Above average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Baker-katz Skilled Nursing And Rehabilitation Ctr during CMS and state inspections, most recent first.
Two residents at high risk for pressure ulcers did not receive timely and appropriate care as ordered. One resident's blister was not promptly assessed or treated, and documentation was incomplete. Another resident did not have prescribed interventions such as offloading, air boots, and lambswool consistently applied, despite having active skin issues. Staff interviews confirmed that physician orders and care plans were not consistently followed, and required documentation was lacking.
Staff did not change oxygen and nebulizer tubing weekly as ordered for two residents requiring respiratory care, resulting in the use of outdated equipment despite clear physician orders and facility policy. Observations and staff interviews confirmed that tubing was not replaced on schedule for residents dependent on oxygen and nebulizer therapy.
Surveyors observed treatment carts containing prescription ointments, creams, and other supplies left unlocked and unattended in two halls, with multiple staff and residents passing by. Facility policy and staff interviews confirmed that carts should be locked unless a nurse is present, but this was not followed.
Housekeeping staff failed to follow infection control protocols by not performing hand hygiene after removing gloves and before donning new gloves, and by wearing potentially contaminated gloves between resident rooms and in hallways. These actions were observed multiple times and confirmed by interviews with staff and management, indicating a breakdown in adherence to the facility's infection prevention policies.
A resident experienced an unwitnessed fall, and the assigned nurse failed to report the incident to the physician, guardian, DON, or oncoming nurse, as required by facility policy. The resident, with a history of falls and multiple medical conditions, was later found to have rib fractures and sepsis at the hospital. The incident was not documented in the resident's medical record, and the facility's protocol for reporting and documenting such incidents was not followed.
A resident with multiple health conditions experienced an unwitnessed fall in an LTC facility. Although a nurse claimed to have assessed the resident, there was no documentation to support this. The resident was later found to have rib fractures and sepsis at the hospital. The facility failed to follow its policy on resident assessment and incident reporting, and the incident was not communicated to administration until the resident's condition worsened.
The facility failed to implement physician-ordered TED hose for a resident with severe cognitive impairment and multiple diagnoses, including cerebral infarction and hypertension. Observations and staff interviews revealed that the nursing staff was unaware of the order, leading to non-compliance with the resident's care plan.
The facility failed to develop individualized trauma-informed care plans for two residents with PTSD, resulting in generic care plans that did not identify specific triggers for retraumatization or preferences for female caregivers. The deficiencies were identified during a survey, and the care plans were only updated after the surveyor's interviews with the social worker and DON.
Failure to Implement and Document Pressure Ulcer Prevention and Treatment Orders
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice for two residents who were assessed to be at high risk for developing pressure ulcers. For one resident with multiple sclerosis and significant immobility, a blister was identified on the ankle by staff, but there was no immediate skin assessment, no timely implementation of a physician's order for treatment, and incomplete documentation regarding the wound's characteristics and progress. The weekly skin check was not performed as scheduled, and the treatment order for the blister was not implemented until five days after the area was first identified. Interviews with nursing staff and administration confirmed that the expected protocol was not followed, and the required documentation and monitoring were lacking. For another resident with dementia, a history of pressure ulcers, and severe cognitive impairment, the facility did not ensure that the care plan and physician's orders related to skin integrity were implemented. Observations revealed that the resident's feet and heels were not offloaded as ordered, and prescribed interventions such as air boots, foam dressings, and lambswool between all toes were not consistently in place. The resident was observed with blood blisters and redness on the feet and toes, and there was no documentation of treatment refusal. Staff interviews confirmed that the physician's orders were not being followed, and the resident's care plan interventions were not consistently implemented. The facility's own policy required systematic skin inspections, prompt assessment and intervention for skin issues, and thorough documentation of wound characteristics and progress. In both cases, there were failures to adhere to these protocols, including missed assessments, delayed or omitted treatments, and incomplete documentation. These actions and inactions directly led to the deficiencies cited by surveyors.
Failure to Change Oxygen and Nebulizer Tubing per Physician Orders
Penalty
Summary
Facility staff failed to provide respiratory care services in accordance with professional standards and physician orders for two residents who required oxygen and nebulizer therapy. Specifically, staff did not change the oxygen and nebulizer tubing weekly as ordered by the physicians and outlined in the facility's policy. Observations revealed that the tubing for both oxygen and nebulizer equipment was dated well beyond the required weekly change interval for both residents. One resident, with a history of cerebral infarction, chronic heart failure, and atrial fibrillation, was dependent on staff for daily care and used continuous oxygen therapy and daily nebulizer treatments. Despite physician orders and care plan interventions specifying weekly changes and dating of tubing, the oxygen and nebulizer tubing in use was observed to be dated nearly two weeks prior, indicating it had not been changed as required. Interviews with nursing staff and the DON confirmed that the expectation was for weekly changes, and that staff administering treatments should have noticed the outdated tubing. A second resident, diagnosed with acute and chronic respiratory failure and COPD, also required oxygen therapy. Observations showed that this resident's oxygen tubing was similarly dated beyond the weekly interval specified in the physician's orders and care plan. Staff interviews confirmed that the tubing should have been changed weekly and that the observed dates did not meet this requirement.
Unattended and Unlocked Treatment Carts with Medications
Penalty
Summary
Nursing staff failed to store drugs and biologicals in accordance with State and Federal requirements, as evidenced by multiple observations of unlocked and unattended treatment carts in two separate halls. On several occasions, the treatment carts were left unsupervised and accessible to staff and residents, with the surveyor able to access prescription ointments, creams, and other treatment supplies inside the carts. These observations occurred over two consecutive days and involved multiple staff and residents passing by the unsecured carts. Facility policy requires that medication carts and supplies be locked when not attended by authorized personnel. During interviews, both a nurse and facility leadership confirmed that treatment carts should remain locked unless a nurse is present. Despite this policy, the carts were repeatedly left unlocked and unsupervised, directly violating facility procedures and regulatory requirements for medication security.
Failure to Implement Hand Hygiene and Glove Use Protocols by Housekeeping Staff
Penalty
Summary
The facility failed to implement proper infection prevention and control practices as required by its own policies. Specifically, two housekeeping staff members did not perform hand hygiene after removing gloves and before donning new gloves, as observed multiple times during their cleaning routines. One housekeeper was seen exiting a resident's room wearing gloves, touching the housekeeping cart and various cleaning supplies, and then entering another resident's room without changing gloves or performing hand hygiene. This sequence was repeated, with the staff member continuing to use the same potentially contaminated gloves across different rooms and tasks. Another housekeeper also failed to perform hand hygiene between glove changes and was observed wearing gloves in the hallway, which is against facility policy. Interviews with the housekeeping staff, the unit manager, and the infection control preventionist nurse confirmed that staff are expected to perform hand hygiene before and after glove use, not wear gloves in the hallway, and change gloves between rooms and tasks. Despite this, the observed actions of the housekeeping staff did not align with these expectations, resulting in a failure to follow established infection control procedures designed to prevent the spread of infection among residents, staff, and visitors.
Failure to Report and Document Resident Fall
Penalty
Summary
The facility failed to ensure proper notification and documentation following an unwitnessed fall involving a resident. On the specified date, a nurse found the resident lying on the floor in an unoccupied room. Despite assessing the resident and finding no immediate visible injuries, the nurse did not report the incident to the physician, the resident's guardian, the Director of Nurses (DON), or the oncoming shift nurse, as required by the facility's policy. Additionally, there was no documentation of the fall in the resident's medical record, including a progress note or a Fall/Incident Report. The resident, who had a history of falls and multiple medical conditions including dementia and diabetes, was later found to have elevated blood sugar levels and was transferred to the hospital. It was at the hospital that the resident was discovered to have rib fractures, bruising, and sepsis. The facility's report indicated that the nurse failed to notify the necessary parties and did not complete the required documentation or assessments following the fall. Interviews with the nursing staff and the DON revealed that the nurse did not follow the facility's protocol for reporting and documenting the incident. The DON and the facility administrator were not informed of the fall until after the resident was transferred to the hospital and the hospital staff notified the facility of the resident's injuries. The lack of communication and documentation was a clear violation of the facility's policies and procedures for handling such incidents.
Failure to Document and Assess After Resident Fall
Penalty
Summary
The facility failed to ensure that a resident received nursing care and treatment that met professional standards of quality care following an unwitnessed fall. On the specified date, a nurse found the resident lying on the floor in an unoccupied room. Although the nurse claimed to have assessed the resident for potential injuries, there was no documentation in the medical record to support that any assessment, including vital signs, was completed immediately after the fall. The resident, who had a history of dementia, type II diabetes, hypertension, osteoarthritis, schizophrenia, delusional disorders, anxiety, depression, and previous falls, was later transferred to the hospital due to high blood glucose levels and mental status changes. The hospital reported that the resident had rib fractures, bruising, and sepsis. Despite the nurse's assertion that an assessment was conducted, the lack of documentation and failure to follow the facility's policy on resident assessment and incident reporting were noted. Interviews with the nursing staff revealed that the incident was not properly communicated to the facility's administration until after the resident's condition worsened. The Director of Nurses confirmed the absence of documentation regarding the fall and the expected procedures that should have been followed, including obtaining neurological signs and completing a fall packet, were not adhered to.
Failure to Implement Physician-Ordered Compression Stockings
Penalty
Summary
The facility failed to ensure that resident-centered care plans were implemented for one resident out of a total sample of 14 residents. Specifically, for Resident #43, the facility did not implement the use of TED hose (compression stockings) as ordered by the physician. Resident #43, who has severe cognitive impairment and multiple diagnoses including cerebral infarction, aortic aneurysm, and hypertension, was observed on multiple occasions without the prescribed compression stockings. The care plan and physician's order clearly indicated the need for TED hose to be worn every morning and removed every bedtime to minimize syncopal episodes, but this was not followed. Interviews with the nursing staff revealed a lack of awareness regarding the resident's need for compression stockings. Both the nurse and the CNA assigned to Resident #43 were unaware of the physician's order for TED hose. The Director of Nursing confirmed that the staff should follow each resident's plan of care and expressed that the compression stockings should have been applied as per the physician's order. The failure to implement the care plan as ordered resulted in a deficiency in resident-centered care for Resident #43.
Failure to Develop Individualized Trauma Informed Care Plans
Penalty
Summary
The facility failed to ensure a plan of care was developed for Trauma Informed Care with individualized interventions for two residents with a history of Post Traumatic Stress Disorder (PTSD). Resident #3, who was admitted in January 2018, had diagnoses including anxiety disorder, major depressive disorder, and dementia. The resident's care plan did not identify specific triggers for retraumatization, despite the resident's history of physical and sexual abuse. The care plan was generic and did not include the resident's preference for female caregivers, which was only updated after the surveyor's interview with the social worker and the Director of Nursing (DON). The resident exhibited behaviors such as yelling out, resistance to care, and selective medication intake, which were not adequately addressed in the care plan. The social worker admitted to not discussing the PTSD with the family, despite their involvement, and acknowledged that the care plan should have been individualized with specific triggers and preferences noted upon admission and during quarterly assessments. Resident #41, admitted in April 2024, also had a history of PTSD, anxiety, and depression. The resident's PTSD and Trauma Assessment did not indicate specific triggers for retraumatization, and the care plan was similarly generic. The resident's son provided information about the history of trauma, but the assessment failed to document potential triggers or the need for female-only caregivers, despite the resident's history of sexual assault. The social worker confirmed that the care plan should have included specific triggers and interventions, and acknowledged that the care plan was updated only after the surveyor's interview. Both residents' care plans lacked individualized interventions and failed to identify specific triggers for retraumatization, which is a critical component of trauma-informed care. The facility's policy on Trauma Informed Care was not adequately followed, leading to deficiencies in the care provided to residents with PTSD. The Director of Nursing (DON) confirmed that it was the expectation for care plans to be individualized for residents with PTSD, but this was not done in these cases.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Haverhill
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Penacook Place, Inc | 0.7 mi | ★★★★★ | 2 | 0 |
| Lakeview House Skld Nrsg And Residential Care Fac | 1.8 mi | ★★★★★ | 0 | 0 |
| Oxford Rehabilitation & Health Care Center | 2.1 mi | ★★★★★ | 21 | 0 |
| Aspen Hill Rehabiliation & Healthcare Center | 2.4 mi | ★★★★★ | 8 | 0 |
| Haverhill Rehabilitation And Healthcare Center | 2.7 mi | ★★★★★ | 8 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.