Elderwood At Burlington: Medication Error Cited - VT
The facility violated regulations designed to prevent chemical restraints by prescribing Lorazepam to Resident #2 without including a mandatory 14-day stop date on the physician's order. The anti-anxiety medication was administered from July 23 through August 11, when inspectors arrived to investigate.
Resident #2 has vascular dementia, a condition that impairs reasoning, planning, judgment and memory due to reduced blood flow to the brain. The resident also suffers from Stage 2 chronic kidney disease and chronic obstructive pulmonary disease. A cognitive assessment in July yielded a score of 9 on the Brief Interview of Mental Status, indicating significant cognitive impairment.
The physician's order dated July 23 stated: "Lorazepam tablet 0.5 mg: Give one tablet by mouth every 6 hours as needed for itching and anxiety." Federal regulations require psychotropic medications prescribed "as needed" to include automatic stop dates within 14 days to prevent overuse and chemical restraint of vulnerable residents.
No such protection existed for Resident #2.
The Director of Nursing confirmed to inspectors on August 11 that the Lorazepam order lacked the required 14-day stop date. This admission came during the same visit when inspectors discovered the medication had been given eight times since the order was written.
Chemical restraint violations represent a particularly serious concern for dementia patients, who cannot advocate for themselves or fully understand the effects of psychotropic medications. Federal research has documented widespread overuse of these drugs in nursing homes, leading to stricter oversight requirements.
Lorazepam belongs to a class of medications called benzodiazepines, which can cause drowsiness, confusion and increased fall risk in elderly patients. The drug is especially problematic for residents with existing cognitive impairment, as it can worsen confusion and reduce a person's ability to function independently.
The violation occurred despite federal regulations specifically designed to prevent nursing homes from using psychotropic medications to chemically restrain residents. These rules require facilities to demonstrate that such medications serve a legitimate medical purpose and include appropriate safeguards against overuse.
Elderwood at Burlington's failure to include the mandatory stop date meant Resident #2 could theoretically receive the anxiety medication indefinitely, with no automatic trigger for medical review. The eight documented administrations over nearly three weeks suggest the medication became routine rather than truly "as needed."
The inspection was conducted in response to a complaint, though the report does not specify the nature of the original concern that prompted federal investigators to examine the facility's medication practices.
This type of violation falls under federal tag F0605, which addresses the prevention of unnecessary psychotropic medications. The Centers for Medicare and Medicaid Services classified the harm level as "minimal harm or potential for actual harm" affecting "few" residents.
However, for Resident #2, the impact was concrete. Each administration of Lorazepam without proper oversight represented a potential chemical restraint, limiting the resident's ability to function at their highest possible level.
The facility must now submit a plan of correction to address the violation and demonstrate how it will prevent similar incidents. Federal regulators will monitor compliance with any corrective measures.
For families with loved ones in nursing homes, this case illustrates the importance of reviewing medication orders and asking questions about psychotropic drugs. The 14-day stop date requirement exists specifically to protect vulnerable residents from becoming chemically restrained through routine medication administration.
Resident #2 continues to live at Elderwood at Burlington, where the facility must now ensure all future psychotropic orders include the federally mandated safety protections that were missing from this case.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Elderwood At Burlington from 2025-08-11 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
Elderwood at Burlington in Burlington, VT was cited for violations during a health inspection on August 11, 2025.
The anti-anxiety medication was administered from July 23 through August 11, when inspectors arrived to investigate.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.