Regulators have cited Elderwood at Burlington for serious lapses in patient care during a recent COVID-19 outbreak that has infected 127 of the nursing home's residents and employees.

The recent investigation, spurred by five anonymous complaints, did not find any shortcomings in infection control that may have contributed to viral spread. It confirmed instead that a staffing crisis led to dangerously diminished care.

A state inspector, working on behalf of the federal Centers for Medicare & Medicaid Services, visited the home on December 9 and 10, while Elderwood was still in the throes of an outbreak that began just before Thanksgiving. The inspection report was published this week.

The inspector's findings echo many of the concerns that family members and nursing staff relayed to Seven Days last month. With too few nurses, the home wasn't able to hand out medications or dress wounds on time, and residents were left sitting in urine as they waited for nurses to respond to call bells. 
In one case, a resident with a stage IV pressure ulcer — the most severe form — didn't have bandages changed on five occasions over the course of a week. The ulcer itself was supposed to be assessed and measured weekly, but the patient's records showed it hadn't been examined in more than a month.

Inspectors from the state Department of Disabilities, Aging and Independent Living (DAIL) also discovered that at least a dozen residents didn't receive their prescribed medications, including insulin, during a seven-hour period on December 2.

A nurse who was responsible for administering the medications that day had already been fired by the time of the state inspection. The state interviewed a licensed practical nurse who worked alongside the fired staffer. That nurse said the coworker hadn't wanted to work on the assigned unit and worked extremely slowly. It was an especially busy day during the outbreak, with many residents moved into new rooms as part of the containment effort.

"I don't know how much training [LPN #1] had," the coworker told investigators. "Maybe she was a new nurse."

Nurses interviewed by the state said a staffing shortage led to the lapses in care. Some employees previously told Seven Days that they were tasked with doing the work of four people on some days during the outbreak. More than 40 Elderwood employees tested positive for COVID-19 as part of the outbreak, Vermont Department of Health data shows.

One nursing assistant told the state, "We do the best we can, but it's just not personal. It has been hard not having time to do the extras [the residents] deserve."

Residents reported waiting more than 45 minutes for staff to respond to their call bells during the outbreak, leading to accidental urination. Another resident told the inspector that their urinary catheter bag wasn't being emptied regularly.

An investigator watched two residents wait more than 30 minutes for assistance on the day of the survey. The staffer who eventually came told the investigator that they weren't performing their normal duties and that Elderwood didn't have enough staff to meet residents' needs, especially during mealtimes.

Another resident had been left bed-bound for at least several days because there weren't enough workers to help get the resident out of bed, according to the report.

Staffing is a longstanding problem in Vermont eldercare homes that has been exacerbated by the pandemic. But it's unusual for a home to be cited for not meeting the minimum requirements, as Elderwood was, Vermont Long-Term Care Ombudsman Sean Londergan said. Londergan said the Elderwood employees' statements to investigators gave DAIL clear evidence of a violation. "It is kind of an almost egregious situation, so I think it's easier for the state to cite them," he said.

Even before the COVID-19 outbreak, Elderwood staff were complaining about their working conditions. Several Black traveling nurses told Seven Days last October that the home failed to protect them from an abusive resident who routinely yelled racial epithets. A DAIL official at the time said the allegations were outside the agency's purview but were especially distressing given the importance of traveling workers during the pandemic.
Elderwood's official plan of correction for the December staff shortage is vague. It states only that the facility "continues to hire, train and schedule enough competent staff to meet the needs of the residents and surpass the minimum staffing requirements."

"How are they going to increase staffing if they're basically going to continue doing what they did before?" Londergan asked.

The company, a regional chain with other homes in New York, Pennsylvania and Rhode Island, did not make anyone available for an interview to answer that question.

"I can, however, share with you that Elderwood at Burlington provides safe, quality care for all of our residents," spokesperson Charles Hayes wrote in an emailed statement. "We work collaboratively with the VT Department of Health to appropriately identify and address any and all potential areas for improvement. As always, our primary focus continues to be the health and well-being of our residents."
DAIL is the state agency that regulates eldercare homes, not the Vermont Department of Health. Because of the nature of the citations, a DAIL inspector will revisit Elderwood on an unannounced date for a follow-up inspection, licensing chief Pam Cota said.

"If we find that your facility has failed to achieve or maintain substantial compliance, remedies may be imposed," she wrote in a January 19 letter to Elderwood administrator Lisa Peacock.

Londergan said pandemic-related restrictions on visitation in nursing homes have made it hard for families to know what caliber of care their loved ones are receiving. Yet the federal and state oversight systems are largely driven by complaints.

"If people don't know what's happening and are left guessing, that rightfully causes a lot of angst," Londergan said. "Then something like this happens, and it kind of affirms what people have been thinking."

On top of the patient care problems, Elderwood was also violating a federal rule that requires families be notified the day following any new COVID-19 cases in the building. Elderwood's administration told the state that it was updating residents' families "at least every seven days."

"It's pretty bad when you have to hear it on the news or newspaper," one family member told the state inspector.

At least 18 Elderwood residents have died after getting infected with COVID-19, according to death certificates obtained by Seven Days.

Read the inspection report and Elderwood's plan of correction here: