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Nursing HomeMedicaid Investigative

Twin Oaks Center

Below-average Medicare ratings — review the inspection history and ask the administrator about recent corrections before visiting.

63 Locust Street, Danvers, MA 01923101 bedsLicensed & Active
1/5
Medicare
Inspection
Quality
Staffing
Google rating
3.5/5

based on 43 Google reviews

5
4
3
2
1
Twin Oaks Center Nursing Home in Danvers, MA — Street View
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6/ 10
high Risk

Quality Concerns Identified

Medicare inspection and quality data reveal areas that families should carefully evaluate before choosing this facility.

  • Low overall rating (1/5 stars)
  • Low staffing rating (1/5 stars)
  • Above-median deficiencies (19 vs median 7.0)
  • High staff turnover (55%)
  • High RN turnover (91%)

Bottom 25% in MA · Critically understaffed (RN) · $141,733 in fines

Source: Medicare data

What this means for your family

While the physical therapy department is frequently praised, the facility faces consistent, serious allegations regarding cleanliness and patient neglect. Families should conduct an unannounced visit to inspect the environment personally and ask for a clear plan on how the facility ensures communication with families regarding medical changes.

Google Reviews

Google Reviews

43 reviews on Google
Twin Oaks Center receives highly polarized feedback, with long-term residents often reporting satisfaction while family members of short-term rehab patients frequently express severe concerns. Critical issues include reports of poor hygiene, neglect, and communication failures, while positive reviews often highlight specific staff members and the effectiveness of the physical therapy department.

Quality Themes

Tap a score for details
Food3.0Staff5.0Clean2.0Activities5.0Meds1.0MemoryN/AComms2.0ValueN/A

Strengths

  • Effective physical and occupational therapy
  • Specific, dedicated nursing and CNA staff
  • Helpful social services department

Concerns

  • Unsanitary facility conditions and lack of cleanliness (mentioned by 6 reviewers)
  • Poor communication with families regarding patient status (mentioned by 3 reviewers)
  • Inattentive or rude staff behavior (mentioned by 5 reviewers)
  • Medication management and over-sedation issues (mentioned by 2 reviewers)

Rating Trends

Tap a year to see what changed

234'14(1)'19(5)'21(10)'23(4)'25(9)'26(7)

Distribution · 45 analyzed

5
24
4
4
3
0
2
4
1
13

How They Respond to Reviews

23%response rate

This facility rarely responds to reviews.

Questions for Your Tour

  • 1Given the recent focus on facility maintenance, could you walk me through your current daily cleaning schedule and how you ensure high standards of hygiene in resident rooms?
  • 2I noticed that communication is a top priority for families; what is your specific process for updating family members on a resident's health status or any changes in their care plan?
  • 3With your strong reputation for physical and occupational therapy, how do you integrate those services into the daily routine of residents who aren't in active rehab sessions?
  • 4What protocols do you have in place to ensure accuracy and safety during medication administration, and how do you monitor for potential side effects?
  • 5I see that you occasionally respond to feedback online; how do you use that input from families to improve the day-to-day experience and staff interactions within the facility?
  • 6How do you support your nursing and CNA staff to ensure they have the resources needed to provide attentive and compassionate care to every resident throughout their shift?

Personalized based on this facility's data


Key Review Excerpts

My father is a fully functional person he had to be sent here due to COPD from the hospital for rehab and his health declined being there. The facility is gross the bathrooms and rooms. some staff sleeping on the job , Some of the nurse staff is awful

Rehab patient's family · 2025☆☆☆☆

I really enjoy going to therapy everyday and working with Denise and Brian from therapy. PT and OT does a fantastic job.

Long-term resident · 2025★★★★★

The fact that any positive review here is from staff members,who I'm sure we're asked to write one, should tell you all you need to know. The place is dirty, disorganized, poorly run and anyone who steps in there for 30seconds with an objective opinion would see that.

Visitor · 2021☆☆☆☆
Source: 43 Google reviews

Staffing

Staffing Hours

per resident/day · Medicare 2026
RN Hours
0.29hrs
38%
Registered nurses for medical care
Total Nursing
2.89hrs
70%
All nurses + aides combined
Staff Turnover
47%
Lower is better (< 30% = good)
RN Turnover
79%
Lower is better (< 30% = good)

Both RN and total nursing hours are below national benchmarks. This can mean less clinical attention per resident, so ask about their staffing plan.

Quality Measures

Quality Measures

Resident outcomes compared with national, state, and local averages · 17 measures

Medicare Rating
2/ 5
Better Than Avg

6

measures

Worse Than Avg

10

measures

Mixed Results

1

measures

Long-Stay Residents
💊

Residents on antipsychotic medication

↓ Lower is better
This Facility41.5%
Worse than Avg
Here
41.5%
US
15.4%
MA
21.3%
Essex
22.8%
😔

Residents with depression symptoms

↓ Lower is better
This Facility26.9%
Worse than Avg
Here
26.9%
US
12.1%
MA
13.7%
Essex
18.2%

Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.

💉

Residents vaccinated for pneumonia

↑ Higher is better
This Facility81.1%
Worse than Avg
Here
81.1%
US
93.4%
MA
92.4%
Essex
93.5%
💊

Residents on anti-anxiety or sleep medication

↓ Lower is better
This Facility28.1%
Worse than Avg
Here
28.1%
US
19.5%
MA
19.4%
Essex
19.3%
🚿

Residents whose bladder or bowel control got worse

↓ Lower is better
This Facility24.7%
Worse than Avg
Here
24.7%
US
19.4%
MA
21.4%
Essex
20.8%
💉

Residents vaccinated for the flu

↑ Higher is better
This Facility91.8%
Worse than Avg
Here
91.8%
US
95.5%
MA
94.8%
Essex
96.2%
Short-Stay Residents (Rehab / Post-Acute)
💉

Short-stay residents vaccinated for the flu

↑ Higher is better
This Facility34.6%
Worse than Avg
Here
34.6%
US
79.7%
MA
77.7%
Essex
82.8%
💉

Short-stay residents vaccinated for pneumonia

↑ Higher is better
This Facility40.8%
Worse than Avg
Here
40.8%
US
81.8%
MA
77.6%
Essex
83.1%
💊

Short-stay residents newly given antipsychotics

↓ Lower is better
This Facility0.0%
Better than Avg
Here
0.0%
US
1.6%
MA
1.3%
Essex
1.6%
Source: Medicare quality measures

US average from Medicare published data

Inspection History

Medicare Inspection History

3-year lookback · Medicare 2026

19deficiencies
1penalties
Well above state avg (8.9)
1 complaint-triggered
$141,733 in fines

Twin Oaks Center shows significant recurring compliance issues across multiple surveys, with 82 deficiencies spanning medication management, resident care planning, and safety systems. The facility has faced problems with medication errors (including one high-severity case), emergency preparedness failures, and fire safety violations that persist across different survey periods. One family filed a complaint regarding mishandling of residents' personal funds, indicating ongoing concerns about financial management and resident rights.

Jun 18, 2025Routine
33
0004Potential for harm · WidespreadCorrected

Emergency Preparedness Deficiencies

Develop and maintain an Emergency Preparedness Program (EP).

0013Potential for harm · WidespreadCorrected

Emergency Preparedness Deficiencies

Develop Emergency Preparedness policies and procedures.

0029Potential for harm · WidespreadCorrected

Emergency Preparedness Deficiencies

Develop a communication plan.

0036Potential for harm · WidespreadCorrected

Emergency Preparedness Deficiencies

Establish emergency prep training and testing.

0211Potential for harm · WidespreadCorrected

Egress Deficiencies

Keep aisles, corridors, and exits free of obstruction in case of emergency.

0222Potential for harm · WidespreadCorrected

Egress Deficiencies

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

0324Potential for harm · WidespreadCorrected

Smoke Deficiencies

Provide properly protected cooking facilities.

0345Potential for harm · WidespreadCorrected

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

0353Potential for harm · WidespreadCorrected

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

0521Potential for harm · WidespreadCorrected

Services Deficiencies

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

0531Potential for harm · WidespreadCorrected

Services Deficiencies

Have elevators that firefighters can control in the event of a fire.

0712Potential for harm · WidespreadCorrected

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

0914Potential for harm · WidespreadCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

0918Potential for harm · WidespreadCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

0835Potential for harm · WidespreadCorrected

Administration Deficiencies

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

0837Potential for harm · WidespreadCorrected

Administration Deficiencies

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.

0865Potential for harm · WidespreadCorrected

Administration Deficiencies

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

0867Potential for harm · WidespreadCorrected

Administration Deficiencies

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

0880Potential for harm · WidespreadCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

0881Potential for harm · WidespreadCorrected

Infection Control Deficiencies

Implement a program that monitors antibiotic use.

0761Potential for harm · PatternCorrected

Pharmacy Service Deficiencies

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.

0550Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

0609Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

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

0656Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

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

0658Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

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

0684Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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

0688Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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.

0692Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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

0699Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide care or services that was trauma informed and/or culturally competent.

0759Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

0842Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

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

0883Potential for harm · IsolatedCorrected

Infection Control Deficiencies

Develop and implement policies and procedures for flu and pneumonia vaccinations.

0887Potential for harm · IsolatedCorrected

Infection Control Deficiencies

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.

Jul 11, 2024Routine
10
0692Actual harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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

0773Actual harm · IsolatedCorrected

Administration Deficiencies

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

0351Potential for harm · PatternCorrected

Smoke Deficiencies

Install an approved automatic sprinkler system.

0658Potential for harm · PatternCorrected

Resident Assessment and Care Planning Deficiencies

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

0015Potential for harm · IsolatedCorrected

Emergency Preparedness Deficiencies

Address subsistence needs for staff and patients.

0026Potential for harm · IsolatedCorrected

Emergency Preparedness Deficiencies

Establish roles under a Waiver declared by secretary.

0036Potential for harm · IsolatedCorrected

Emergency Preparedness Deficiencies

Establish emergency prep training and testing.

0037Potential for harm · IsolatedCorrected

Emergency Preparedness Deficiencies

Establish staff and initial training requirements.

0324Potential for harm · IsolatedCorrected

Smoke Deficiencies

Provide properly protected cooking facilities.

0353Potential for harm · IsolatedCorrected

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Dec 12, 2023Complaint
1
0568Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

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

May 3, 2023Routine
38
0760Actual harm · PatternCorrected

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

0689Actual harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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

0291Potential for harm · WidespreadCorrected

Egress Deficiencies

Install emergency lighting that can last at least 1 1/2 hours.

0712Potential for harm · WidespreadCorrected

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

0761Potential for harm · WidespreadCorrected

Miscellaneous Deficiencies

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

0584Potential for harm · WidespreadCorrected

Resident Rights Deficiencies

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.

0636Potential for harm · WidespreadCorrected

Resident Assessment and Care Planning Deficiencies

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

0730Potential for harm · WidespreadCorrected

Nursing and Physician Services Deficiencies

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

0761Potential for harm · WidespreadCorrected

Pharmacy Service Deficiencies

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.

0835Potential for harm · WidespreadCorrected

Administration Deficiencies

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

0865Potential for harm · WidespreadCorrected

Administration Deficiencies

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

0867Potential for harm · WidespreadCorrected

Administration Deficiencies

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

0925Potential for harm · WidespreadCorrected

Environmental Deficiencies

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

0656Potential for harm · PatternCorrected

Resident Assessment and Care Planning Deficiencies

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

0679Potential for harm · PatternCorrected

Quality of Life and Care Deficiencies

Provide activities to meet all resident's needs.

0759Potential for harm · PatternCorrected

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

0804Potential for harm · PatternCorrected

Nutrition and Dietary Deficiencies

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

0812Potential for harm · PatternCorrected

Nutrition and Dietary Deficiencies

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

0842Potential for harm · PatternCorrected

Resident Assessment and Care Planning Deficiencies

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

0610Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

0695Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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

0552Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

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

0585Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

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.

0609Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

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

0638Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

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

0641Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Ensure each resident receives an accurate assessment.

0658Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

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

0676Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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

0677Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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

0684Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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

0687Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide appropriate foot care.

0693Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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.

0698Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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

0725Potential for harm · IsolatedCorrected

Nursing and Physician Services Deficiencies

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

0726Potential for harm · IsolatedCorrected

Nursing and Physician Services Deficiencies

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.

0791Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide or obtain dental services for each resident.

0881Potential for harm · IsolatedCorrected

Infection Control Deficiencies

Implement a program that monitors antibiotic use.

0947Potential for harm · IsolatedCorrected

Nursing and Physician Services Deficiencies

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

Federal Penalties

Fine

Jul 11, 2024

$2,186

Ownership & Operations

Who Operates This Facility

Owner / Operator

Twin Oaks Center

Organization Type

for profit

Ownership & Management

Owners

Ma Snf Holdings LLC

Owner · Organization

100%

Ishakis, Yochanan

Owner (parent company)

45%

Levine, Yisroel

Owner (parent company)

55%

Key personnel

Celtic Bank Corporation5% or Greater Mortgage InterestZenith Care LLCManagerBastien, ReginaldManagerLevine, YisroelManagerMa Snf Holdings LLCAdp of the Snf
Source: Medicare provider data

Contact

Get in Touch

Contact this facility directly and verify the details that matter most to your family.

References & Resources

EveryPlace is a research directory. Facility information is compiled from public sources — Medicare.gov, state licensing portals, Google Places, and publicly available street-level imagery. Listings do not constitute endorsement, recommendation, or advertisement, and we do not accept payment for placement. Families should verify all details directly with the facility and the original sources linked above before making any care decisions. See our Research Policy for our editorial standards, correction process, and image-removal policy.

Safer Alternatives Nearby

Based on current clinical data, we identified 6 nearby facilities within 10 miles that may offer a stronger care environment. We encourage families to compare options carefully.

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