Penacook Place, INC
150 Water Street, Haverhill, MA 01830 · Essex County · 160 certified beds · avg 102 residents/day · certified since Jul 1, 1990
Part of chain: COVENANT HEALTH (8 facilities, chain avg rating 3.0★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★★★☆4/5 · CMS overall rating: 4/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Actual harm, one-off · Apr 29, 2025 · F-0760 · triggered by a complaint
The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication.
Why it matters: A serious medication error can cause real harm, hospitalization, or worse.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Mar 20, 2025 (Past Non-Compliance)
All citations in the current public record (26)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Jan 20, 2026 | D · Potential for harm, one-off | The facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection. · from a complaint |
| Jan 20, 2026 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Apr 29, 2025 | ▲ G · Actual harm, one-off | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint |
| May 8, 2024 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| May 8, 2024 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| May 8, 2024 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| May 8, 2024 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| May 8, 2024 | D · Potential for harm, one-off | The facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail. |
| Dec 12, 2023 | D · Potential for harm, one-off | The facility used physical restraints — devices that limit a resident's movement — when they weren't needed for medical treatment. · from a complaint |
| Mar 20, 2023 | E · Potential for harm, repeated | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. |
| Mar 20, 2023 | E · Potential for harm, repeated | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Mar 20, 2023 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Mar 20, 2023 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Mar 20, 2023 | E · Potential for harm, repeated | The facility did not make sure its nurse aides had the skills needed to care for residents, including training in dementia care and abuse prevention. |
| Mar 20, 2023 | D · Potential for harm, one-off | The facility did not make sure residents were fully informed about their own health, care, and treatments in a way they could understand. |
| Mar 20, 2023 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. |
| Mar 20, 2023 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| Mar 20, 2023 | D · Potential for harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| Mar 20, 2023 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Mar 20, 2023 | D · Potential for harm, one-off | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. |
| Mar 20, 2023 | D · Potential for harm, one-off | The facility used feeding tubes without a valid medical reason or the resident's agreement, or did not provide proper care to residents who have feeding tubes. |
| Mar 20, 2023 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| Mar 20, 2023 | D · Potential for harm, one-off | The facility did not provide the right treatment and services for residents with dementia or signs of dementia. Dementia care requires specific approaches, training, and patience. |
| Mar 20, 2023 | D · Potential for harm, one-off | The facility did not provide or arrange specialized rehabilitation services — such as physical, occupational, or speech therapy — for residents who needed them. |
| Mar 20, 2023 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. |
| Mar 20, 2023 | B · Minimal risk, repeated | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
Inspection trend by year
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 18 | 0 | E |
| 2024 | 5 | 0 | D |
| 2025 | 1 | 1 | G ▲ |
| 2026 | 2 | 0 | D |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
1 fine totaling $10,868.
| Date | Type | Amount / length |
|---|---|---|
| Apr 29, 2025 | Fine | $10,868 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Massachusetts avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 4.11 | 3.89 | 3.95 | top 28% in Massachusetts; top 35% in the U.S. |
| Registered Nurse hours | 0.70 | 0.65 | 0.69 | top 31% in Massachusetts; top 36% in the U.S. |
| Weekend total nurse staffing | 3.97 | 3.51 | 3.50 | top 19% in Massachusetts; top 24% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.38 | 0.46 | 0.48 | bottom 42% in Massachusetts; bottom 49% in the U.S. |
| Total nursing staff turnover (%) | 39.0 | 38.2 | 45.8 | bottom 45% in Massachusetts; top 34% in the U.S. |
| RN turnover (%) | 30.8 | 42.6 | 42.9 | top 27% in Massachusetts; top 30% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.76, RN 0.64, weekend 3.63. Staffing rating: 4/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 3/5 · long-stay residents: 3/5 · short-stay residents: 2/5
Who owns this facility
Non profit - Church related
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Bell, Michael | Individual | Corporate Director | NOT APPLICABLE | 10/20/2020 |
| Castillo, Nicole | Individual | W-2 Managing Employee | NOT APPLICABLE | 05/18/2018 |
| Delaney, John | Individual | Corporate Officer | NOT APPLICABLE | 09/01/2020 |
| Masys, Caitlin | Individual | Corporate Officer | NOT APPLICABLE | 01/01/2017 |
| Mortimer, Thomas | Individual | Corporate Officer | NOT APPLICABLE | 01/01/2012 |
| Riopelle, Judithann | Individual | Corporate Officer | NOT APPLICABLE | 01/01/2020 |
| Sarro, John | Individual | Corporate Officer | NOT APPLICABLE | 01/01/2017 |
| Shaw, Gregory | Individual | Corporate Officer | NOT APPLICABLE | 01/01/2019 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What systems do you use to prevent medication errors, and what happens when one occurs?"
- "What specific steps do you take to prevent abuse and neglect, and how are staff trained on them?"
- "When abuse or theft is suspected, who do you notify, how fast, and how do you inform the family?"
- "Can you show me an example care plan, and how are families included when it's created and updated?"
- "How many aides are on each shift, and how do you make sure every resident gets timely help with bathing, dressing, and meals?"
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "How many residents here use oxygen or breathing equipment, and who checks that equipment each shift?"
- "How do you coordinate and monitor care for residents who receive dialysis?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Baker-Katz Skilled Nursing and Rehabilitation Ctr | 0.7 mi | Haverhill, MA | ★★★★☆ | 4/5 | |
| Oxford Rehabilitation & Health Care Center | 1.6 mi | Haverhill, MA | ★☆☆☆☆ | 1/5 | |
| Lakeview House SKLD Nrsg and Residential Care Fac | 1.9 mi | Haverhill, MA | ★★★★☆ | 4/5 | |
| Aspen Hill Rehabiliation & Healthcare Center | 1.9 mi | Haverhill, MA | ★★★☆☆ | 2/5 | |
| Haverhill Rehabilitation and Healthcare Center | 2.0 mi | Haverhill, MA | ★★☆☆☆ | 3/5 | |
| Whittier Bradford Transitional Care Unit | 2.5 mi | Bradford, MA | ★★★★★ | 5/5 | |
| Prescott House | 5.4 mi | North Andover, MA | ★★☆☆☆ | 2/5 | |
| Meadows, the | 5.4 mi | North Andover, MA | ★★★★★ | 5/5 | |
| Cedar View Rehabilitation and Healthcare Center | 5.5 mi | Methuen, MA | ★★★★★ | 5/5 | |
| M I Nursing & Restorative Center | 6.3 mi | Lawrence, MA | ★★★☆☆ | 2/5 | |
| Nevins Nursing & Rehabilitation Center | 6.3 mi | Methuen, MA | ★★☆☆☆ | 2/5 | |
| Salemhaven | 7.0 mi | Salem, NH | ★★☆☆☆ | 2/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 225376.