Inspection Reports for
Elm Wood Center at Claremont
290 HANOVER STREET, CLAREMONT, NH, 03743
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
9.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
127% worse than New Hampshire average
New Hampshire average: 4.1 deficiencies/yearDeficiencies per year
16
12
8
4
0
Occupancy
Latest occupancy rate
75% occupied
Based on a June 2024 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Sep 11, 2025
Visit Reason
The inspection was conducted due to allegations of emotional abuse and exploitation of residents by staff, triggered by video evidence shared on social media.
Complaint Details
The complaint was substantiated based on video evidence and investigations. Three residents were identified as victims of emotional abuse by staff. Telepsychology services found no psychosocial harm. Staff involved were terminated and reported to regulatory and law enforcement authorities.
Findings
The facility failed to protect residents' rights to be free from emotional abuse by staff, as video recordings showed staff mocking and inappropriately interacting with three residents. Disciplinary actions including termination and reporting to the Board of Nursing and local police were taken.
Deficiencies (1)
Failure to protect residents from emotional abuse and exploitation by staff, evidenced by video recordings mocking residents.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff I | Licensed Nurse Aide (LNA) | Named in emotional abuse findings involving video recordings mocking residents. |
| Staff J | Licensed Nurse Aide (LNA) | Named in emotional abuse findings involving video recordings mocking residents. |
| Staff G | Registered Nurse | Received videos and reported incidents to Administrator and Director of Nursing. |
| Staff A | Administrator | Reported to by Staff G and confirmed findings during interview. |
| Staff B | Director of Nursing | Reported to by Staff G and confirmed findings during interview. |
| Staff C | Social Services | Interviewed residents and staff, confirmed no recall of incidents and referral to telepsychology. |
Inspection Report
Deficiencies: 6
Date: Aug 1, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident dignity, PASARR screening, meal service preferences, facility staffing assessment, hospice care coordination, and infection prevention and control.
Findings
The facility was found deficient in multiple areas including failure to serve meals simultaneously to residents at the same table, inaccurate PASARR Level I screenings for mental disorders, failure to accommodate resident meal preferences, incomplete facility staffing assessment by shift and unit, failure to coordinate hospice care properly, and inadequate implementation of infection prevention policies including Enhanced Barrier Precautions.
Deficiencies (6)
Failure to treat residents with dignity by not serving all residents at the same table their meals together in 5 of 5 meals observed.
Failure to have accurate Level I PASARR screening for mental disorders for 2 of 2 residents reviewed.
Failure to ensure residents' individual meal preferences were accommodated for 2 of 4 residents reviewed.
Failure to conduct a facility-wide assessment including specific staffing needs for each unit and shift.
Failure to coordinate hospice care properly for 1 of 1 resident reviewed for hospice care.
Failure to implement Enhanced Barrier Precautions and proper cleaning of glucometer, including failure to wear gowns during high contact care for residents on EBP.
Report Facts
Residents waiting for meals: 19
Facility Assessment staffing numbers: 5
Facility Assessment staffing numbers: 12
Facility Assessment staffing numbers: 2
Average census: 60
Chocolate milk quantity: 8
Sample size for PASARR review: 19
Residents reviewed for food preferences: 4
Residents reviewed for hospice care: 1
Residents observed for Enhanced Barrier Precautions: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff J | Licensed Practical Nurse | Interviewed regarding meal service process and failure to serve meals simultaneously. |
| Staff L | Food Service Director | Interviewed about meal service issues and resident meal preferences. |
| Staff A | Social Service Director | Interviewed regarding PASARR screening inaccuracies and hospice care coordination. |
| Staff G | Administrator | Interviewed regarding facility assessment and staffing. |
| Staff B | Licensed Nursing Assistant | Interviewed about hospice care visits and knowledge. |
| Staff C | Registered Nurse | Interviewed about hospice care visits and knowledge. |
| Staff D | Registered Nurse | Interviewed and observed regarding Enhanced Barrier Precautions and infection control. |
| Staff F | Licensed Practical Nurse | Interviewed about glucometer cleaning and infection control. |
| Staff H | Infection Preventionist | Interviewed regarding infection prevention policies and practices. |
| Staff I | Licensed Nursing Assistant | Observed and interviewed regarding Enhanced Barrier Precautions. |
Inspection Report
Routine
Census: 51
Deficiencies: 7
Date: Jun 13, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication administration, staffing, and facility operations at Elm Wood Center at Claremont.
Findings
The facility was found deficient in multiple areas including failure to timely provide Medicare Non-Coverage notices to residents, failure to follow physician's medication orders, inadequate audiology services, delayed pain management, insufficient weekend staffing during winter months, incomplete controlled substance inventory documentation, and a medication error rate exceeding 5%.
Deficiencies (7)
Failed to ensure timely notification of Medicare Non-Coverage or Advance Beneficiary Notice for 2 of 3 residents reviewed.
Failed to follow physician's orders for medication administration for 3 residents.
Failed to ensure audiology appointments were made for a resident with hearing impairment.
Failed to provide effective pain management for a resident due to delayed administration of pain medication.
Failed to provide sufficient nursing staff to meet residents' needs on weekends in January, February, and March 2024.
Failed to maintain accurate controlled substance inventory records with required two nurse signatures.
Medication error rate was 8%, exceeding the 5% threshold, due to wrong dose and wrong probiotic administered.
Report Facts
Medication error rate: 8
Residents affected: 2
Residents affected: 3
Residents affected: 1
Residents affected: 1
Staffing levels: 2
Staffing levels: 3
Unit census: 51
Narcotic shift count missing signatures: 5
Narcotic shift count missing signatures: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff J | Business Officer | Confirmed failure to provide Medicare Non-Coverage notices for Residents #33 and #217 |
| Staff B | Unit Manager | Confirmed medication administration findings for Residents #22 and #64; aware of Resident #118's pain and staffing concerns |
| Staff E | Unit Manager | Confirmed medication administration findings for Resident #25; involved in audiology referral process |
| Staff A | Licensed Practical Nurse | Confirmed medication administration errors for Resident #25 and medication error with Resident #33 |
| Staff F | Customer Service Representative for Audiology Company | Confirmed audiology appointments were canceled due to incomplete paperwork |
| Staff C | Staff Scheduler | Confirmed staffing assignments to LTC or Medical Skilled Unit |
| Staff D | Director of Nursing | Confirmed staffing action plan and controlled substance inventory requirements |
| Staff G | Licensed Practical Nurse | Reported working additional shifts due to call outs during winter |
| Staff H | Licensed Nursing Assistant | Reported staffing improvements |
| Staff K | Licensed Practical Nurse | Confirmed controlled substance inventory findings for Medication Cart #2 |
Inspection Report
Routine
Census: 63
Deficiencies: 14
Date: May 2, 2023
Visit Reason
Routine inspection to assess compliance with healthcare regulations and standards at Elm Wood Center at Claremont.
Findings
The facility had multiple deficiencies including failure to inform representatives about antipsychotic medication risks, failure to follow advance directives, failure to notify providers of resident status changes, unsafe environment due to mattress storage, inaccurate Minimum Data Set (MDS) assessments, failure to follow physician orders, failure to ensure timely physician visits, lack of IV therapy certification for an LPN, inadequate insulin monitoring, medication errors, expired and improperly stored medications, incomplete facility assessment regarding staffing, inaccurate medical records, and malfunctioning patient care equipment.
Deficiencies (14)
Failed to inform resident's representative of risks and benefits of antipsychotic medication use for a resident lacking decision-making capacity.
Failed to honor residents' rights to request, refuse, or discontinue treatment and to formulate advance directives.
Failed to ensure provider was updated regarding changes in residents' status for 3 residents.
Failed to ensure a safe and homelike environment due to mattresses stored in resident's room.
Failed to accurately complete Minimum Data Set (MDS) assessments for pressure ulcers and pain management.
Failed to follow physicians' orders for 3 residents including medication administration outside parameters and missing orders.
Failed to ensure residents were seen by a physician at least once every 60 days with required alternation between physician and PA.
Licensed Practical Nurse providing IV care without required certification and competencies.
Failed to ensure adequate monitoring of blood glucose levels for insulin administration for 1 resident.
Medication error rate exceeded 5 percent with errors in dose and medication preparation.
Expired medication found on medication cart and controlled substances not separately locked in medication room.
Facility assessment failed to include number of staff needed to meet residents' needs.
Resident medical records were inaccurate and incomplete for 2 residents.
Patient care equipment (scale lift) was not maintained and was out of calibration.
Report Facts
Residents reviewed: 26
Residents affected: 63
Medication errors: 3
Medication error rate: 10.71
Weight loss percentage: 19.5
Blood glucose readings above 240: 12
Scale calibration offset: 3.51
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff G | Director of Nursing | Confirmed multiple findings including medication errors, physician visit deficiencies, and lack of IV certification |
| Staff B | Licensed Practical Nurse | Observed administering medications with errors and without IV certification |
| Staff H | Licensed Practical Nurse | Observed preparing wrong doses of medications |
| Staff L | Minimum Data Set Nurse | Confirmed inaccuracies in MDS and resident diagnoses |
| Staff D | Maintenance Director | Confirmed scale lift was out of calibration and taken out of service |
| Staff J | Unit Manager | Confirmed lack of provider notification and documentation |
| Staff E | Unit Manager | Confirmed order entry errors and mattress storage issue |
| Staff Q | Wound Nurse | Confirmed missing weekly wound assessments |
| Staff N | Regional Clinical Manager | Confirmed LPN lacked IV certification |
| Staff R | Administrator | Confirmed facility assessment deficiencies |
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