 18, 2025 | Administer the facility in a manner that enables it to use its resources effectively and efficiently. F0835, Administration, Standard inspection | Potential for harm, widespread | Corrected by Jul 24, 2025 |
| Jun 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. F0837, Administration, Standard inspection | Potential for harm, widespread | Corrected by Jul 24, 2025 |
| Jun 18, 2025 | Have a plan that describes the process for conducting QAPI and QAA activities. F0865, Administration, Standard inspection | Potential for harm, widespread | Corrected by Jul 24, 2025 |
| Jun 18, 2025 | Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. F0867, Administration, Standard inspection | Potential for harm, widespread | Corrected by Jul 24, 2025 |
| Jun 18, 2025 | Provide and implement an infection prevention and control program. F0880, Infection Control, Standard inspection | Potential for harm, widespread | Corrected by Jul 24, 2025 |
| Jun 18, 2025 | Implement a program that monitors antibiotic use. F0881, Infection Control, Standard inspection | Potential for harm, widespread | Corrected by Jul 24, 2025 |
| Jun 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. F0761, Pharmacy Service, Standard inspection | Potential for harm, pattern | Corrected by Jul 24, 2025 |
| Jun 18, 2025 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. F0550, Resident Rights, Standard inspection | Potential for harm, isolated | Corrected by Jul 24, 2025 |
| Jun 18, 2025 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. F0609, Freedom from Abuse, Neglect, and Exploitation, Standard inspection | Potential for harm, isolated | Corrected by Jul 24, 2025 |
| Jun 18, 2025 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. F0656, Resident Assessment and Care Planning, Standard inspection | Potential for harm, isolated | Corrected by Jul 24, 2025 |
| Jun 18, 2025 | Ensure services provided by the nursing facility meet professional standards of quality. F0658, Resident Assessment and Care Planning, Standard inspection | Potential for harm, isolated | Corrected by Jul 24, 2025 |
| Jun 18, 2025 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. F0684, Quality of Life and Care, Standard inspection | Potential for harm, isolated | Corrected by Jul 24, 2025 |
| Jun 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. F0688, Quality of Life and Care, Standard inspection | Potential for harm, isolated | Corrected by Jul 24, 2025 |
| Jun 18, 2025 | Provide enough food/fluids to maintain a resident's health. F0692, Quality of Life and Care, Standard inspection | Potential for harm, isolated | Corrected by Jul 24, 2025 |
| Jun 18, 2025 | Provide care or services that was trauma informed and/or culturally competent. F0699, Quality of Life and Care, Standard inspection | Potential for harm, isolated | Corrected by Jul 24, 2025 |
| Jun 18, 2025 | Ensure medication error rates are not 5 percent or greater. F0759, Pharmacy Service, Standard inspection | Potential for harm, isolated | Corrected by Jul 24, 2025 |
| Jun 18, 2025 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. F0842, Resident Assessment and Care Planning, Standard inspection | Potential for harm, isolated | Corrected by Jul 24, 2025 |
| Jun 18, 2025 | Develop and implement policies and procedures for flu and pneumonia vaccinations. F0883, Infection Control, Standard inspection | Potential for harm, isolated | Corrected by Jul 24, 2025 |
| Jun 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. F0887, Infection Control, Standard inspection | Potential for harm, isolated | Corrected by Jul 24, 2025 |
| Jul 11, 2024 | Provide enough food/fluids to maintain a resident's health. F0692, Quality of Life and Care, Standard inspection | Actual harm, isolated | Corrected by Jul 11, 2024 |
| Jul 11, 2024 | Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. F0773, Administration, Standard inspection | Actual harm, isolated | Corrected by Jul 11, 2024 |
| Jul 11, 2024 | Ensure services provided by the nursing facility meet professional standards of quality. F0658, Resident Assessment and Care Planning, Standard inspection | Potential for harm, pattern | Corrected by Jul 11, 2024 |
| Dec 12, 2023 | Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. F0568, Resident Rights, Complaint inspection | Potential for harm, isolated | Corrected by Jan 15, 2024 |
| May 3, 2023 | Ensure that residents are free from significant medication errors. F0760, Pharmacy Service, Standard inspection | Actual harm, pattern | Corrected by May 3, 2023 |
| May 3, 2023 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. F0689, Quality of Life and Care, Standard inspection | Actual harm, isolated | Corrected by May 4, 2023 |
| May 3, 2023 | 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. F0584, Resident Rights, Standard inspection | Potential for harm, widespread | Corrected by May 8, 2023 |
| May 3, 2023 | Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. F0636, Resident Assessment and Care Planning, Standard inspection | Potential for harm, widespread | Corrected by Jun 9, 2023 |
| May 3, 2023 | Observe each nurse aide's job performance and give regular training. F0730, Nursing and Physician Services, Standard inspection | Potential for harm, widespread | Corrected by Jun 16, 2023 |
| May 3, 2023 | 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. F0761, Pharmacy Service, Standard inspection | Potential for harm, widespread | Corrected by Jun 27, 2023 |
| May 3, 2023 | Administer the facility in a manner that enables it to use its resources effectively and efficiently. F0835, Administration, Standard inspection | Potential for harm, widespread | Corrected by May 9, 2023 |
| Quality Measure | Provider | National Avg. |
|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | 18.03 | 13.87 |
| Percentage of long-stay residents who lose too much weight | 8.23 | 5.19 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.56 | 0.82 |
| Percentage of long-stay residents with a urinary tract infection | 0 | 1.59 |
| Percentage of long-stay residents who have depressive symptoms | 38.78 | 12.8 |
| Percentage of long-stay residents who were physically restrained | 0 | 0.13 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.07 | 3.23 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 84.29 | 93.55 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 54.17 | 82.04 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0 | 1.56 |
| Percentage of long-stay residents whose ability to walk independently worsened | 11.32 | 14.07 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 25.59 | 19.52 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 91.78 | 95.46 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 34.62 | 79.75 |
| Percentage of long-stay residents with pressure ulcers | 3.95 | 4.62 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.87 | 19.01 |
| Percentage of long-stay residents who received an antipsychotic medication | 41.72 | 15.38 |
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