Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record

Penacook Place, Inc

HAVERHILL, MA · 160 certified beds · Last Life Safety survey June 4, 2025

CMS Certification Number 225376 · first certified July 1990

Ownership

Operated by COVENANT HEALTH · Non profit - Church related

No change of ownership on CMS record since January 1, 2016, when the records begin.

25
Citations on file
Rolling three-year window
3
Life Safety surveys
In the same window
3
Tags cited more than once
Across separate surveys
11
Inspection & testing records
Of the citations on file

Position within MA

25 citations — more than 91% of the 341 certified nursing homes in MA. Compared within MA rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated

Slippingmore citations at the latest survey than at its earlier surveys in the window.

The latest survey found 17 citations; the earlier surveys in the window averaged 4. With 3 surveys on file this is a direction of travel, not a conclusion.

When is the next survey likely?

Well past the typical window (June 2026 to August 2026), and past the point by which nine in ten MA facilities have been surveyed. This facility’s last Life Safety survey was June 2025. Facilities in MA are typically surveyed 12–15 months after the last one (median 13), measured over 556 consecutive surveys in the last two years of CMS records.

A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured

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Which alerts

3 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.

Emergency preparedness

6 of the 25 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index

Physical environment (health survey)

2 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 25 Life Safety citations above. The Physical Environment Index

  • F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  • F-0880 Provide and implement an infection prevention and control program.

How that compares

Citations on file over three years

Compared with the median facility in MA, and nationally. Surveyors differ markedly between states, so the MA figure is the meaningful one.

This facility25MA median11National median11
Citations on file over three years, compared
MeasureCitations
This facility25
Median facility in MA11
Median facility nationally11

Survey history

Citations at each Life Safety survey
82023-0302024-05172025-06
Citations at each Life Safety survey
Survey dateCitations
March 20, 20238
May 8, 20240
June 4, 202517

Most-cited tags

Most-cited tags at this facility
K-03242K-07612K-03452K-05311K-05111E-00301K-09141K-07121
Most-cited tags at this facility
TagWhat the surveyor checksTimes citedLast cited
K-0324Provide properly protected cooking facilities.22025-06-04
K-0761To conduct inspection, testing and maintenance of fire doors by qualified individuals.22025-06-04
K-0345Have approved installation, maintenance and testing program for fire alarm systems.22025-06-04
K-0531Have elevators that firefighters can control in the event of a fire.12025-06-04
K-0511Have properly installed electrical wiring and gas equipment.12023-03-20
E-0030List the names and contact information of those in the facility.12025-06-04
K-0914Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.12025-06-04
K-0712Have simulated fire drills held at unexpected times.12025-06-04

What the citations cover

Citations by CMS category
  • Smoke Deficiencies 8
  • Emergency Preparedness Deficiencies 6
  • Miscellaneous Deficiencies 4
  • Gas, Vacuum, and Electrical Systems Deficiencies 3
  • Other 4
Citations by CMS category
CategoryCitations
Smoke Deficiencies8
Emergency Preparedness Deficiencies6
Miscellaneous Deficiencies4
Gas, Vacuum, and Electrical Systems Deficiencies3
Egress Deficiencies2
Services Deficiencies2

Every citation on file

As published by CMS, newest survey first. Descriptions are CMS’s own wording.

June 4, 2025 — 17 citations

Citations issued on June 4, 2025
TagWhat the surveyor checksStatus
E-0015Address subsistence needs for staff and patients.Deficient, Provider has date of correction (August 26, 2025)
E-0018Establish procedures for tracking staff and patients during an emergency.Deficient, Provider has date of correction (August 26, 2025)
E-0025Create arrangements with other facilities to receive patients.Deficient, Provider has date of correction (August 26, 2025)
E-0030List the names and contact information of those in the facility.Deficient, Provider has date of correction (August 26, 2025)
E-0037Establish staff and initial training requirements.Deficient, Provider has date of correction (August 26, 2025)
E-0039Conduct testing and exercise requirements.Deficient, Provider has date of correction (August 26, 2025)
K-0293Have properly located and lighted "Exit" signs.Deficient, Provider has date of correction (August 26, 2025)
K-0311Have an enclosure around a vertical opening shaft.Deficient, Provider has date of correction (August 26, 2025)
K-0324Provide properly protected cooking facilities.Deficient, Provider has date of correction (August 26, 2025)
K-0345Have approved installation, maintenance and testing program for fire alarm systems.Deficient, Provider has date of correction (August 26, 2025)
K-0353Inspect, test, and maintain automatic sprinkler systems.Deficient, Provider has date of correction (August 26, 2025)
K-0372Ensure smoke barriers are constructed to a 1 hour fire resistance rating.Deficient, Provider has date of correction (August 26, 2025)
K-0531Have elevators that firefighters can control in the event of a fire.Deficient, Provider has date of correction (August 26, 2025)
K-0712Have simulated fire drills held at unexpected times.Deficient, Provider has date of correction (August 26, 2025)
K-0761To conduct inspection, testing and maintenance of fire doors by qualified individuals.Deficient, Provider has date of correction (August 26, 2025)
K-0914Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.Deficient, Provider has date of correction (August 26, 2025)
K-0918Have generator or other power source capable of supplying service within 10 seconds.Deficient, Provider has date of correction (August 26, 2025)

March 20, 2023 — 8 citations

Citations issued on March 20, 2023
TagWhat the surveyor checksStatus
K-0225Have stairways and smokeproof enclosures used as exits that meet safety requirements.Deficient, Provider has date of correction (April 30, 2023)
K-0321Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.Deficient, Provider has date of correction (April 30, 2023)
K-0324Provide properly protected cooking facilities.Deficient, Provider has date of correction (April 30, 2023)
K-0345Have approved installation, maintenance and testing program for fire alarm systems.Deficient, Provider has date of correction (April 30, 2023)
K-0511Have properly installed electrical wiring and gas equipment.Deficient, Provider has date of correction (April 30, 2023)
K-0754Provide properly sized and located linen or trash receptacles.Deficient, Provider has date of correction (April 30, 2023)
K-0761To conduct inspection, testing and maintenance of fire doors by qualified individuals.Deficient, Provider has date of correction (April 30, 2023)
K-0927Have proper fire barriers, ventilation and signs for the transfilling of oxygen.Deficient, Provider has date of correction (April 30, 2023)

Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.