St. Johnsbury Health & Rehab

In the surveyor’s words

From the most serious findings on record at St. Johnsbury Health & Rehab, in the surveyor’s own words.

• Immediate jeopardy, widespreadF600Jul 24, 2025

  Based on record review and interview, the facility failed to protect the residents' right to be free from neglect by not providing goods and services to residents' that are necessary to avoid physical harm, pain, mental anguish or emotional distress by failing to develop and implement adequate systems to meet the care and service needs of residents.During the investigation the team identified many failures, some of which are widespread system failure, which included: providing adequate nursing staff to safely care for all residents;development of baseline care plans for newly admitted residents;development, revision, and implementation of comprehensive care plans to meet resident's needs;ensure all applicable residents have care plan interventions and supervision to prevent… […]

• Immediate jeopardy, widespreadF841Jul 24, 2025

  Based on document review and interview, it was determined that the facility failed to ensure the Medical Director duties per the Medical Director Agreement and Medical Director facility policy were performed, including ensuring resident care policies were implemented and coordination of care was provided to ensure resident care and services were provided to all resident that were consistent with current professional standards of practice for 2 of 2 units. On 7/18/25 the facility was notified of non-compliance at the immediate jeopardy (IJ) level for Medical Director. This is a repeat deficiency for this facility, with the violation cited during the previous complaint survey, dated 4/8/25. On 7/23/25 the facility's IJ plan of correction was accepted. […]

• Immediate jeopardy, patternF678Jul 6, 2022

  Based on staff interview and record review, the facility failed to ensure that staff were certified to provide basic life support, including Cardiopulmonary Resuscitation (CPR), and familiar with facility policies related to CPR. Findings include: 1. Per record review, facility staff failed to follow advance directives and physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #2's medical record includes: a DNR/COLST (Clinician order for [MEDICAL RECORD OR PHYSICIAN ORDER] #2] has an advanced directive of Full Code, with the goal listed as [Resident #2]'s advanced directives will be honored, and an intervention listed as CPR will be performed as need. […]

• Immediate jeopardy, isolatedF600May 28, 2025

  Based on interview and record review, the facility failed to protect the resident's right to be free from neglect for 1 [Resident #1] of 3 sampled residents regarding staff having the knowledge and ability to provide care and services, but choosing not to do it, or acknowledge the request for assistance from a resident resulting in care deficits to a resident. Resident #1 suffered serious harm that rose to the immediate jeopardy level due to the facility's failure to prevent neglect. As a result, Resident #1 expereinced symptoms related to very high, unsafe blood sugar and psychosocial harm. Findings include: Review of the admission Packet given to every resident in the facility includes the facility's Abuse, Neglect and Exploitation Policy. […]

• Immediate jeopardy, isolatedF658May 28, 2025

  Based on interview and record review, the facility failed to ensure 1 [Resident #1] of 3 sampled residents received care and services according to accepted standards of clinical practice. Resident #1 suffered serious harm that rose to the immediate jeopardy level due to the facility's failure to provide care in accordance with professional standards, As a result, Resident #1 experienced symptoms related to very high, unsafe blood sugar and psychosocial harm. Findings include: According to the American Nurses Association: Scope and Standards of Practice (http://www.Nursingworld.org © 2010 American Nurses Association) The Standards of Professional Nursing Practice are authoritative statements of the duties that all registered nurses, regardless of role, population, or specialty, are… […]