Elderwood at Burlington

In the surveyor’s words

From the most serious findings on record at Elderwood at Burlington, in the surveyor’s own words.

• Actual harm, patternF686Jan 11, 2024

  Based 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. Findings include: Facility policy titled Pressure Ulcer, Pressure Injury & Other Skin Conditions: Initial Assessment, Care Planning, Ongoing Evaluation and Management (HAM, [NAME], SS, WAV, WMS [facility name initails]) SNF, last revised on 2/27/2023 reveals the following under procedures: Care Plan Development & Implementation: a baseline care plan will be developed by the IDT [interdisciplinary team] within 48 hours… […]

• Actual harm, isolatedF697Jan 11, 2024

  Based 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. Findings include: Per record review, Resident #7 has diagnoses that include spastic quadriplegic cerebral palsy (a physical disability that causes muscle rigidity that affects all four limbs and often a person's torso, facial, and oral muscles), polyneuropathy (nerve damage which can cause symptoms including pain and trouble swallowing), dysphagia (difficulties swallowing), and anarthria (loss of speech). […]

• Actual harm, isolatedF755Jan 11, 2024

  Per 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). Findings include: 1. Per record review, Resident #7 has diagnoses that include spastic quadriplegic cerebral palsy (a physical disability that causes muscle rigidity that affects all four limbs and often a person's torso, facial, and oral muscles), polyneuropathy (nerve damage which can cause symptoms including pain and trouble swallowing), dysphagia (difficulties swallowing), and anarthria (loss of speech). Resident #7's 10/2/23 Minimum Data Set (MDS; a comprehensive assessment used as a care- planning tool) dated 10/2/23 reveals that s/he shows indicators of pain daily. […]

• Actual harm, isolatedF760Jan 11, 2024

  Based 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. Findings include: 1. Per record review, Resident #7 has diagnoses that include spastic quadriplegic cerebral palsy (a physical disability that causes muscle rigidity that affects all four limbs and often a person's torso, facial, and oral muscles), polyneuropathy (nerve damage which can cause symptoms including pain and trouble swallowing), dysphagia (difficulties swallowing), and anarthria (loss of speech). […]

• Actual harm, isolatedF883Jan 11, 2024

  Based 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. […]