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LIFE BYVardellNursing Home
Report

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Twin Oaks Center

Skilled nursing facility and nursing facility

63 Locust Street
Danvers, MA 01923

Report Date
Nov 1, 2026
Data Through
Oct 1, 2026
Report ID
VR-MA-225198-2611
← Twin Oaks Center, free profile

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The Vardell Report.Twin Oaks Center

The deeper story, beautifully organized. Available records, historical context, and questions worth asking.

Provider Category
Nursing home
Location
Danvers, MA
Record Period
2023–2025
Source Documents
6
Read the report

This report is free. Vardell does not certify, grade or endorse; it shows what the record documents.

01

The Essentials

Summary

Across 4 inspections from May 2023 to June 2025, state surveyors documented 58 findings at Twin Oaks Center; 58 have a recorded correction; CMS lists 1 enforcement action in the window.

Inspections
4
2023–2025, standard and complaint
Findings
58
Deficiencies cited by state inspectors
Corrected
58
Of 58 findings, with a recorded correction date
Penalties
1
1 fine; payment not published

Findings by Year

  • Findings
  • Of which, actual harm (level G or above)
2023: 36 findings across 2 inspections; of which, actual harm (level G or above): 23620232 inspections2024: 3 findings across 1 inspection; of which, actual harm (level G or above): 2320241 inspection2025: 19 findings across 1 inspection1920251 inspection2026: 0 findings across 0 inspections02026*0 inspections2023: 36 findings across 2 inspections; of which, actual harm (level G or above): 23620232 insp.2024: 3 findings across 1 inspection; of which, actual harm (level G or above): 2320241 insp.2025: 19 findings across 1 inspection1920251 insp.2026: 0 findings across 0 inspections02026*0 insp.

* Partial year, through October 1, 2026.

Findings by year
YearInspectionsFindingsOf which, actual harm (level G or above)
20232362
2024132
20251190
2026000

What the Record Shows

  • 58 of 58 findings have a recorded correction date.
  • CMS lists 1 enforcement action in the window: 1 fine of $2,186, its payment not published.
  • 1 visit in this window included a complaint investigation. CMS publishes what a complaint investigation cited, not what the complaint alleged.
  • The latest standard inspection, June 18, 2025, recorded 19 findings (most serious: Level F).

What to Ask About

Report at a Glance

Facility
Twin Oaks Center
Address
63 Locust Street, Danvers, MA 01923
CMS Certification Number
225198
Provider Type
Skilled nursing facility and nursing facility
Certified Beds
101
Ownership
For profit - Limited Liability company
Record Window
May 3, 2023 to October 1, 2026
02

Chronology

Inspection History

Every inspection in the record window, newest first. A finding is a deficiency an inspector cited. CMS publishes what a complaint investigation cited, not what the complaint alleged.

  1. 2025

    Standard health inspection

    19 findings

    • F835Administer the facility in a manner that enables it to use its resources effectively and efficiently.Level FNo actual harm, potential for moreCorrected Jul 24, 2025
    • F837Establish 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.Level FNo actual harm, potential for moreCorrected Jul 24, 2025
    • F865Have a plan that describes the process for conducting QAPI and QAA activities.Level FNo actual harm, potential for moreCorrected Jul 24, 2025
    • F867Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.Level FNo actual harm, potential for moreCorrected Jul 24, 2025
    • F880Provide and implement an infection prevention and control program.Level FNo actual harm, potential for moreCorrected Jul 24, 2025
    • F881Implement a program that monitors antibiotic use.Level FNo actual harm, potential for moreCorrected Jul 24, 2025
    • F761Ensure 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.Level ENo actual harm, potential for moreCorrected Jul 24, 2025
    • F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Level DNo actual harm, potential for moreCorrected Jul 24, 2025
    • F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Jul 24, 2025
    • F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level DNo actual harm, potential for moreCorrected Jul 24, 2025
    • F658Ensure services provided by the nursing facility meet professional standards of quality.Level DNo actual harm, potential for moreCorrected Jul 24, 2025
    • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Jul 24, 2025
    • F688Provide 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.Level DNo actual harm, potential for moreCorrected Jul 24, 2025
    • F692Provide enough food/fluids to maintain a resident's health.Level DNo actual harm, potential for moreCorrected Jul 24, 2025
    • F699Provide care or services that was trauma informed and/or culturally competent.Level DNo actual harm, potential for moreCorrected Jul 24, 2025
    • F759Ensure medication error rates are not 5 percent or greater.Level DNo actual harm, potential for moreCorrected Jul 24, 2025
    • F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Level DNo actual harm, potential for moreCorrected Jul 24, 2025
    • F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Level DNo actual harm, potential for moreCorrected Jul 24, 2025
    • F887Educate 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.Level DNo actual harm, potential for moreCorrected Jul 24, 2025

    Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  2. 2024

    Standard health inspection

    3 findings

    • F692Provide enough food/fluids to maintain a resident's health.Level GActual harmCorrected Jul 11, 2024
    • F773Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.Level GActual harmCorrected Jul 11, 2024
    • F658Ensure services provided by the nursing facility meet professional standards of quality.Level ENo actual harm, potential for moreCorrected Jul 11, 2024

    Enforcement Action

    Civil money penalty, $2,186 imposed July 11, 2024. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of July 11, 2024, the nearest before the penalty date.

    Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  3. 2023

    Complaint investigation

    1 finding

    • F568Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.Level DNo actual harm, potential for moreCorrected Jan 15, 2024

    Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  4. 2023

    Standard health inspection

    35 findings

    • F760Ensure that residents are free from significant medication errors.Level HActual harmCorrected May 3, 2023
    • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level GActual harmCorrected May 4, 2023
    • F584Honor 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.Level FNo actual harm, potential for moreCorrected May 8, 2023
    • F636Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.Level FNo actual harm, potential for moreCorrected Jun 9, 2023
    • F730Observe each nurse aide's job performance and give regular training.Level FNo actual harm, potential for moreCorrected Jun 16, 2023
    • F761Ensure 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.Level FNo actual harm, potential for moreCorrected Jun 27, 2023
    • F835Administer the facility in a manner that enables it to use its resources effectively and efficiently.Level FNo actual harm, potential for moreCorrected May 9, 2023
    • F865Have a plan that describes the process for conducting QAPI and QAA activities.Level FNo actual harm, potential for moreCorrected Jun 2, 2023
    • F867Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.Level FNo actual harm, potential for moreCorrected Jun 2, 2023
    • F925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.Level FNo actual harm, potential for moreCorrected May 15, 2023
    • F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level ENo actual harm, potential for moreCorrected Jun 27, 2023
    • F679Provide activities to meet all resident's needs.Level ENo actual harm, potential for moreCorrected Jun 9, 2023
    • F759Ensure medication error rates are not 5 percent or greater.Level ENo actual harm, potential for moreCorrected Jun 16, 2023
    • F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Level ENo actual harm, potential for moreCorrected Jun 2, 2023
    • F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level ENo actual harm, potential for moreCorrected May 29, 2023
    • F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Level ENo actual harm, potential for moreCorrected Jun 9, 2023
    • F552Ensure that residents are fully informed and understand their health status, care and treatments.Level DNo actual harm, potential for moreCorrected Jun 16, 2023
    • F585Honor 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.Level DNo actual harm, potential for moreCorrected Jun 9, 2023
    • F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Jun 9, 2023
    • F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected Jun 9, 2023
    • F638Assure that each resident’s assessment is updated at least once every 3 months.Level DNo actual harm, potential for moreCorrected Jun 9, 2023
    • F641Ensure each resident receives an accurate assessment.Level DNo actual harm, potential for moreCorrected Jun 9, 2023
    • F658Ensure services provided by the nursing facility meet professional standards of quality.Level DNo actual harm, potential for moreCorrected Jun 9, 2023
    • F676Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.Level DNo actual harm, potential for moreCorrected Jun 9, 2023
    • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected Jun 9, 2023
    • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Jun 9, 2023
    • F687Provide appropriate foot care.Level DNo actual harm, potential for moreCorrected Jun 9, 2023
    • F693Ensure 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.Level DNo actual harm, potential for moreCorrected May 3, 2023
    • F695Provide safe and appropriate respiratory care for a resident when needed.Level DNo actual harm, potential for moreCorrected Jun 9, 2023
    • F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Level DNo actual harm, potential for moreCorrected Jun 9, 2023
    • F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Level DNo actual harm, potential for moreCorrected Jun 12, 2023
    • F726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.Level DNo actual harm, potential for moreCorrected Jun 16, 2023
    • F791Provide or obtain dental services for each resident.Level DNo actual harm, potential for moreCorrected Jun 9, 2023
    • F881Implement a program that monitors antibiotic use.Level DNo actual harm, potential for moreCorrected May 5, 2023
    • F947Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.Level DNo actual harm, potential for moreCorrected Jun 9, 2023

    Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

Severity levels follow the CMS scope and severity grid. A–C: potential for minimal harm. D–F: no actual harm, potential for more than minimal harm. G–I: actual harm. J–L: immediate jeopardy.

03

Context

Patterns Worth Examining

A repeated citation can merit attention, but context and corrective action must be reviewed before drawing a conclusion.

  1. 1

    Professional Standards, Cited in Three Inspections

    Inspectors cited F658 in May 2023, July 2024 and June 2025. This citation covers whether the home’s services meet professional standards of quality. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    23232425F658 across all 4 inspections, oldest to newest
  2. 2

    Reporting Suspected Abuse, Cited in Two Inspections

    Inspectors cited F609 in May 2023 and June 2025. This citation covers whether suspected abuse, neglect or theft is reported to the authorities on time, with the results of the home’s investigation. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    23232425F609 across all 4 inspections, oldest to newest
  3. 3

    Care Plans, Cited in Two Inspections

    Inspectors cited F656 in May 2023 and June 2025. This citation covers whether each resident has a written care plan that meets their needs, with goals that can be measured. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    23232425F656 across all 4 inspections, oldest to newest
  4. 4

    Quality of Care, Cited in Two Inspections

    Inspectors cited F684 in May 2023 and June 2025. This citation covers whether residents receive the treatment their orders, preferences and goals call for. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    23232425F684 across all 4 inspections, oldest to newest
  5. 5

    Nutrition and Hydration, Cited in Two Inspections

    Inspectors cited F692 in July 2024 and June 2025. This citation covers whether residents get enough food and fluids to stay healthy. The most serious of these was recorded at level G (actual harm). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    23232425F692 across all 4 inspections, oldest to newest
  6. 6

    Medication Error Rate, Cited in Two Inspections

    Inspectors cited F759 in May 2023 and June 2025. This citation covers whether medication errors stayed under 5 percent when inspectors watched medications being given. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    23232425F759 across all 4 inspections, oldest to newest
  7. 7

    Medication Labeling and Storage, Cited in Two Inspections

    Inspectors cited F761 in May 2023 and June 2025. This citation covers how drugs are labeled and kept locked, including controlled drugs. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    23232425F761 across all 4 inspections, oldest to newest
  8. 8

    Administration, Cited in Two Inspections

    Inspectors cited F835 in May 2023 and June 2025. This citation covers whether the home is run in a way that uses its resources effectively. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    23232425F835 across all 4 inspections, oldest to newest
  9. 9

    Medical Records, Cited in Two Inspections

    Inspectors cited F842 in May 2023 and June 2025. This citation covers whether resident records are complete, accurate and kept confidential. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    23232425F842 across all 4 inspections, oldest to newest
  10. 10

    Citation F865, Cited in Two Inspections

    Inspectors cited F865 in May 2023 and June 2025. The agency describes it this way: Have a plan that describes the process for conducting QAPI and QAA activities. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    23232425F865 across all 4 inspections, oldest to newest
  11. 11

    Citation F867, Cited in Two Inspections

    Inspectors cited F867 in May 2023 and June 2025. The agency describes it this way: Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    23232425F867 across all 4 inspections, oldest to newest
  12. 12

    Antibiotic Use, Cited in Two Inspections

    Inspectors cited F881 in May 2023 and June 2025. This citation covers the home’s program for monitoring antibiotic use. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    23232425F881 across all 4 inspections, oldest to newest
04

For Your Next Visit

Questions to Ask on Your Visit

Bring these to the tour. Each one comes from something in the record; the reason is under the question.

  1. 01

    How do you check that nurses and aides follow professional standards, and what happens when they do not?

    Professional Standards: cited in three inspections, most seriously at level E.

  2. 02

    How are staff trained to report suspected abuse or neglect, and who reports it to the state?

    Reporting Suspected Abuse: cited in two inspections, most seriously at level D.

  3. 03

    How is a care plan written and reviewed here, and how do families take part in it?

    Care Plans: cited in two inspections, most seriously at level E.

  4. 04

    How do nurses make sure a doctor’s orders are carried out, and how are families told when something is missed?

    Quality of Care: cited in two inspections, most seriously at level D.

  5. 05

    How are weight and fluid intake tracked, and what happens when a resident starts losing weight?

    Nutrition and Hydration: cited in two inspections, most seriously at level G.

  6. 06

    How are medication passes checked, and what happens when an error is found?

    Medication Error Rate: cited in two inspections, most seriously at level E.

  7. 07

    How are medications stored and secured, and who checks the medication carts?

    Medication Labeling and Storage: cited in two inspections, most seriously at level F.

  8. 08

    How long have the administrator and the director of nursing been in their roles?

    Administration: cited in two inspections, most seriously at level F.

  9. 09

    How can a family request a resident’s records, and how are they kept accurate?

    Medical Records: cited in two inspections, most seriously at level E.

  10. 10

    What changed after F865 was cited, and how do you check it now?

    Citation F865: cited in two inspections, most seriously at level F.

  11. 11

    What changed after F867 was cited, and how do you check it now?

    Citation F867: cited in two inspections, most seriously at level F.

  12. 12

    How do you track antibiotic use and decide when one is needed?

    Antibiotic Use: cited in two inspections, most seriously at level F.

  13. 13

    How many nurses and aides are on each shift, including nights and weekends, for the unit we are considering?

    Insufficient nursing staff was cited in May 2023.

  14. 14

    What led to the 2024 fine, and has it been paid?

    A $2,186 civil money penalty was imposed July 11, 2024. CMS publishes the fine, not whether it has been paid.

05

The Evidence

Sources and Coverage

Inspection results and penalties are published by the Centers for Medicare & Medicaid Services from surveys conducted by the Massachusetts state survey agency.

  • Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

    Massachusetts state survey agency

    Inspection May 3, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

  • Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

    Massachusetts state survey agency

    Inspection Dec 12, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

  • Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

    Massachusetts state survey agency

    Inspection Jul 11, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

  • Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

    Massachusetts state survey agency

    Inspection Jun 18, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

  • Penalties, Provider Data Catalog

    Centers for Medicare & Medicaid Services

    Published Oct 1, 2026 · Retrieved Nov 1, 2026

    View Dataset ↗
  • Provider Information, Provider Data Catalog

    Centers for Medicare & Medicaid Services · 225198

    Published Oct 1, 2026 · Retrieved Nov 1, 2026

    View Dataset ↗

Coverage

Record windowMay 3, 2023 – October 1, 2026

  • CMS publishes about three inspection cycles; inspections before May 2023 are not in this release.
  • CMS refreshes these files monthly, after statements of deficiencies are processed, so an inspection from the last two months may not appear yet.

What This Report Cannot Tell You

Complaints not investigated onsite
Allegations screened out by the state before an onsite visit are not published.
Complaint allegations
CMS publishes the deficiencies a complaint survey cited, not the allegation itself.
Facility-reported incidents
Self-reported incidents appear only if they led to an inspection.
Follow-up visits
CMS's files list standard, complaint and infection control surveys, not revisits; a correction date is the one CMS records.
Fire safety inspections
Published by CMS separately and not included in this record yet.
Staffing levels and ownership history
Published by CMS separately and not included in this record.
Whether fines were paid
CMS publishes the fines imposed, not whether or when they were paid.

Historical coverage varies by agency and location. Missing records do not mean that no complaint or violation occurred.

Data architecture: Cierto supplies the source-backed machine-readable bundle. Life by Vardell independently creates the narrative, design, and consumer report.