Twin Oaks Center
63 Locust Street, Danvers, MA 01923 · Essex County · 101 certified beds · avg 75 residents/day · certified since Jun 30, 1970 · Medicare and Medicaid certified
Certified for both programmes. Certification means the facility can bill Medicaid — it does not mean a Medicaid-funded bed is free right now, so ask directly. Who pays for nursing home care →
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 1/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Actual harm, one-off · Jul 11, 2024 · F-0692
The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration.
Why it matters: Malnutrition and dehydration can quickly weaken a resident and lead to serious complications.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jul 11, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Jul 11, 2024 · F-0773
The facility did not provide or obtain laboratory tests when a doctor ordered them, or did not promptly report the results back to the doctor who ordered them.
Why it matters: Delayed labs or unreported results can hold up a diagnosis and delay urgent treatment.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jul 11, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, repeated · May 3, 2023 · F-0760
The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication.
Why it matters: A serious medication error can cause real harm, hospitalization, or worse.
Severity (H): Multiple residents were actually harmed by the same failure — a pattern of real harm, not an isolated incident.
Corrected: May 3, 2023 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · May 3, 2023 · F-0689
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: May 4, 2023 (Deficient, Provider has date of correction)
All citations in the current public record (58)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Jun 18, 2025 | F · Potential for harm, facility-wide | The facility was not managed in a way that uses its money, staff, and resources effectively and efficiently to care for residents. |
| Jun 18, 2025 | F · Potential for harm, facility-wide | The facility did not have a proper governing body legally responsible for its policies and operations, or that body failed to appoint a properly licensed administrator to manage the facility. |
| Jun 18, 2025 | F · Potential for harm, facility-wide | The facility did not have a written plan describing how it runs its quality improvement program — the ongoing process of finding problems in care and fixing them. |
| Jun 18, 2025 | F · Potential for harm, facility-wide | The facility did not run an ongoing quality assurance committee that reviews care problems and creates plans to fix them. |
| Jun 18, 2025 | F · Potential for harm, facility-wide | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Jun 18, 2025 | F · Potential for harm, facility-wide | The facility did not have a working program to monitor how antibiotics are used. Tracking antibiotic use helps make sure these drugs are given only when needed and remain effective. |
| Jun 18, 2025 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Jun 18, 2025 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. |
| Jun 18, 2025 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. |
| Jun 18, 2025 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Jun 18, 2025 | D · Potential for harm, one-off | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. |
| Jun 18, 2025 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Jun 18, 2025 | D · Potential for harm, one-off | The facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline. |
| Jun 18, 2025 | D · Potential for harm, one-off | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. |
| Jun 18, 2025 | D · Potential for harm, one-off | The facility did not provide care that took into account residents' past trauma or their cultural backgrounds. Care is supposed to be sensitive to what residents have lived through and where they come from. |
| Jun 18, 2025 | D · Potential for harm, one-off | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. |
| Jun 18, 2025 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. |
| Jun 18, 2025 | D · Potential for harm, one-off | The facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations. |
| Jun 18, 2025 | D · Potential for harm, one-off | The facility did not educate residents and staff about COVID-19 vaccination, offer the vaccine to those eligible after that education, or properly document everyone's vaccination status. |
| Jul 11, 2024 | ▲ G · Actual harm, one-off | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. |
| Jul 11, 2024 | ▲ G · Actual harm, one-off | The facility did not provide or obtain laboratory tests when a doctor ordered them, or did not promptly report the results back to the doctor who ordered them. |
| Jul 11, 2024 | E · Potential for harm, repeated | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. |
| Dec 12, 2023 | D · Potential for harm, one-off | The facility did not properly hold, secure, and manage residents' personal money that was deposited with it for safekeeping. Facilities holding residents' funds must keep careful, honest accounts. · from a complaint |
| May 3, 2023 | ▲ H · Actual harm, repeated | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. |
| May 3, 2023 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| May 3, 2023 | F · Potential for harm, facility-wide | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. |
| May 3, 2023 | F · Potential for harm, facility-wide | The facility did not fully assess residents on time — a complete assessment of health, abilities, and needs is required when a resident is first admitted and at least once every 12 months after that. |
| May 3, 2023 | F · Potential for harm, facility-wide | The facility did not observe each nurse aide's job performance or provide regular training as required. |
| May 3, 2023 | F · Potential for harm, facility-wide | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| May 3, 2023 | F · Potential for harm, facility-wide | The facility was not managed in a way that uses its money, staff, and resources effectively and efficiently to care for residents. |
| May 3, 2023 | F · Potential for harm, facility-wide | The facility did not have a written plan describing how it runs its quality improvement program — the ongoing process of finding problems in care and fixing them. |
| May 3, 2023 | F · Potential for harm, facility-wide | The facility did not run an ongoing quality assurance committee that reviews care problems and creates plans to fix them. |
| May 3, 2023 | F · Potential for harm, facility-wide | The facility did not maintain an effective pest control program to prevent or deal with mice, insects, or other pests. |
| May 3, 2023 | E · Potential for harm, repeated | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| May 3, 2023 | E · Potential for harm, repeated | The facility did not provide activities that meet residents' needs and interests. Nursing homes must offer meaningful activity programs, not just leave residents idle. |
| May 3, 2023 | E · Potential for harm, repeated | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. |
| May 3, 2023 | E · Potential for harm, repeated | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. |
| May 3, 2023 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| May 3, 2023 | E · Potential for harm, repeated | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. |
| May 3, 2023 | D · Potential for harm, one-off | The facility did not make sure residents were fully informed about their own health, care, and treatments in a way they could understand. |
| May 3, 2023 | D · Potential for harm, one-off | The facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly. |
| May 3, 2023 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. |
| May 3, 2023 | D · Potential for harm, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. |
| May 3, 2023 | D · Potential for harm, one-off | The facility did not update each resident's care assessment at least once every 3 months. These regular check-ins keep the resident's care plan matched to their current condition. |
| May 3, 2023 | D · Potential for harm, one-off | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| May 3, 2023 | D · Potential for harm, one-off | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. |
| May 3, 2023 | D · Potential for harm, one-off | The facility allowed residents to lose the ability to do daily activities — like bathing, dressing, and eating — when there was no medical reason for the decline. Good care helps residents keep the abilities they have. |
| May 3, 2023 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| May 3, 2023 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| May 3, 2023 | D · Potential for harm, one-off | The facility did not provide proper foot care for residents. Foot care includes routine care like nail trimming and attention to foot problems, which matter greatly for older adults. |
| May 3, 2023 | D · Potential for harm, one-off | The facility used feeding tubes without a valid medical reason or the resident's agreement, or did not provide proper care to residents who have feeding tubes. |
| May 3, 2023 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| May 3, 2023 | D · Potential for harm, one-off | The facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail. |
| May 3, 2023 | D · Potential for harm, one-off | The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. |
| May 3, 2023 | D · Potential for harm, one-off | The facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident. |
| May 3, 2023 | D · Potential for harm, one-off | The facility did not provide or arrange dental services for its residents. Nursing homes are responsible for making sure residents can get dental care. |
| May 3, 2023 | D · Potential for harm, one-off | The facility did not have a working program to monitor how antibiotics are used. Tracking antibiotic use helps make sure these drugs are given only when needed and remain effective. |
| May 3, 2023 | D · Potential for harm, one-off | The facility did not make sure its nurse aides had the skills needed to care for residents, including training in dementia care and abuse prevention. |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (3 → 19).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 36 | 2 | H ▲ |
| 2024 | 3 | 2 | G ▲ |
| 2025 | 19 | 0 | F |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
1 fine totaling $2,186.
| Date | Type | Amount / length |
|---|---|---|
| Jul 11, 2024 | Fine | $2,186 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Massachusetts avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.03 | 3.89 | 3.95 | bottom 8% in Massachusetts; bottom 15% in the U.S. |
| Registered Nurse hours | 0.24 | 0.65 | 0.69 | bottom 2% in Massachusetts; bottom 5% in the U.S. |
| Weekend total nurse staffing | 2.85 | 3.51 | 3.50 | bottom 12% in Massachusetts; bottom 23% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.15 | 0.46 | 0.48 | bottom 3% in Massachusetts; bottom 5% in the U.S. |
| Total nursing staff turnover (%) | 44.3 | 38.2 | 45.8 | bottom 27% in Massachusetts; top 48% in the U.S. |
| RN turnover (%) | 66.7 | 42.6 | 42.9 | bottom 12% in Massachusetts; bottom 15% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.02, RN 0.24, weekend 2.84. Staffing rating: 1/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 2/5 · long-stay residents: 3/5 · short-stay residents: 2/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Ishakis, Yochanan | Individual | 5% or Greater Indirect Ownership Interest | 45% | 03/15/2024 |
| Levine, Yisroel | Individual | 5% or Greater Indirect Ownership Interest | 55% | 03/15/2024 |
| Ma SNF Holdings LLC | Organization | 5% or Greater Direct Ownership Interest | 100% | 03/15/2024 |
| Aweh, Nelson | Individual | ADP of the SNF | NOT APPLICABLE | 12/03/2024 |
| Bastien, Reginald | Individual | Operational/Managerial Control | NOT APPLICABLE | 09/03/2024 |
| Bastien, Reginald | Individual | ADP of the SNF | NOT APPLICABLE | 09/03/2024 |
| Celtic Bank Corporation | Organization | 5% or Greater Mortgage Interest | NOT APPLICABLE | 09/03/2024 |
| Ishakis, Yochanan | Individual | ADP of the SNF | NOT APPLICABLE | 09/03/2024 |
| Levine, Yisroel | Individual | Operational/Managerial Control | NOT APPLICABLE | 12/03/2024 |
| Levine, Yisroel | Individual | ADP of the SNF | NOT APPLICABLE | 12/03/2024 |
| Ma SNF Holdings LLC | Organization | ADP of the SNF | NOT APPLICABLE | 12/03/2024 |
| Zenith Care LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 09/03/2024 |
| Zenith Care LLC | Organization | ADP of the SNF | NOT APPLICABLE | 12/03/2024 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "How do you monitor residents' weight and eating, and what happens when someone starts losing weight?"
- "When a doctor orders lab work, how quickly is it done and how are results communicated back?"
- "What systems do you use to prevent medication errors, and what happens when one occurs?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "What were the findings behind this administration citation, and what has leadership changed since?"
- "Who owns and governs this facility, and how long has the current administrator been here?"
- "How does your quality improvement program work, and can you share a recent example of a problem you found and fixed?"
- "How does your quality committee work, and can you give an example of a problem it recently identified and fixed?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Hunt Nursing & Rehab Center | 0.4 mi | Danvers, MA | ★★★★☆ | 4/5 | |
| Brentwood Rehabilitation and Healthcare Ctr (the) | 1.0 mi | Danvers, MA | ★★★★☆ | 4/5 | |
| Care One at Peabody | 1.8 mi | Peabody, MA | ★★★★★ | 5/5 | |
| Hathorne Hill Rehabilitation and Healthcare Center | 1.9 mi | Danvers, MA | ★★★★☆ | 4/5 | |
| New England Homes for the Deaf, INC | 2.1 mi | Danvers, MA | ★★★★☆ | 3/5 | |
| Continuing Care at Brooksby Village | 2.3 mi | Peabody, MA | ★★★★☆ | 3/5 | |
| Ledgewood Rehabilitation and Nursing Center | 3.1 mi | Beverly, MA | ★★★★☆ | 4/5 | |
| Pilgrim Rehabilitation & Skilled Nursing Center | 3.2 mi | Peabody, MA | ★★★★☆ | 4/5 | |
| Blueberry Hill Rehabilitation and Healthcare Ctr | 3.3 mi | Beverly, MA | ★☆☆☆☆ | 1/5 | |
| Alliance Health at Rosewood | 3.4 mi | Peabody, MA | ★★★☆☆ | 3/5 | |
| Care One at Essex Park | 3.8 mi | Beverly, MA | ★★★★☆ | 4/5 | |
| Masconomet Rehabilitation and Healthcare Center | 4.1 mi | Topsfield, MA | ★★★☆☆ | 3/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 225198.