Above average — CMS composite of the measures below.
A standard survey is most likely before around September 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 Penacook Place, Inc during CMS and state inspections, most recent first.
A resident with dementia, severe cognitive impairment, and behavioral disturbances, care-planned for mood alterations and agitation, was involved in an incident where a CNA responded to the resident’s insult by repeating the same derogatory phrase back to the resident in a loud manner. Another CNA witnessed this exchange but did not immediately report it, waiting several days before informing supervisory staff, citing confusion about how to report when the DON and Administrator were not on-site. During this delay, the alleged perpetrating CNA continued to work multiple shifts. When the allegation was finally brought forward, it was not relayed to the DON immediately, further delaying appropriate administrative awareness, contrary to the facility’s policy requiring immediate reporting of all abuse allegations.
A resident with dementia and behavioral disturbance was involved in a verbally abusive exchange with a CNA in an activity room, during which both the resident and the CNA used derogatory language toward each other. Another CNA witnessed the incident but did not immediately report it as required by facility policy, instead waiting several days and only disclosing it after recalling the event during a later conversation. Subsequent reports moved through the Scheduling Coordinator and Human Resources before reaching the DON, resulting in the allegation of abuse being reported to the state agency several days after the incident, outside the policy’s defined 2-hour reporting requirement.
A resident with diabetes was given three times the prescribed dose of Toujeo insulin after a nurse used a standard insulin syringe instead of the required pen needle, failing to verify the medication concentration and administration method. The resident developed hypoglycemia and required treatment and close monitoring until stabilized.
The facility failed to follow a physician's order to offload a resident's heels, despite the resident having severe cognitive impairment and being dependent on staff for bed mobility. Observations over several days showed the resident's heels were directly on the bed without any offloading measures, contrary to the care plan.
A resident with dementia and severely impaired cognition was left unsupervised while eating breakfast on multiple occasions, despite assessments indicating the need for supervision. Interviews with staff confirmed the requirement for supervision, highlighting a failure to adhere to the resident's care plan and facility protocols.
A resident with a non-healing surgical wound did not receive weekly wound measurements or timely updates to their care plan based on physician recommendations. Despite staff awareness, necessary documentation was not obtained, leading to delays in appropriate wound care.
A resident with chronic respiratory conditions was observed receiving oxygen at 3.5 liters per minute instead of the prescribed 4 liters per minute. Additionally, the oxygen concentrator filters were found to be covered in dust, indicating a failure to follow the facility's maintenance protocols.
The facility failed to provide emergency dialysis supplies for two residents with tunneled hemodialysis catheters. One resident, who was cognitively impaired, did not have emergency clamps or pressure dressings in his room. Another resident, who was cognitively intact, also lacked a dialysis emergency kit. Nurses were unaware of the location of these emergency supplies, and the DON confirmed that such kits should be present but were not.
Failure to Immediately Report and Act on Allegation of Verbal Abuse
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff consistently implemented and followed its abuse policy regarding immediate protection and reporting of abuse allegations. The facility’s written policy, dated 03/01/25, required that all allegations of abuse, neglect, exploitation, or mistreatment be reported immediately to the Administrator and that policies and procedures be operationalized for resident protection and reporting. Despite this, a certified nurse aide (CNA) who witnessed an alleged incident of verbal abuse did not report it at the time it occurred and delayed reporting for three days. The resident involved had diagnoses including dementia with behavioral disturbance and anxiety, with a quarterly MDS showing severely impaired cognition, disorganized thinking, and daily rejection of care. The resident’s care plan, updated with the November 2025 MDS, identified risk for mood alterations such as agitation and tearfulness due to dementia and disorientation, with interventions including medications, behavioral health consults as needed, and monitoring for acute episodes of sadness. On the evening of 12/13/25, while supervising residents with severe cognitive impairment in the activity room, CNA #2 observed an interaction in which the resident loudly told CNA #1 to get out of my uncle’s restaurant, and CNA #1 responded loudly to mind your own business, I am not talking to you. The resident then called CNA #1 an ugly bitch, and CNA #1 repeated the insult back to the resident before leaving the room with another resident. CNA #2 did not confront CNA #1 and did not immediately report the incident to any supervisor or designated person. She later stated she believed allegations of abuse needed to be reported to the DON or Administrator within two hours but did not do so because the incident occurred on an evening over a weekend when they were not in the facility, and she had not received instruction on what to do in their absence. She did not report the incident until the morning of 12/16/25, first to a unit manager and a nurse (who both later denied recalling such a report), and then to the Scheduling Coordinator, who immediately informed the Human Resource Director. During the three-day delay, CNA #1 continued to work on the unit on multiple shifts. The Human Resource Director also did not immediately relay the allegation to the DON upon first receiving it, waiting until after a meeting to do so. The DON stated that staff were expected to immediately report any alleged incidents of abuse per facility policy.
Failure to Timely Report Alleged Verbal Abuse Incident
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff immediately reported an allegation of verbal abuse in accordance with its abuse reporting policy. The facility’s policy, dated September 2022, required that any suspicion of abuse be reported immediately to the administrator and appropriate agencies, defining “immediately” as within two hours of an allegation involving abuse. Resident #1, who had diagnoses including dementia with behavioral disturbance and anxiety and was described as severely cognitively impaired, was involved in an altercation with a CNA on 12/13/25 in the activity room. During this incident, Resident #1 told CNA #1 to get out of his/her uncle’s restaurant, and CNA #1 responded loudly for the resident to mind his/her own business. Resident #1 then called CNA #1 an “ugly bitch,” and CNA #1 repeated the insult back to the resident before leaving the room with another resident. CNA #2, who witnessed the exchange, did not report the incident at the time it occurred. She later stated that she did not report it until the morning of 12/16/25 because the incident occurred on an evening over the weekend when the DON and Administrator were not in the facility, and she forgot about it until overhearing a discussion about Resident #1. On 12/16/25, CNA #2 reported the incident to the Unit Manager and Nurse #1, though both later said they did not recall receiving this information. CNA #2 also reported the incident to the Scheduling Coordinator, who then reported it to the Human Resource Director, who in turn informed the DON later that day. The DON acknowledged that staff were expected to immediately report any alleged incidents of abuse so the facility could report to the State Agency within two hours of the allegation being known. The state reporting system showed the facility’s report of the alleged verbal abuse was created on 12/16/25 at 5:37 P.M., three days after the incident occurred, demonstrating the failure to follow the facility’s abuse reporting policy and required time frames.
Significant Medication Error: Insulin Overdose Due to Improper Administration
Penalty
Summary
A deficiency occurred when a resident with diabetes, who was prescribed Toujeo (a long-acting insulin) at a dose of 36 units daily via a pre-filled pen, was administered an incorrect dose. On the day of the incident, the assigned nurse was unable to locate the appropriate pen needles in the medication cart and, without seeking additional supplies or assistance, used a standard 100 unit/mL insulin syringe to draw up and inject 36 units from the Toujeo pen. This resulted in the resident receiving three times the prescribed dose, as Toujeo is concentrated at 300 units/mL, unlike standard insulin preparations. The error was discovered after the resident's blood sugar was found to be significantly low (52 mg/dL) during a routine check, and the resident subsequently developed symptoms of hypoglycemia, including pallor, sweating, cool and clammy skin, and malaise. The nurse had not verified the insulin concentration or the proper administration method as required by facility policy, and did not realize the risk of overdose when using a syringe with a different calibration than the pen device. The facility's policies clearly stated that insulin should be administered according to the physician's order and manufacturer instructions, which prohibit withdrawing Toujeo from the pen with a syringe due to the risk of overdose. The resident required treatment for hypoglycemia, including oral glucose, intravenous dextrose, and increased monitoring until blood sugar levels stabilized. Interviews confirmed that the nurse was familiar with the resident and the medication, but failed to follow proper procedures for insulin administration and did not check for available supplies elsewhere in the facility. The Director of Nursing confirmed that additional pen needles were available in the supply room at the time of the incident.
Failure to Follow Physician's Order to Offload Heels
Penalty
Summary
The facility failed to follow the plan of care for a resident by not adhering to a doctor's order to offload the resident's heels. The resident, who was admitted in August 2023 with diagnoses including dementia and pain in both feet, had a severe cognitive impairment and was dependent on staff for all bed mobility tasks. Observations on multiple occasions from 5/06/24 to 5/08/24 revealed that the resident was lying in bed with both heels directly on the bed, without any pillow present to offload pressure from the heels, as required by the physician's order initiated on 4/24/24. The nursing note dated 5/02/24 indicated that the resident had bruising on the right lateral foot and redness on the left heel, with the nurse practitioner being informed and assessing the situation. Despite this, the physician's order to offload the heels every shift when in bed was not followed. Interviews with a nurse and the Director of Nursing confirmed that the expectation was for all orders to be followed as prescribed, highlighting a clear deficiency in the facility's adherence to the care plan.
Failure to Provide Supervision with Meals
Penalty
Summary
The facility staff failed to provide necessary supervision with meals for a resident diagnosed with dementia and severely impaired cognition. The resident, admitted in October 2021, was assessed to require supervision with eating according to the most recent Minimum Data Set (MDS) assessment and the Functional Abilities and Goals Assessment. Despite this, observations on three separate occasions revealed that the resident was left unsupervised while eating breakfast in their room, struggling to eat toast with a spoon without any staff present to assist or supervise. Interviews with facility staff, including a nurse and the Director of Nursing (DON), confirmed that the resident requires supervision with meals. The DON stated that residents needing supervision should be in common areas like the hallway or dining room, or if they prefer to stay in their room, a staff member should be present to supervise them while eating. The lack of supervision observed over multiple days indicates a failure to adhere to the resident's care plan and the facility's protocols for meal supervision.
Failure to Conduct Weekly Wound Measurements and Obtain Physician Recommendations
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice. Specifically, the facility did not obtain weekly wound measurements and failed to obtain recommendations for wound treatments from a follow-up physician appointment. The resident, who was admitted with diagnoses including peripheral vascular disease and diabetes, had a non-healing surgical wound on the right amputation incision. Despite the care plan indicating the need for weekly wound measurements, the last documented measurement was over 10 weeks prior to the surveyor's review. During interviews, it was revealed that the nursing staff, including the Assistant Director of Nursing (ADON) and Nurse #4, were aware that weekly wound measurements were not being conducted. The ADON had informed the Unit Manager multiple times about the necessity of these measurements and the need to obtain documentation from the vascular physician. However, these actions were not taken, and the facility did not have the required documentation from recent physician visits. The resident's wound care was not updated according to the vascular physician's recommendations due to the lack of timely documentation. The Director of Nursing (DON) confirmed that the resident should have had weekly wound assessments and that the nurses were responsible for obtaining and reviewing paperwork from appointments. The failure to obtain and review the necessary documentation led to a delay in updating the resident's wound care plan. This deficiency was observed during a wound dressing change, where the Nurse Practitioner had to approve the wound recommendation from the vascular physician over a month after it was initially suggested.
Failure to Provide Proper Respiratory Care
Penalty
Summary
The facility failed to provide respiratory care services in accordance with professional standards of practice for Resident #5. The resident, who was admitted with chronic obstructive pulmonary disorder, neoplasm of bronchus or lung, and chronic respiratory failure, was observed on multiple occasions receiving oxygen at 3.5 liters per minute, contrary to the physician's order of 4 liters per minute. Additionally, the oxygen concentrator filters were found to be covered with a thick layer of dust, despite the facility's policy requiring weekly cleaning and changing of the filters and tubing. The Treatment Administration Record indicated that the oxygen tube and filter were changed as scheduled, but observations contradicted this documentation. Interviews with the nursing staff and the Director of Nursing confirmed that the oxygen settings and maintenance of the equipment did not align with the physician's orders and facility protocols. Nurse #1 acknowledged that the oxygen should be set at 4 liters per minute and that the filters should not be dusty if they had been changed recently. The Director of Nursing reiterated that the expectation is for nurses to follow the physician's orders for oxygen settings and equipment maintenance.
Failure to Provide Emergency Dialysis Supplies
Penalty
Summary
The facility failed to provide care and services consistent with professional standards for two residents who required renal dialysis. Specifically, the facility did not ensure that emergency clamps and pressure dressings were available in the rooms of residents with tunneled hemodialysis catheters. Resident #103, who was cognitively impaired and dependent on dialysis, did not have emergency clamps or pressure dressings in his room. Nurse #1 confirmed that these items should be taped to the wall in the resident's room at all times but were not present during the surveyor's observation. Similarly, Resident #57, who was cognitively intact and received dialysis through a tunneled hemodialysis catheter, also did not have a dialysis emergency kit in his room. Both Nurse #3 and Nurse #4 were unaware of the location of the emergency kits or how to obtain emergency supplies in case of unexpected bleeding. The Director of Nursing confirmed that there should be a dialysis emergency kit in the room of every resident who receives dialysis, but this was not the case for Resident #57.
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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) |
|---|---|---|---|---|
| Baker-katz Skilled Nursing And Rehabilitation Ctr | 0.7 mi | ★★★★★ | 0 | 0 |
| Oxford Rehabilitation & Health Care Center | 1.5 mi | ★★★★★ | 21 | 0 |
| Lakeview House Skld Nrsg And Residential Care Fac | 1.9 mi | ★★★★★ | 0 | 0 |
| Aspen Hill Rehabiliation & Healthcare Center | 1.9 mi | ★★★★★ | 8 | 0 |
| Haverhill Rehabilitation And Healthcare Center | 2 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.