Nursing Care Index

Twin Oaks Center

Danvers, Essex County, Massachusetts · CCN 225198 · For-profit (LLC) · not part of a chain

CMS rates Twin Oaks Center 1 of 5 overall as of August 2026. 101 certified beds, 75 residents a day on average. 58 citations on record from the current inspection cycles, 4 involving actual harm; 1 fine totalling $2,186.

CMS’s ratings

The Five-Star Quality Rating System, as CMS publishes it. Where CMS gives no rating, the reason CMS gives is printed instead.

Overall★☆☆☆☆ 1 of 5
Health inspections★☆☆☆☆ 1 of 5
Staffing★☆☆☆☆ 1 of 5
Quality measures★★☆☆☆ 2 of 5
Quality: long-stay / short-stay3 / 2 of 5

Staffing

Total nurse staffing3.0185 hours per resident per day
Registered nurses0.23865 hours per resident per day
Weekend total2.83918 hours per resident per day
Nursing staff turnover44.3% (registered nurses 66.7%)
Administrators who left1

Citations from health inspections

Each is a finding by a state surveyor on the date shown, in CMS’s words. The severity is CMS’s scope-and-severity grid, spelled out: harm on the left, how widespread on the right.

SurveyFindingSeverityStatus
2025-06-18 Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Administration Deficiencies · tag F0835
F No actual harm, with potential for more than minimal harm; widespread Deficient, Provider has date of correction
2025-07-24
2025-06-18 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.
Administration Deficiencies · tag F0837
F No actual harm, with potential for more than minimal harm; widespread Deficient, Provider has date of correction
2025-07-24
2025-06-18 Have a plan that describes the process for conducting QAPI and QAA activities.
Administration Deficiencies · tag F0865
F No actual harm, with potential for more than minimal harm; widespread Deficient, Provider has date of correction
2025-07-24
2025-06-18 Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Administration Deficiencies · tag F0867
F No actual harm, with potential for more than minimal harm; widespread Deficient, Provider has date of correction
2025-07-24
2025-06-18 Provide and implement an infection prevention and control program.
Infection Control Deficiencies · tag F0880
F No actual harm, with potential for more than minimal harm; widespread Deficient, Provider has date of correction
2025-07-24
2025-06-18 Implement a program that monitors antibiotic use.
Infection Control Deficiencies · tag F0881
F No actual harm, with potential for more than minimal harm; widespread Deficient, Provider has date of correction
2025-07-24
2025-06-18 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.
Pharmacy Service Deficiencies · tag F0761
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2025-07-24
2025-06-18 Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Resident Rights Deficiencies · tag F0550
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-07-24
2025-06-18 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0609
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-07-24
2025-06-18 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Assessment and Care Planning Deficiencies · tag F0656
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-07-24
2025-06-18 Ensure services provided by the nursing facility meet professional standards of quality.
Resident Assessment and Care Planning Deficiencies · tag F0658
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-07-24
2025-06-18 Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies · tag F0684
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-07-24
2025-06-18 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.
Quality of Life and Care Deficiencies · tag F0688
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-07-24
2025-06-18 Provide enough food/fluids to maintain a resident's health.
Quality of Life and Care Deficiencies · tag F0692
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-07-24
2025-06-18 Provide care or services that was trauma informed and/or culturally competent.
Quality of Life and Care Deficiencies · tag F0699
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-07-24
2025-06-18 Ensure medication error rates are not 5 percent or greater.
Pharmacy Service Deficiencies · tag F0759
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-07-24
2025-06-18 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Resident Assessment and Care Planning Deficiencies · tag F0842
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-07-24
2025-06-18 Develop and implement policies and procedures for flu and pneumonia vaccinations.
Infection Control Deficiencies · tag F0883
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-07-24
2025-06-18 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.
Infection Control Deficiencies · tag F0887
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-07-24
2024-07-11 Provide enough food/fluids to maintain a resident's health.
Quality of Life and Care Deficiencies · tag F0692
G Actual harm that is not immediate jeopardy; isolated Deficient, Provider has date of correction
2024-07-11
2024-07-11 Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Administration Deficiencies · tag F0773
G Actual harm that is not immediate jeopardy; isolated Deficient, Provider has date of correction
2024-07-11
2024-07-11 Ensure services provided by the nursing facility meet professional standards of quality.
Resident Assessment and Care Planning Deficiencies · tag F0658
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2024-07-11
2023-12-12
complaint survey
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Resident Rights Deficiencies · tag F0568
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-01-15
2023-05-03 Ensure that residents are free from significant medication errors.
Pharmacy Service Deficiencies · tag F0760
H Actual harm that is not immediate jeopardy; pattern Deficient, Provider has date of correction
2023-05-03
2023-05-03 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · tag F0689
G Actual harm that is not immediate jeopardy; isolated Deficient, Provider has date of correction
2023-05-04
2023-05-03 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.
Resident Rights Deficiencies · tag F0584
F No actual harm, with potential for more than minimal harm; widespread Deficient, Provider has date of correction
2023-05-08
2023-05-03 Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Resident Assessment and Care Planning Deficiencies · tag F0636
F No actual harm, with potential for more than minimal harm; widespread Deficient, Provider has date of correction
2023-06-09
2023-05-03 Observe each nurse aide's job performance and give regular training.
Nursing and Physician Services Deficiencies · tag F0730
F No actual harm, with potential for more than minimal harm; widespread Deficient, Provider has date of correction
2023-06-16
2023-05-03 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.
Pharmacy Service Deficiencies · tag F0761
F No actual harm, with potential for more than minimal harm; widespread Deficient, Provider has date of correction
2023-06-27
2023-05-03 Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Administration Deficiencies · tag F0835
F No actual harm, with potential for more than minimal harm; widespread Deficient, Provider has date of correction
2023-05-09
2023-05-03 Have a plan that describes the process for conducting QAPI and QAA activities.
Administration Deficiencies · tag F0865
F No actual harm, with potential for more than minimal harm; widespread Deficient, Provider has date of correction
2023-06-02
2023-05-03 Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Administration Deficiencies · tag F0867
F No actual harm, with potential for more than minimal harm; widespread Deficient, Provider has date of correction
2023-06-02
2023-05-03 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Environmental Deficiencies · tag F0925
F No actual harm, with potential for more than minimal harm; widespread Deficient, Provider has date of correction
2023-05-15
2023-05-03 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Assessment and Care Planning Deficiencies · tag F0656
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2023-06-27
2023-05-03 Provide activities to meet all resident's needs.
Quality of Life and Care Deficiencies · tag F0679
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2023-06-09
2023-05-03 Ensure medication error rates are not 5 percent or greater.
Pharmacy Service Deficiencies · tag F0759
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2023-06-16
2023-05-03 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Nutrition and Dietary Deficiencies · tag F0804
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2023-06-02
2023-05-03 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies · tag F0812
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2023-05-29
2023-05-03 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Resident Assessment and Care Planning Deficiencies · tag F0842
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2023-06-09
2023-05-03 Ensure that residents are fully informed and understand their health status, care and treatments.
Resident Rights Deficiencies · tag F0552
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-06-16
2023-05-03 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.
Resident Rights Deficiencies · tag F0585
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-06-09
2023-05-03 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0609
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-06-09
2023-05-03 Respond appropriately to all alleged violations.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0610
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-06-09
2023-05-03 Assure that each resident’s assessment is updated at least once every 3 months.
Resident Assessment and Care Planning Deficiencies · tag F0638
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-06-09
2023-05-03 Ensure each resident receives an accurate assessment.
Resident Assessment and Care Planning Deficiencies · tag F0641
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-06-09
2023-05-03 Ensure services provided by the nursing facility meet professional standards of quality.
Resident Assessment and Care Planning Deficiencies · tag F0658
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-06-09
2023-05-03 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Quality of Life and Care Deficiencies · tag F0676
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-06-09
2023-05-03 Provide care and assistance to perform activities of daily living for any resident who is unable.
Quality of Life and Care Deficiencies · tag F0677
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-06-09
2023-05-03 Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies · tag F0684
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-06-09
2023-05-03 Provide appropriate foot care.
Quality of Life and Care Deficiencies · tag F0687
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-06-09
2023-05-03 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.
Quality of Life and Care Deficiencies · tag F0693
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-05-03
2023-05-03 Provide safe and appropriate respiratory care for a resident when needed.
Quality of Life and Care Deficiencies · tag F0695
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-06-09
2023-05-03 Provide safe, appropriate dialysis care/services for a resident who requires such services.
Quality of Life and Care Deficiencies · tag F0698
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-06-09
2023-05-03 Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Nursing and Physician Services Deficiencies · tag F0725
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-06-12
2023-05-03 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.
Nursing and Physician Services Deficiencies · tag F0726
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-06-16
2023-05-03 Provide or obtain dental services for each resident.
Quality of Life and Care Deficiencies · tag F0791
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-06-09
2023-05-03 Implement a program that monitors antibiotic use.
Infection Control Deficiencies · tag F0881
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-05-05
2023-05-03 Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Nursing and Physician Services Deficiencies · tag F0947
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-06-09

Fines and payment denials

DatePenaltyAmount
2024-07-11Fine$2,186

Who owns and runs it

Every owner, officer and manager CMS lists, as filed. These are the names in CMS’s ownership record; anyone named in the ownership record can ask about it on the about page.

NameRoleShareSince
Ma Snf Holdings LLC
Organization
5% or greater direct ownership interest100%2024-03-15
Celtic Bank Corporation
Organization
5% or greater mortgage interest2024-09-03
Ma Snf Holdings LLC
Organization
adp of the snf2024-12-03
Zenith Care LLC
Organization
adp of the snf2024-12-03
Zenith Care LLC
Organization
operational/managerial control2024-09-03
Ishakis, Yochanan
Individual
5% or greater indirect ownership interest45%2024-03-15
Levine, Yisroel
Individual
5% or greater indirect ownership interest55%2024-03-15
Aweh, Nelson
Individual
adp of the snf2024-12-03
Bastien, Reginald
Individual
adp of the snf2024-09-03
Ishakis, Yochanan
Individual
adp of the snf2024-09-03
Levine, Yisroel
Individual
adp of the snf2024-12-03
Bastien, Reginald
Individual
operational/managerial control2024-09-03
Levine, Yisroel
Individual
operational/managerial control2024-12-03

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Source: Centers for Medicare & Medicaid Services, Provider Data Catalog (public domain), files dated 2026-08-01. Ratings are CMS’s; citations are state surveyors’ findings; nothing here is estimated or a recommendation. Every nursing home in Essex County.