
Report
TheVardellReport
Elderwood at Burlington
Skilled nursing facility and nursing facility
98 Starr Farm Rd.
Burlington, VT 05408

TheVardellReport
Skilled nursing facility and nursing facility
98 Starr Farm Rd.
Burlington, VT 05408
Life by Vardell Presents
The deeper story, beautifully organized. Available records, historical context, and questions worth asking.
This report is free. Vardell does not certify, grade or endorse; it shows what the record documents.
The Essentials
Across 10 inspections from January 2024 to July 2026, state surveyors documented 74 findings at Elderwood at Burlington; 74 have a recorded correction; CMS lists 2 enforcement actions in the window.
* Partial year, through October 1, 2026.
| Year | Inspections | Findings | Of which, actual harm (level G or above) |
|---|---|---|---|
| 2024 | 3 | 41 | 5 |
| 2025 | 4 | 17 | 0 |
| 2026 | 3 | 16 | 0 |
Chronology
Every inspection in the record window, newest first. A finding is a deficiency an inspector cited. CMS publishes what a complaint investigation cited, not what the complaint alleged.
4 findings
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
9 findings
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
3 findings
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
1 finding
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
2 findings
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
2 findings
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
12 findings
The same visit included a complaint investigation.
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
4 findings
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
2 findings
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
35 findings
Enforcement Action
Civil money penalty, $220,961 imposed January 11, 2024. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of January 11, 2024, the nearest before the penalty date.
Enforcement Action
Denial of payment imposed January 11, 2024. Status: Closed, April 12, 2024. CMS does not tie a penalty to a survey; listed with the standard health inspection of January 11, 2024, the nearest before the penalty date.
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Severity levels follow the CMS scope and severity grid. A–C: potential for minimal harm. D–F: no actual harm, potential for more than minimal harm. G–I: actual harm. J–L: immediate jeopardy.
Context
A repeated citation can merit attention, but context and corrective action must be reviewed before drawing a conclusion.
Inspectors cited F658 in January 2024, April 2025 and March 2026. This citation covers whether the home’s services meet professional standards of quality. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F684 in January 2024, April 2025 and July 2026. This citation covers whether residents receive the treatment their orders, preferences and goals call for. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F725 in January 2024, August 2024 and April 2025. This citation covers whether there are enough nurses and aides to meet residents’ needs, with a licensed nurse in charge on each shift. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F761 in January 2024, April 2025 and March 2026. This citation covers how drugs are labeled and kept locked, including controlled drugs. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F880 in January 2024, April 2025 and March 2026. This citation covers hand hygiene, isolation practice and the home’s infection-prevention program. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F609 in February 2024 and May 2025. This citation covers whether suspected abuse, neglect or theft is reported to the authorities on time, with the results of the home’s investigation. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F655 in January 2024 and April 2025. This citation covers the baseline care plan for a new resident’s immediate needs, due within 48 hours of admission. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F677 in January 2024 and August 2024. This citation covers help with bathing, dressing, eating and toileting for residents who cannot manage alone. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F689 in January 2024 and July 2026. This citation covers whether residents are protected from accident hazards and supervised closely enough to prevent accidents, including falls. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F711 in January 2024 and August 2024. The agency describes it this way: Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F726 in January 2024 and July 2026. The agency describes it this way: Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F755 in January 2024 and January 2026. This citation covers pharmacy services and the licensed pharmacist who oversees them. The most serious of these was recorded at level G (actual harm). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F758 in January 2024 and August 2024. This citation covers how psychotropic drugs are used, including dose reductions and limits on as-needed orders. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F760 in January 2024 and August 2025. This citation covers whether residents are free from significant medication errors. The most serious of these was recorded at level G (actual harm). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F812 in January 2024 and March 2026. This citation covers how food is stored, prepared and served. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F883 in January 2024 and March 2026. The agency describes it this way: Develop and implement policies and procedures for flu and pneumonia vaccinations. The most serious of these was recorded at level G (actual harm). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F887 in January 2024 and March 2026. The agency describes it this way: Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
For Your Next Visit
Bring these to the tour. Each one comes from something in the record; the reason is under the question.
How do you check that nurses and aides follow professional standards, and what happens when they do not?
Professional Standards: cited in three inspections, most seriously at level D.
How do nurses make sure a doctor’s orders are carried out, and how are families told when something is missed?
Quality of Care: cited in three inspections, most seriously at level D.
How many nurses and aides are on each shift, including nights and weekends, for the unit we are considering?
Nursing Staff Levels: cited in three inspections, most seriously at level F.
How are medications stored and secured, and who checks the medication carts?
Medication Labeling and Storage: cited in three inspections, most seriously at level F.
Who leads infection control here, and how often are hand-hygiene and isolation practices audited?
Infection Control: cited in three inspections, most seriously at level E.
How are staff trained to report suspected abuse or neglect, and who reports it to the state?
Reporting Suspected Abuse: cited in two inspections, most seriously at level E.
What happens in the first 48 hours after admission, and who writes the first care plan?
The First 48 Hours: cited in two inspections, most seriously at level D.
How long do residents usually wait for help with bathing, dressing or the bathroom, and how is that tracked?
Help With Daily Living: cited in two inspections, most seriously at level E.
What changed in fall prevention and supervision after the last citation, and how do you check that it is still working?
Accident Hazards and Supervision: cited in two inspections, most seriously at level D.
What changed after F711 was cited, and how do you check it now?
Citation F711: cited in two inspections, most seriously at level E.
What changed after F726 was cited, and how do you check it now?
Citation F726: cited in two inspections, most seriously at level F.
How often does the consultant pharmacist review each resident’s medications?
Pharmacy Services: cited in two inspections, most seriously at level G.
How many residents take psychotropic medications, and how often are doses reviewed for reduction?
Psychotropic Medications: cited in two inspections, most seriously at level E.
What happened after the medication error citation, and how are high-risk drugs double-checked?
Significant Medication Errors: cited in two inspections, most seriously at level G.
May we see the kitchen, and what do your own sanitation checks look like week to week?
Kitchen and Food Safety: cited in two inspections, most seriously at level F.
What changed after F883 was cited, and how do you check it now?
Citation F883: cited in two inspections, most seriously at level G.
What changed after F887 was cited, and how do you check it now?
Citation F887: cited in two inspections, most seriously at level E.
What led to the 2024 fine, and has it been paid?
A $220,961 civil money penalty was imposed January 11, 2024. CMS publishes the fine, not whether it has been paid. The record holds two enforcement actions in the window.
The Evidence
Inspection results and penalties are published by the Centers for Medicare & Medicaid Services from surveys conducted by the Vermont state survey agency.
Vermont state survey agency
Inspection Jan 11, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Vermont state survey agency
Inspection Feb 23, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Vermont state survey agency
Inspection Aug 15, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Vermont state survey agency
Inspection Apr 2, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Vermont state survey agency
Inspection May 12, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Vermont state survey agency
Inspection Aug 11, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Vermont state survey agency
Inspection Dec 10, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Vermont state survey agency
Inspection Jan 14, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Vermont state survey agency
Inspection Mar 25, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Vermont state survey agency
Inspection Jul 1, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Centers for Medicare & Medicaid Services
Published Oct 1, 2026 · Retrieved Nov 1, 2026
Centers for Medicare & Medicaid Services · 475030
Published Oct 1, 2026 · Retrieved Nov 1, 2026
Record windowJanuary 11, 2024 – October 1, 2026
Historical coverage varies by agency and location. Missing records do not mean that no complaint or violation occurred.
Data architecture: Cierto supplies the source-backed machine-readable bundle. Life by Vardell independently creates the narrative, design, and consumer report.