Deficiencies (last 4 years)
Deficiencies (over 4 years)
17.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
293% worse than Vermont average
Vermont average: 4.4 deficiencies/yearDeficiencies per year
28
21
14
7
0
Inspection Report
Deficiencies: 2
Date: Dec 10, 2025
Visit Reason
The inspection was conducted to evaluate compliance with requirements related to documentation and notification of resident transfers to outside facilities and communication with resident representatives and the Long-Term Care Ombudsman.
Findings
The facility failed to send written documentation to resident representatives about transfers for one of three sampled residents and failed to send transfer records to the Long-Term Care Ombudsman for all three sampled residents. Interviews confirmed these notifications were not sent as required by facility policy.
Deficiencies (2)
Failure to send written documentation to resident and resident representative about transfers to outside facilities for one of three sampled residents.
Failure to send transfer records to the Long-Term Care Ombudsman for three of three sampled residents.
Report Facts
Residents affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Confirmed that written notices of transfers were not sent to resident representatives or the Long-Term Care Ombudsman |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Aug 11, 2025
Visit Reason
The inspection was conducted due to complaints regarding the use of unnecessary psychotropic medications and significant medication errors affecting residents.
Complaint Details
The visit was complaint-related, focusing on medication management issues including chemical restraint use and medication errors. Substantiation status is not explicitly stated.
Findings
The facility failed to ensure one resident was free from chemical restraints due to a psychotropic medication order lacking a 14-day stop date, and failed to prevent significant medication errors for another resident by administering medication despite low blood pressure and not providing required IV fluids before hospital transfer.
Deficiencies (2)
Failure to ensure one resident was free from chemical restraints by prescribing an as needed psychotropic medication with no 14-day stop date.
Failure to prevent significant medication errors for one resident, including administering Lisinopril despite low systolic blood pressure and not administering normal saline IV prior to hospital transfer.
Report Facts
Residents sampled: 4
Lorazepam administrations: 8
BIMS score: 9
BIMS score: 4
Blood pressure readings: 89
Blood pressure readings: 77
Medication dose: 0.5
Medication dose: 40
IV fluid volume: 500
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Confirmed medication order lacked stop date and acknowledged medication error report |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: May 12, 2025
Visit Reason
The inspection was conducted due to allegations of employee misconduct and possible abuse involving a resident's roommate and a Licensed Nursing Assistant, reported by Resident #1 on 2025-02-18.
Complaint Details
The complaint involved allegations of employee misconduct and possible abuse reported by Resident #1 on 2025-02-18. The facility did not report the allegations to the State Survey Agency until 7 days later on 2025-02-26, after Adult Protective Services arrived. There was no documentation of an investigation prior to APS involvement, and no measures were taken to prevent further abuse during that period.
Findings
The facility failed to timely report suspected abuse and failed to implement immediate measures to prevent further potential abuse after allegations were reported. There was no documentation of an investigation or reporting to the State Survey Agency prior to Adult Protective Services' involvement 7 days after the incident.
Deficiencies (2)
Failed to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Failed to immediately put measures in place to ensure that further potential abuse, neglect, exploitation, or mistreatment did not occur after allegations of abuse were reported.
Report Facts
Residents sampled: 3
Residents affected: 1
Days delay in reporting: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Former Administrator | Conducted investigation but no documentation found | |
| Assistant Director of Nursing | Interviewed regarding investigation and reporting | |
| Current Administrator | Confirmed reporting and investigation details | |
| Director of Nursing | Confirmed reporting and investigation details |
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Apr 2, 2025
Visit Reason
The inspection was conducted to assess the facility's compliance with regulatory requirements, focusing on trauma-informed care practices and infection prevention and control program oversight.
Findings
The facility failed to provide trauma-informed care by not identifying triggers that may cause re-traumatization for 5 of 9 sampled residents with PTSD. Additionally, the facility did not designate a qualified infection preventionist to oversee the infection prevention and control program, with the Director of Nursing performing both roles without meeting federal requirements.
Deficiencies (2)
Failed to provide trauma informed care by not identifying triggers that may cause re-traumatization for 5 of 9 sampled residents with PTSD.
Failed to designate a qualified infection preventionist to be responsible for the infection prevention and control program in the nursing home.
Report Facts
Residents sampled with PTSD: 9
Residents affected: 5
Date of Facility Assessment: 111524
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Worker | Confirmed facility did not identify trauma triggers or use standardized assessment tools | |
| Social Service Director | Confirmed Resident #60 had PTSD but no identified triggers in care plan and lack of system to document triggers | |
| Director of Nursing (DON) | Responsible for infection prevention and control program and DON role; confirmed federal requirement for part-time Infection Preventionist position |
Inspection Report
Annual Inspection
Deficiencies: 12
Date: Apr 2, 2025
Visit Reason
The inspection was a recertification survey conducted to assess compliance with regulatory requirements, including resident rights, care planning, medication administration, staffing, food service, infection control, and other aspects of facility operations.
Findings
The facility was found deficient in multiple areas including failure to provide residents the choice to eat meals in the dining room, inadequate grievance policies, incomplete baseline care plans, untimely medication administration, inadequate skin care and repositioning, lack of trauma-informed care, insufficient nursing staff, poor food quality and menu options, improper medication storage, and infection control lapses.
Deficiencies (12)
Failed to ensure residents are given the opportunity to eat meals in the dining room during breakfast, dinner, and weekend meal service.
Failed to establish an anonymous grievance reporting system supporting residents' right to voice grievances without discrimination or reprisal.
Failed to develop and implement a baseline care plan within 48 hours of admission including instructions for effective and person-centered care.
Failed to ensure services met professional standards by not following physicians' orders related to timing of medication administration.
Failed to provide treatment and care according to orders and resident preferences including prevention of skin breakdown.
Failed to provide trauma-informed care by not identifying triggers that may cause re-traumatization for residents with PTSD.
Failed to provide enough nursing staff to meet resident needs including timely medication administration and resident dining preferences.
Failed to ensure all drugs and biologicals were stored in locked compartments and only accessible to authorized personnel.
Failed to ensure food served was palatable, attractive, and served at a safe and appetizing temperature.
Failed to provide residents appealing menu items that accommodate allergies, intolerances, and preferences.
Failed to maintain infection control practices specific to medication administration and failed to ensure mechanical lift equipment was cleaned and maintained sanitarily.
Failed to designate a qualified infection preventionist responsible for the infection prevention and control program.
Report Facts
Medication late administration count: 11
Medication late administration count: 8
Medication late administration count: 9
Medication late administration count: 7
Medication late administration count: 3
Medication administration delay: 4
Sampled residents: 27
Residents affected: 7
Residents affected: 12
Residents affected: 6
Residents affected: 5
Residents affected: 1
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Stated dining room only open for lunch Monday through Friday due to staffing shortages. | |
| Social Worker | Confirmed lack of anonymous grievance system and lack of trauma trigger assessments. | |
| Unit Manager | Confirmed care plan omissions and interventions for residents. | |
| Licensed Nurse | Confirmed medication pass delays and medication cart left unlocked. | |
| Director of Nursing | Confirmed medication administration delays and infection preventionist role responsibilities. | |
| Registered Nurse | Observed improper medication administration infection control practice. | |
| Laundry Aide | Described process of hanging wet lift pads over dry ones in laundry room. | |
| Housekeeping/Laundry Director | Acknowledged infection control risks with lift pad drying practice. | |
| Kitchen Manager | Confirmed menus and alternative choices are controlled by Corporate and limited in options. |
Inspection Report
Routine
Deficiencies: 4
Date: Aug 15, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with regulatory requirements related to resident care, including assistance with activities of daily living (ADLs), physician oversight, staffing adequacy, and monitoring of psychotropic medication side effects.
Findings
The facility failed to provide timely and adequate assistance with ADLs for multiple residents, had insufficient nursing and aide staffing to meet resident needs, did not ensure physician visits accurately reviewed residents' total care programs, and failed to monitor residents for adverse effects of psychotropic medications.
Deficiencies (4)
Failure to provide care and assistance to perform activities of daily living for residents unable to do so independently, affecting 8 of 11 sampled residents.
Failure to ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders at each required visit for 1 of 3 sampled residents.
Failure to provide enough nursing staff every day to meet the needs of every resident and have a licensed nurse in charge on each shift, potentially impacting all residents.
Failure to implement gradual dose reductions and monitor for adverse effects of psychotropic medications for 3 sampled residents.
Report Facts
Residents needing 2 staff assistance with ADLs: 15
Residents needing assistance with eating: 4
Licensed nurse shifts not filled or reassigned: 12
LNA shifts not filled or reassigned: 29
Residents pressing call light: 6
Residents needing assistance with eating: 3
Residents needing assistance with eating: 1
Residents needing 2 staff assistance with ADLs: 16
Residents needing 2 staff assistance with ADLs: 3
Residents needing assistance with eating: 3
Lower extremity ROM completed: 4
Dumbbell upper extremity strengthening performed: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nursing Assistant #4 | Licensed Nursing Assistant | Interviewed regarding failure to provide incontinent care to Resident #10. |
| Licensed Nursing Assistant #5 | Licensed Nursing Assistant | Confirmed not providing incontinent care to Resident #10 during shift. |
| Licensed Nursing Assistant #6 | Licensed Nursing Assistant | Provided incontinent care to Resident #10 while scheduled for central supply. |
| Director of Nursing | Director of Nursing | Confirmed Resident #1 should be out of bed for dinner and that physician visits did not reflect actual medications for Resident #9. |
| Licensed Nursing Assistant #1 | Licensed Nursing Assistant | Reported Resident #9 is always sleepy and hollers when awake. |
| Unit Manager | Unit Manager | Reported staffing shortages requiring working as floor nurse. |
| Scheduler | Scheduler | Reported call outs and shift substitutions affecting staffing. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Feb 23, 2024
Visit Reason
The inspection was conducted due to complaints and concerns regarding the facility's failure to timely report suspected abuse, neglect, or theft, and failure to maintain accurate medical records related to skin conditions for residents.
Complaint Details
The complaint investigation revealed failures in timely reporting of abuse allegations, incomplete and insufficient reporting to the State Agency, and inadequate documentation of residents' skin conditions and bruising. The Administrator acknowledged lack of awareness of reporting requirements and failure to meet regulatory standards.
Findings
The facility failed to report allegations of abuse within the required 2-hour timeframe, did not provide sufficient information in initial and 5-day investigation reports to the State Agency, and lacked adequate policies for reporting suspected crimes. Additionally, the facility failed to accurately document skin conditions and bruising for two sampled residents.
Deficiencies (2)
Failure to timely report suspected abuse and provide sufficient information in reports to the State Agency.
Failure to maintain accurate medical records related to skin conditions for two sampled residents.
Report Facts
Residents sampled: 4
Dates of initial reports to State Agency: Initial resident to resident altercation reports received on 12/5/23, 12/17/23, and 2/12/23 lacked required information.
Dates of 5-day investigation summary reports: 5-day investigation summary reports following up on initial violations reported on 12/5/23 and 12/17/23 lacked required information.
Bruise measurements: Resident #4 had multiple bruises measured, e.g., left leg 10x8 inches, right leg 2x1.5 inches, inner left arm 6x3 inches.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Activity Staff #1 | Named in failure to report resident to resident altercation involving Resident #1 and Resident #2. | |
| Administrator | Confirmed failures in reporting allegations and lack of awareness of reporting requirements. | |
| Licensed Practical Nurse (LPN) | Reported remembering bruising on Resident #3 during care. | |
| Director of Nursing | Confirmed bruising should be documented in resident records. | |
| Unit Manager | Reported Resident #4 had bruising that should be documented. |
Inspection Report
Annual Inspection
Census: 80
Capacity: 80
Deficiencies: 25
Date: Jan 11, 2024
Visit Reason
The inspection was conducted as part of the annual recertification survey to assess compliance with regulatory requirements and evaluate the quality of care provided to residents.
Findings
The facility was found to have multiple deficiencies including failure to maintain clean wheelchairs, failure to schedule timely care plan meetings, inadequate medication self-administration assessments, inaccurate advanced directive documentation, incomplete resident assessments and care plans, insufficient wound care and pressure ulcer management, inadequate staffing levels, medication administration errors, infection control lapses, and failure to provide required vaccinations and staff training.
Deficiencies (25)
Failed to treat residents reliant on wheelchairs with dignity by failing to clean the wheelchairs.
Failed to schedule timely care plan meetings and facilitate inclusion of resident's representatives.
Failed to determine clinical appropriateness for residents to self-administer medications.
Failed to ensure accurate advanced directive choices were indicated.
Failed to use data from assessments to develop comprehensive care plans and failed to accurately code MDS assessments.
Failed to create and implement a baseline care plan within 48 hours of admission addressing minimum healthcare information.
Failed to develop and implement comprehensive person-centered care plans for residents.
Failed to review and revise care plans after assessments and with required interdisciplinary team.
Failed to provide social services consistent with professional standards, including managing resident-to-resident aggression.
Failed to provide care and assistance to maintain good personal hygiene for residents unable to perform ADLs.
Failed to provide activities that support each resident's physical, mental, and psychosocial well-being.
Failed to provide care and treatment consistent with physician orders and professional standards for wound care, resulting in new or worsening pressure ulcers.
Failed to provide range of motion rehabilitation services as per care plans.
Failed to ensure resident environment is free from accident hazards and provide adequate supervision to prevent accidents.
Failed to provide appropriate care and services to prevent urinary tract infections for resident with indwelling catheter.
Failed to provide appropriate colostomy, urostomy, or ileostomy care consistent with care plan and professional standards.
Failed to maintain acceptable nutritional status by failing to obtain weights as ordered, document meal intakes and refusals, and update physician on weight loss.
Failed to provide safe and appropriate respiratory care consistent with professional standards and medical orders.
Failed to obtain physician orders and ensure physician supervision of resident care during required visits.
Failed to ensure sufficient nursing staff to meet resident needs and have licensed nurse in charge on each shift.
Failed to ensure nurses and nurse aides have appropriate competencies to care for residents.
Failed to provide medications as ordered resulting in missed doses and untreated symptoms.
Failed to ensure drugs and biologicals are labeled, stored securely, removed when expired, and properly stored in resident rooms.
Failed to procure food from approved sources and store, prepare, distribute and serve food in accordance with professional standards.
Failed to educate residents and staff on COVID-19 vaccination, offer vaccine to eligible residents, and properly document vaccination status.
Report Facts
Residents using wheelchairs: 80
Deficiency counts: 30
Falls: 16
Weight loss percentage: 10.66
Missed medication doses: 7
Missed medication doses: 9
Missed medication doses: 1
Missed medication doses: 1
Missed medication doses: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Unit Manager | Unit Manager | Confirmed wheelchair cleaning failure, medication administration issues, and wound care lapses |
| Director of Nursing | Director of Nursing | Confirmed multiple care plan, medication, staffing, and infection control deficiencies |
| Medical Director | Medical Director | Unaware of wound management and regulatory visit documentation requirements |
| Staff Educator | Staff Educator | Confirmed insufficient trauma informed care training for staff |
| Regional Nurse Consultant | Regional Nurse Consultant | Confirmed medication administration omissions and pain management issues |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: May 15, 2023
Visit Reason
The inspection was conducted following complaints regarding failure to update care plans after falls and inaccurate documentation related to resident safety and supervision.
Complaint Details
The investigation was complaint-driven, focusing on failure to update care plans after falls and inaccurate documentation leading to inadequate supervision and resident falls. The nurse on duty admitted to falsifying documentation, and the Director of Nursing confirmed these findings.
Findings
The facility failed to update a care plan after a resident's fall leading to serious injury and death, and failed to maintain professional standards of documentation for another resident, resulting in inadequate supervision and a fall. The nurse on duty falsified documentation of safety checks, and the facility did not implement adequate supervision measures to prevent accidents.
Deficiencies (3)
Failed to update care plan following a fall to prevent further falls or reduce injury risk for Resident #1.
Failed to maintain compliance with professional standards related to inaccurate documentation for Resident #2, including falsifying safety check documentation.
Failed to ensure adequate supervision to prevent accidents for Residents #1 and #2, resulting in falls and serious injury.
Report Facts
Residents sampled: 5
Residents sampled: 4
BIMS score: 14
Date of falls: 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed and confirmed failure to update care plan and falsification of documentation | |
| Assistant Director of Nursing | Interviewed and agreed care plan was not updated after fall | |
| Nurse on duty | Admitted to falsifying documentation of safety checks for Resident #2 |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Mar 21, 2023
Visit Reason
The inspection was conducted due to complaints regarding inadequate documentation of resident transfers and discharges, failure to provide timely notification of transfers to residents and representatives, inadequate pressure ulcer care, and failure to safeguard resident-identifiable information.
Complaint Details
The complaint investigation found substantiated deficiencies related to inadequate documentation of resident transfers, failure to notify residents and representatives of transfers, inadequate pressure ulcer care, and breach of confidentiality of resident medical records.
Findings
The facility failed to ensure proper physician documentation for resident transfers, timely notification of transfers to residents and representatives, appropriate pressure ulcer care for several residents, and confidentiality of resident medical records. Corrective actions were implemented for wound care deficiencies prior to the onsite investigation.
Deficiencies (4)
Failure to ensure physician documentation specified needs that could not be met and services at receiving facility for transferred residents.
Failure to provide timely notification to residents, representatives, and ombudsman before transfer or discharge.
Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing for 3 residents.
Failure to safeguard resident-identifiable information and maintain confidentiality of medical records for 1 resident.
Report Facts
Residents affected: 4
Residents affected: 3
Residents affected: 1
Dates of resident transfers: 2023
Correction completion date: 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Confirmed lack of physician documentation for transfers, failure to notify residents and representatives, and breach of confidentiality |
| Licensed Nurse | Confirmed handing Resident #3's spouse the wrong medication list |
Inspection Report
Complaint Investigation
Deficiencies: 11
Date: Dec 7, 2022
Visit Reason
The inspection was conducted to investigate multiple complaints related to abuse reporting, care planning, personal hygiene, pain management, respiratory care, catheter care, activity provision, food safety, and infection control at Elderwood at Burlington nursing home.
Complaint Details
The visit was complaint-related, investigating allegations including abuse reporting failures, inadequate care planning, insufficient personal hygiene assistance, pain management issues, respiratory care lapses, catheter care errors, lack of activity provision, food safety violations, and infection control deficiencies.
Findings
The facility failed to timely report alleged abuse, develop and revise care plans appropriately, provide adequate personal hygiene and pain management, ensure safe catheter and respiratory care, offer activities according to resident preferences, maintain food safety standards, and implement infection prevention protocols. Several residents experienced inadequate care resulting in minimal to actual harm.
Deficiencies (11)
Failed to timely report suspected abuse to appropriate state agencies within 2 hours for 1 of 27 residents.
Failed to develop a baseline care plan within 48 hours of admission related to pain management and skin integrity for 1 of 27 residents.
Failed to develop and implement a complete care plan for oxygen therapy for 1 of 26 residents.
Failed to revise care plans to reflect changing goals, preferences, and needs for 3 residents.
Failed to provide necessary assistance with activities of daily living including bathing for 3 residents.
Failed to provide ongoing activities based on resident preferences and care plans for 2 residents.
Failed to provide appropriate treatment and care according to orders and professional standards for 3 residents, including catheter care and timely diagnostic testing.
Failed to properly manage Foley catheter care for 1 resident resulting in emergent hospital transport due to overfilled retention balloon.
Failed to provide safe and appropriate respiratory care for 1 resident; oxygen tank was empty despite physician orders.
Failed to procure, store, prepare, distribute, and serve food in accordance with professional standards, including temperature control and sanitation issues.
Failed to maintain an infection prevention and control program, including lack of appropriate signage for transmission-based precautions and failure of staff to use required personal protective equipment.
Report Facts
Residents sampled: 27
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 3
Residents affected: 3
Residents affected: 2
Residents affected: 3
Residents affected: 1
Residents affected: 1
Temperature deviations: 31
Temperature deviations: 11
Temperature deviations: 21
Temperature deviations: 31
Temperature deviations: 30
Temperature deviations: 22
Temperature deviations: 27
Temperature deviations: 22
Temperature deviations: 26
Temperature deviations: 5
Temperature deviations: 12
Temperature deviations: 11
Temperature deviations: 9
Temperature deviations: 15
Temperature deviations: 10
Temperature deviations: 8
Temperature deviations: 17
Temperature deviations: 18
Temperature deviations: 31
Temperature deviations: 31
Temperature deviations: 3
Temperature deviations: 6
Temperature deviations: 19
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Unit Manager | Confirmed multiple deficiencies including care plan issues, hygiene, infection control, and activity provision | |
| Director of Nursing | DON | Confirmed care plan deficiencies, pain management issues, catheter care problems, and infection control lapses |
| Licensed Practical Nurse | LPN | Interviewed regarding pain management and infection control observations |
| Food Service Director | FSD | Confirmed food service temperature and sanitation deficiencies |
| RN Supervisor | RN Supervisor | Provided catheter insertion kit and confirmed catheter type |
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