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.
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
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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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
How that compares
Compared with the median facility in MA, and nationally. Surveyors differ markedly between states, so the MA figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 25 |
| Median facility in MA | 11 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| March 20, 2023 | 8 |
| May 8, 2024 | 0 |
| June 4, 2025 | 17 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0324 | Provide properly protected cooking facilities. | 2 | 2025-06-04 |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | 2 | 2025-06-04 |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 2 | 2025-06-04 |
| K-0531 | Have elevators that firefighters can control in the event of a fire. | 1 | 2025-06-04 |
| K-0511 | Have properly installed electrical wiring and gas equipment. | 1 | 2023-03-20 |
| E-0030 | List the names and contact information of those in the facility. | 1 | 2025-06-04 |
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | 1 | 2025-06-04 |
| K-0712 | Have simulated fire drills held at unexpected times. | 1 | 2025-06-04 |
What the citations cover
- Smoke Deficiencies 8
- Emergency Preparedness Deficiencies 6
- Miscellaneous Deficiencies 4
- Gas, Vacuum, and Electrical Systems Deficiencies 3
- Other 4
| Category | Citations |
|---|---|
| Smoke Deficiencies | 8 |
| Emergency Preparedness Deficiencies | 6 |
| Miscellaneous Deficiencies | 4 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 3 |
| Egress Deficiencies | 2 |
| Services Deficiencies | 2 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
June 4, 2025 — 17 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0015 | Address subsistence needs for staff and patients. | Deficient, Provider has date of correction (August 26, 2025) |
| E-0018 | Establish procedures for tracking staff and patients during an emergency. | Deficient, Provider has date of correction (August 26, 2025) |
| E-0025 | Create arrangements with other facilities to receive patients. | Deficient, Provider has date of correction (August 26, 2025) |
| E-0030 | List the names and contact information of those in the facility. | Deficient, Provider has date of correction (August 26, 2025) |
| E-0037 | Establish staff and initial training requirements. | Deficient, Provider has date of correction (August 26, 2025) |
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (August 26, 2025) |
| K-0293 | Have properly located and lighted "Exit" signs. | Deficient, Provider has date of correction (August 26, 2025) |
| K-0311 | Have an enclosure around a vertical opening shaft. | Deficient, Provider has date of correction (August 26, 2025) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (August 26, 2025) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (August 26, 2025) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (August 26, 2025) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (August 26, 2025) |
| K-0531 | Have elevators that firefighters can control in the event of a fire. | Deficient, Provider has date of correction (August 26, 2025) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (August 26, 2025) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (August 26, 2025) |
| K-0914 | Ensure 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-0918 | Have 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
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0225 | Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Deficient, Provider has date of correction (April 30, 2023) |
| K-0321 | Ensure 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-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (April 30, 2023) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (April 30, 2023) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (April 30, 2023) |
| K-0754 | Provide properly sized and located linen or trash receptacles. | Deficient, Provider has date of correction (April 30, 2023) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (April 30, 2023) |
| K-0927 | Have 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.