TWIN OAKS CENTER
63 LOCUST STREET, DANVERS, MA, 01923 · 9787770011
Legal business name: LOCUST STREET OPERATIONS LLC
On the CMS record
- Overall rating (CMS)
- 1 / 5
- Health inspection rating
- 1 / 5
- Staffing rating
- 1 / 5
- Certified beds
- 101
- Ownership type
- For profit - Limited Liability company
Inspection findings on record (58)
Quoted exactly as CMS published them. We do not rewrite findings.
— Administration Deficiencies
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Recorded as corrected on .
— 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.
Recorded as corrected on .
— Administration Deficiencies
Have a plan that describes the process for conducting QAPI and QAA activities.
Recorded as corrected on .
— Administration Deficiencies
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Recorded as corrected on .
— Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Recorded as corrected on .
— Infection Control Deficiencies
Implement a program that monitors antibiotic use.
Recorded as corrected on .
— 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.
Recorded as corrected on .
— Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Recorded as corrected on .
— Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Recorded as corrected on .
— 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.
Recorded as corrected on .
— Resident Assessment and Care Planning Deficiencies
Ensure services provided by the nursing facility meet professional standards of quality.
Recorded as corrected on .
— Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Recorded as corrected on .
— 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.
Recorded as corrected on .
— Quality of Life and Care Deficiencies
Provide enough food/fluids to maintain a resident's health.
Recorded as corrected on .
— Quality of Life and Care Deficiencies
Provide care or services that was trauma informed and/or culturally competent.
Recorded as corrected on .
— Pharmacy Service Deficiencies
Ensure medication error rates are not 5 percent or greater.
Recorded as corrected on .
— 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.
Recorded as corrected on .
— Infection Control Deficiencies
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Recorded as corrected on .
— 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.
Recorded as corrected on .
— Quality of Life and Care Deficiencies
Provide enough food/fluids to maintain a resident's health.
Recorded as corrected on .
— Administration Deficiencies
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Recorded as corrected on .
— Resident Assessment and Care Planning Deficiencies
Ensure services provided by the nursing facility meet professional standards of quality.
Recorded as corrected on .
— Resident Rights Deficiencies
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Recorded as corrected on .
— Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
Recorded as corrected on .
— Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Recorded as corrected on .
— 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.
Recorded as corrected on .
— 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.
Recorded as corrected on .
— Nursing and Physician Services Deficiencies
Observe each nurse aide's job performance and give regular training.
Recorded as corrected on .
— 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.
Recorded as corrected on .
— Administration Deficiencies
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Recorded as corrected on .
— Administration Deficiencies
Have a plan that describes the process for conducting QAPI and QAA activities.
Recorded as corrected on .
— Administration Deficiencies
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Recorded as corrected on .
— Environmental Deficiencies
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Recorded as corrected on .
— 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.
Recorded as corrected on .
— Quality of Life and Care Deficiencies
Provide activities to meet all resident's needs.
Recorded as corrected on .
— Pharmacy Service Deficiencies
Ensure medication error rates are not 5 percent or greater.
Recorded as corrected on .
— Nutrition and Dietary Deficiencies
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Recorded as corrected on .
— Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Recorded as corrected on .
— 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.
Recorded as corrected on .
— Resident Rights Deficiencies
Ensure that residents are fully informed and understand their health status, care and treatments.
Recorded as corrected on .
— 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.
Recorded as corrected on .
— Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Recorded as corrected on .
— Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
Recorded as corrected on .
— Resident Assessment and Care Planning Deficiencies
Assure that each resident’s assessment is updated at least once every 3 months.
Recorded as corrected on .
— Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
Recorded as corrected on .
— Resident Assessment and Care Planning Deficiencies
Ensure services provided by the nursing facility meet professional standards of quality.
Recorded as corrected on .
— 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.
Recorded as corrected on .
— Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Recorded as corrected on .
— Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Recorded as corrected on .
— Quality of Life and Care Deficiencies
Provide appropriate foot care.
Recorded as corrected on .
— 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.
Recorded as corrected on .
— Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
Recorded as corrected on .
— Quality of Life and Care Deficiencies
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Recorded as corrected on .
— 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.
Recorded as corrected on .
— 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.
Recorded as corrected on .
— Quality of Life and Care Deficiencies
Provide or obtain dental services for each resident.
Recorded as corrected on .
— Infection Control Deficiencies
Implement a program that monitors antibiotic use.
Recorded as corrected on .
— 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.
Recorded as corrected on .
Source: Centers for Medicare & Medicaid Services (CMS) · CMS Certification Number 225198