Federal Nursing-Home Survey Record
TWIN OAKS CENTER
Does TWIN OAKS CENTER have a federal violation or abuse history?
According to the public federal record on file with the Centers for Medicare & Medicaid Services (CMS), TWIN OAKS CENTER (CCN 225198), in DANVERS, MA, has federal inspection findings on its record.
In its current inspection cycle, CMS cited the facility for 19 deficiencies; the most serious carries scope/severity F on CMS's A–L scale — CMS's "potential for harm" tier, below actual harm. Citations from earlier inspection cycles appear in the dated timeline below as historical findings, not current ones. CMS has $2,186 in civil money penalties on file against the facility. This page restates the federal record as published by CMS and draws no conclusion of its own. Federal nursing-home surveys are conducted on a recurring cycle by state survey agencies acting on CMS's behalf, and the figures on this page are compiled from CMS's published provider data, as on file with CMS; the federal record may understate what actually occurred, and inspection findings are point-in-time survey results, not a determination that any specific resident was harmed.
The Federal Record
CMS has $2,186 in civil money penalties on file against this facility.
Below is this facility's federal survey record as on file with CMS.
Scope & Severity — current cycle
Civil money penalties on file
$2,186
CMS has $2,186 in civil money penalties on file against this facility.
Overall CMS star rating: this facility vs the CMS-published state average
This facility: 1 · CMS state average: 3.1
Deficiency timeline — full federal history
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Implement a program that monitors antibiotic use.
Provide and implement an infection prevention and control program.
Have a plan that describes the process for conducting QAPI and QAA activities.
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.
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
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.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Ensure services provided by the nursing facility meet professional standards of quality.
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Provide enough food/fluids to maintain a resident's health.
Ensure medication error rates are not 5 percent or greater.
Provide care or services that was trauma informed and/or culturally competent.
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.
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
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.
39 citations from earlier inspection cycles — historical, not current (expand)
Provide enough food/fluids to maintain a resident's health.
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Ensure services provided by the nursing facility meet professional standards of quality.
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Ensure that residents are free from significant medication errors.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
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.
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Observe each nurse aide's job performance and give regular training.
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.
Have a plan that describes the process for conducting QAPI and QAA activities.
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Provide activities to meet all resident's needs.
Ensure medication error rates are not 5 percent or greater.
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Ensure services provided by the nursing facility meet professional standards of quality.
Ensure that residents are fully informed and understand their health status, care and treatments.
Ensure each resident receives an accurate assessment.
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Assure that each resident’s assessment is updated at least once every 3 months.
Respond appropriately to all alleged violations.
Implement a program that monitors antibiotic use.
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Provide safe and appropriate respiratory care for a resident when needed.
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
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.
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.
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Provide appropriate foot care.
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.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Provide or obtain dental services for each resident.
Provide care and assistance to perform activities of daily living for any resident who is unable.
Document what happened
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