Elderwood at Burlington

Inspectors wroteBased on observation, interview and record review the facility failed to provide quality care to 1 of 3 sampled residents (Resident #3) related to skin assessment, and non-pressure wound care.

Inspectors wroteBased on interview and record review, the facility failed to ensure that 1 of 3 sampled residents (Resident #2) remained as free from fall-related accidents as possible by failing to ensure that direct care staff properly use an assistive device and prevent an avoidable accident from occurring.

Inspectors wroteBased on employee file review, record review, and interviews, the facility failed to ensure that direct care staff had the specific competencies, and skill sets necessary to meet residents' needs related to the use of a mechanical lift for 1 of 4 sampled Licensed Nursing Assistant (LNA) [LNA#1].

Inspectors wroteBased on observation, interview, and record review, the facility failed to communication and coordination between the staff with all departments special dietary for 1 of 1 sampled residents (Resident #1).

Inspectors wroteBased on interview and record review, the facility failed to complete a performance review of every nurse aide at least once every 12 months or provide regular in-service education based on the outcome of these reviews for 4 of 4 sampled employee files.

Inspectors wroteBased on observation and interview, the facility failed to ensure expired medications were stored or disposed of properly for 3 of 3 units. This is a repeat deficiency for this facility, with violations cited during the previous two recertification surveys dated 4/2/25 and 1/11/24.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents who require dialysis (A life-sustaining medical treatment that filters waste, toxins, and excess fluids from the blood when the kidneys have failed.) receive services consistent with professional standards of practice for one of two residents (Resident #112).

Inspectors wroteBased on staff interview and record review, the facility failed to assure that a PASARR (Pre-admission Screening and Resident Review) was conducted for 1 applicable resident (Resident #20), who was admitted with a 30-day exemption and has exceeded the expected 30-day stay.

Inspectors wroteBased on interview and record review, the facility failed to follow the providers' orders in administering a medication for one of eight residents (Resident #64). Per record review, Resident #64 has the medical diagnosis of cellulitis of left lower limb, Methicillin Resistant Staphylococcus Aureus infection (MRSA), and pain in their left leg. On 2/19/26, a telehealth provider created a treatment plan including Start linezolid 600 mg BID for five days to cover for MRSA. A second progress note on 2/24/26 by a provider identified that the Resident had been prescribed linezolid on 2/19/26 and that they could not see that it was ever obtained or administered. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to store food in accordance with professional standards for food service safety for 1 applicable unit.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement appropriate infection control practices during medication administration via tube feed for one sampled resident (Resident #14). This is a repeat deficiency for this facility, with violations cited during the previous two recertification surveys dated 4/2/25 and 1/11/24.

Inspectors wroteBased on record review and interviews, the facility failed to document for 1 of 6 residents (Resident #124) whether the resident was offered, educated, and received or declined the influenza and pneumococcal vaccinations.

Inspectors wroteBased on interview and record review the facility failed to include documentation in the electronic medical record (EMR) for 1 of 6 residents (Resident #124) whether the resident was offered, educated, received, or declined the COVID-19 vaccinations.

Inspectors wroteBased on staff interviews and record reviews, the facility failed to ensure that 10 of 10 residents sampled (#1, 2, 3, 4, 5, 6, 7, 8, 9, and 10) were free from misappropriation of 6 different types of controlled medications identified by the facility audit.

Inspectors wroteBased on interview and record review, the facility failed to ensure that 1 of 5 nursing staff had an active [NAME] license to practice.

Inspectors wroteBased on record review and staff interviews, the facility failed to implement a system to ensure nursing staff members administering medications maintain ongoing qualifications for 1 of 5 nursing staff sampled.

Inspectors wroteBased on interview and record review, the facility failed to send written documentation to resident and resident representative about transfers to outside facilities for one of three sampled residents (Resident #1). The facility also failed to send transfer records to the Long-Term Care Ombudsman for three of three sampled residents (Residents #1, #2, and #3).

Inspectors wrotePer 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.

Inspectors wrotePer interview and record review the facility's failed to prevent significant medication errors for one of four residents [Resident #1] sampled.

Inspectors wroteBased on interview and record review, the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act for 1 resident [Resident #1] of 3 sampled residents.

Inspectors wroteBased on interview and record review, the facility 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 to the facility for 1 resident [Resident #1] of 3 sampled residents.

Inspectors wroteBased on staff interview and record review, the facility failed to ensure that the individual who has completed the specialized training in infection prevention and control oversees the facility's infection prevention and control program.

Inspectors wroteBased on observation and interview, the facility failed to ensure residents are given the opportunity to eat meals in the dining room during breakfast, dinner, and the weekend meal service for 7 randomly sampled residents (Residents #73, #4, #13, #10, #54, #6, #74).

Inspectors wrotePer observation, interview, and facility policy review, the facility failed to establish an anonymous grievance reporting system that supports the resident's right to voice any grievance without discrimination, reprisal, or the fear of discrimination or reprisal for 2 of 5 sampled residents (Residents #72 and Resident #82).

Inspectors wroteBased on interview, observation, and record review the facility failed to provide trauma informed care by not identifying triggers that may cause re-traumatization for 5 of 9 sampled residents (Resident #31, #60, #464,#99,#110).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure there was enough nursing staff to administer medications timely for 1 of 27 sampled (Resident #45) and meet resident preferences of where to dine for 7 randomly sampled residents (Residents #73, #4, #13, #10, #54, #6, #74). This has the potential to impact multiple residents. This is a repeat deficiency for this facility, with violations cited during a partial survey, dated 8/15/24, and the previous recertification survey, dated 1/11/24.

Inspectors wroteSurveyor: [NAME], [NAME] Based on observation and interview, the facility failed to ensure that food served to residents is palatable, attractive, and served at an appetizing temperature for 12 randomly sampled residents, (Residents #44 , #74, #4, #14, #72, #50, #97, #74, #33, #25, #68, and #83).

Inspectors wroteBased on interviews, observations, and record review, the facility failed to provide residents appealing menu items that meet the preferences and choices of the residents for 6 randomly sampled residents (Residents #5, #82, #50, #34, #80, and #18).

Inspectors wroteBased on observation and interview, it was determined that the facility failed to maintain infection control practices specific to medication administration for 1 resident (#464) in a standard survey sample of 27, and failed to ensure facility equipment used for mechanic lift transfers was cleaned and maintained sanitarily. This is a repeat deficiency for this facility, with violations cited during the previous two recertification surveys, dated 1/11/24 and 12/7/22.

Inspectors wroteBased on interview and record review the facility failed to develop and implement a baseline care plan within 48 hours of admission that included the instructions needed to provide effective and person-centered care for 2 of 27 residents in the sample (Resident #464 and Resident #34). This is a repeat deficiency for this facility, with violations cited during the previous two recertification surveys, dated 1/11/24 and 12/7/22.

Inspectors wrote1) Based observation, interview and record review, the facility failed to ensure that services provided meet professional standards as evidenced by failing to follow physicians' orders related to the timing of administration for 2 of 27 sampled residents (Residents #45 and #34). This is a repeat deficiency for this facility, with violations cited during the previous recertification survey, dated 1/11/24.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice including prevention of skin breakdown for 1 of 27 sampled residents (Resident # 14).

Inspectors wroteBased on observation and interview, it was determined that the facility failed to store all drugs and biologicals in locked compartments/medication carts and only permit authorized personnel to have access to 1 of 6 medication carts. This is a repeat deficiency for this facility, with violations cited during the previous recertification survey, dated 1/11/24.

Inspectors wroteBased on observation, resident and staff interviews, and record review, the facility failed to ensure there are a sufficient number of skilled licensed nurses, nurse aides, and other nursing personnel to provide care and respond to each resident's basic needs and individual needs as required by the resident's diagnoses, medical condition, or plan of care, potentially impacting all residents of the facility.

Inspectors wroteBased on observation, resident and resident representative interview, staff interview, and record review, the facility failed to ensure that a resident who is unable to carry out activities of daily living (ADLs) without assistance receives the proper level of assistance for 8 of 11 sampled residents (Residents #1, #4, #5, #6, #7, #8, #9, and an anonymous resident).

Inspectors wroteBased on observation, record review and interview the facility failed to monitor 3 out 3 residents sampled for the adverse side effects related to psychotropic medications (Resident's #5, #9, and #10).

Inspectors wroteBased on staff interview and record review, the facility failed to ensure that physicians and other providers (as delegated to per regulation) review the residents' total program of care, including medications and treatment plan at each visit as required for 1 of 3 sampled residents (Resident's #9).

Inspectors wroteBased on interview, record review, and policy review, the facility failed to ensure that allegations involving abuse are reported no later than 2 hours to the Administrator of the facility and the State Survey Agency for 1 of 3 sampled residents (Resident #1); the facility failed to provide the State Agency sufficient information to describe the alleged violation and indicate how residents are being protected in its initial report for 3 of 3 sampled resident to resident altercations; the facility failed to provide sufficient information to describe the results of an investigation, and indicate any corrective actions taken, if the allegation was verified in its final investigation 5 day summary report for 2 of 2 sampled resident to resident altercations; [...]

Inspectors wroteBased on observations, interview, and record review, the facility failed to maintain medical records on each resident that are accurately documented related to skin for two of three sampled residents (Residents #3 and #4).

Inspectors wroteBased on record review and interview, the facility failed to provide safe and effective skin and wound care consistent with facility policy and professional standards of practice for preventing and treating existing pressure ulcers for 7 of 37 sampled residents (Residents #50, #7, #1, #99, #43, #21, and #107), resulting in new or worsening pressure ulcers for all 7 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pain management to a resident experiencing pain for 1 of 35 sampled residents (Resident #7) related to not providing pain medication per physician orders and not administering pain medication that met professional standards of practice resulting in Resident #7 having significant, untreated pain.

Inspectors wrotePer interview and record review, the facility failed to provide medications as ordered by the prescriber to meet the needs of each resident for 4 of 35 sampled residents (Resident #7, #52, #102, and #81).

Inspectors wroteBased on interview and record review, the facility failed to ensure 2 of 35 sampled residents (Residents #7 and #52) are free from significant medication errors related to missed medication administration. As a result, Resident #7 experienced significant, untreated pain and Resident #52 was at increased risk for increased behavioral and mental health symptoms.

Inspectors wroteBased on interview and record review, the facility failed to ensure that 3 eligible residents (Residents #50, #270, and #80) on one unit received the influenza vaccine. As a result, one unvaccinated resident (Resident #50) developed influenza and required hospitalization for dehydration and abnormal lung sounds, and two residents (Resident #270 and #87) were at increased risk for contracting influenza and/or developing influenza complications. 1. Per record review, Resident #50 was admitted to the facility on [DATE] with diagnoses that include diabetes and severe kidney disease. S/He was recently assessed at the emergency room related to elevated kidney function labs and a urinary tract infection according to a 12/16/23 emergency visit note. Resident #50 is considered high risk for influenza complications because of his/her diagnoses and nursing home admission. [...]

Inspectors wroteBased on observation, resident and staff interviews, and record review, the facility failed to ensure there are a sufficient number of skilled licensed nurses, nurse aides, and other nursing personnel to provide care and respond to each resident's basic needs and individual needs as required by the resident's diagnoses, medical condition, or plan of care, impacting all residents of the facility.

Inspectors wroteBased on interview, staff education record review, and the facility assessment, the facility failed to ensure that licensed nurses and licensed nursing assistants were assessed for competency and skill sets to provide care and respond to each resident's individualized needs. This has the potential to affect all residents. The facility's Facility Assessment (an assessment that determines what resources are necessary to care for the residents competently during both day-to-day operations and emergencies), last reviewed 10/2/2023, reveals under section 3 titled Facility Resources Needed to Provide Competent Resident Support and Care Daily and During Emergencies a chart that lists the required staff competencies required to provide the level and types of care needed for the resident population, both initially and annually. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure that food is stored in accordance with professional standards for food service safety. The facility also failed to ensure that dishwasher temperatures were monitored to ensure proper sanitation.

Inspectors wroteBased on interview and document review, it was determined that the facility failed to ensure the Medical Director (MD) duties per the Medical Director Agreement and Medical Director facility policy were implemented to ensure resident care policies and services were provided to all residents that were consistent with current professional standards of practice on 3 of 3 resident units.

Inspectors wroteBased on observation and interview it was determined that the facility failed to maintain an effective pest control program that ensures the facility is free of pests.

Inspectors wroteBased on observations and interviews, the facility failed to treat those residents reliant on wheelchairs with dignity by failing to clean the wheelchairs. The facility has 80 residents who utilize wheelchairs.

Inspectors wroteBased on observation, staff interview, and record review, the facility failed to determine whether it is clinically appropriate for residents to self-administer medications for 2 of 35 residents (Resident #31 and #81).

Inspectors wroteBased on record review the facility failed to use the data collected using the Resident Assessment Instrument (RAI) process, specifically the Minimum Data Set (MDS) assessment, as part of an ongoing process to develop a comprehensive care plan, to provide the appropriate care and services and to modify the care plan for 1 of 35 Resident's sampled (Resident # 28). Additionally, the facility failed to accurately code the MDS assessment, due to lack of accurate review of records and/or lack of actual assessment of the resident's wounds by the facility, for 3 of 35 Resident's sampled (Residents #47, #99, and #1).

Inspectors wroteBased on observations, interviews, and record review, the facility failed to develop a Comprehensive person-centered care plan for 2 of 35 sampled residents (Resident #111 and #88).

Inspectors wroteBased on interview and record review, the facility failed to review and revise care plans for 4 residents of 35 sampled residents (Resident #24, Resident #28, Resident #69 Resident #47) and failed to develop or revise resident's care plans after each assessment and with the required team for 9 of 37 sampled residents (Residents #7, #31, #111, #99, #1, #43, #50, #107, and #21).

Inspectors wroteBased on interviews and record review the facility failed to ensure residents who are unable to carry out activities of daily living receive the necessary services to maintain good personal hygiene for 3 of 35 sampled residents (Residents #111, #7, and #269).

Inspectors wroteBased on interview and record review, the facility failed to provide range of motion rehabilitation services for 2 of 35 sampled residents (Resident #81 and #43).

Inspectors wroteBased on observations, interviews and record review the facility failed to provide respiratory care consistent with professional standards of practice and per medical orders for 2 of 35 sampled residents (Resident #23 & Resident #66).

Inspectors wroteBased on interview, record review, and review of facility policies, the facility failed to ensure that a physician reviewed the total program of care during the required regulatory visits for 9 of 37 sampled residents (Residents #7, #31, #111, #99, #1, #43, #50, #107, and #21).

Inspectors wroteBased on interview and record review the facility failed to ensure residents who are receiving as-needed psychotropic medications have a 14-day stop date for 5 of 5 residents sampled. (Residents #2, #5, #6 #7 and # 8) Per record review on 3/7/24 Resident #7 has a Physician's order that started on 2/28/24 for Lorazepam (an anti-anxiety psychotropic medication) give 0.25 milligrams (mg) sublingually (SL) a route of administration in which the medication is placed under the tongue and is absorbed through the mucous membrane) every 4 hours as needed (PRN) for anxiety/SOB (shortness of breath). There is no 14-day stop date included in the order. Resident #7 also has a Physician order started on 2/28/24 for Haldol (an antipsychotic psychotropic medication given for agitation) give 0.5 milliliters (ml) by mouth every 6 hours as needed for agitation. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that all drugs and biologicals are kept in locked compartments only accessible to authorized personnel for one applicable treatement cart; failed to ensure that medications and biologicals were removed from use when expired for 2 of 3 units; and failed to ensure medications were properly stored for 2 of 35 sampled residents (Resident #31 and #81).

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections as evidenced by the improper use of PPE (personal protective equipment) for 1 of 3 residents on precautions (Resident #50) and throughout the facility; failure to use proper hand hygiene during medication administration; and the failure to clean respiratory equipment (C-PAP and Bi-PAP) machines per orders and facility policy for 3 of 3 sampled residents (Residents #69, 5, & 23).

Inspectors wroteBased on interview and record review, the facility failed to ensure that 3 eligible residents (Residents #50, #271, and #37) on one unit received the COVID-19 vaccine. 1. Per record review, Resident #50, who is [AGE] years old, was admitted to the facility on [DATE] with diagnoses that include diabetes and severe kidney disease. Resident #50 is considered high risk for COVID-19 complications because of his/her diagnoses and age. An undated form titled Vaccination Review: Consent/Declination Resident Form, entered into Resident #50's medical record with the effective date of 11/20/23, reveals that his/her vaccination history was assessed for influenza, COVID-19, and pneumococcal. The form indicates that s/he did not receive a 2023 COVID-19 vaccine. Under decision to vaccinate, the choices not eligible, consented, and declined are all left blank. [...]

Inspectors wroteBased on interview, record review, and review of the facility assessment, the facility failed to ensure that staff had effectively been trained in trauma informed care.

Inspectors wroteBased on interviews and record review, the facility failed to schedule timely care plan meetings and facilitate the inclusion of the resident's representatives to attend the meeting.

Inspectors wroteBased on staff interview and record review, the facility failed to ensure accurate advanced directive choices were indicated for 1 of 35 sampled residents (Resident #7).

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a baseline care plan within 48 hours of admission that included the minimum healthcare information necessary to properly care for the resident for 1 of 35 sampled residents (Residents #50).

Inspectors wroteBased on record review and interview the facility failed to provide services that meet professional standards of quality related to the Social Services for 1 of 35 residents sampled (Resident # 28).

Inspectors wroteBased on Interview, observations, and record review, the facility failed to provide activities that support each resident's physical, mental and psychosocial well-being for 1 of 35 sampled residents (Resident #65).

Inspectors wroteBased on observation, interview, and record review the facility failed to provide care and treatment consistent with the resident's physician orders and professional standards of practice, placing the resident at risk for infection for 1 of 4 residents in the sample (Resident #4).

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance to prevent accidents for 2 of 35 sampled (Resident #5 & #47 ).

Inspectors wroteBased on staff interview and record review, the facility failed to ensure that 1 of 7 sampled residents (Resident #31) with an indwelling catheter receives the appropriate care and services to prevent urinary tract infections to the extent possible.

Inspectors wroteBased on staff interview and record review, the facility failed to ensure that 1 applicable resident (Resident #7) a urostomy receives care consistent with the comprehensive person-centered care plan and professional standards of practice.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain acceptable parameters of nutritional status as evidenced by failing to obtain weights as ordered, failing to consistently document resident meal intakes and meal refusals, and failing to update the physician of refusal of weights for one of the 35 residents sampled (Resident #92).

Inspectors wroteBased on observstion, interview, and record review, the facility failed to ensure that the medical care of each resident is supervised by a physician for 1 of 35 sampled residents (Resident #92).