Complaint Investigation

Elderwood At Burlington

August 11, 2025 · Burlington, VT · 98 Starr Farm Rd.

Citations 2

CMS Rating 2/5

Beds 150

Provider ID 475030

Healthcare Facility

Elderwood At Burlington

Burlington, VT · View full profile →

Source Document

Official CMS Inspection Report (Medicare.gov)

Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.

Inspection Summary

Elderwood at Burlington in Burlington, VT — inspection on August 11, 2025.

Found 2 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

Inspection Findings

FF0605

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Potential for More Than Minimal Harm

Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

Per interview and record review, the facility failed to ensure one of four residents (Resident #2) was free from chemical restraints by prescribing an as needed psychotropic medication with no stop date of 14 days.

Findings include:Per review of Resident #2's medical record, Resident #2 has major diagnoses of vascular dementia [a form of dementia associated with impaired reasoning, planning, judgment, and memory caused by brain damage from impaired blood flow to your brain], Stage 2 chronic kidney disease, and COPD [Chronic Obstructive Pulmonary Disease]. Resident #2 had a BIMS [Brief Interview of Mental Status] score of 9 as of 7/17/25. A BIMS score of 9 indicates that Resident #2 is cognitively impaired.

Per record review of a physician order dated 7/23/25 states, Lorazepam tablet 0.5 mg [milligram]: Give one tablet by mouth every 6 hours as needed for itching and anxiety.

There was no documented stop date of 14 days on this order. Resident #2 was administered the Lorazepam 8 times from 7/23/25 to 8/11/25.An interview was conducted with the DON [Director of Nursing] on 8/11/25 at 11:45 AM.

The DON confirmed that the order for Lorazepam did not include a stop date of 14 days.

Works CitedVascular Dementia.

Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/vascular-dementia/symptoms-causes /syc-20378793.

Accessed 8/12/25.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

Facility ID:

IDENTIFICATION NUMBER:

Building

COMPLETED

08/11/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Elderwood at Burlington

98 Starr Farm Rd.

Burlington, VT 05408

SUMMARY STATEMENT OF DEFICIENCIES

FF0760

Pharmacy Service Deficiencies

Potential for More Than Minimal Harm

https://www.mayoclinic.org/diseases-conditions/schizoaffective-disorder/symptoms-causes/syc-20354504.

Accessed 8/12/25.

Facility ID:

Frequently Asked Questions

What is an F-tag violation?

F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.

Were these violations corrected?

Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.

How often do nursing home inspections happen?

CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.

What should families do about these violations?

Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Burlington, VT, (5) Report new concerns to state authorities.

Where can I see the full inspection report?

Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Elderwood at Burlington or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.

More Reports

About This Inspection Report

Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.

Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.

Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.