A list of the most recent deficiencies for St Johnsbury Health and Rehab. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-05-17 | 2023-06-12 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-05-17 | 2023-06-12 | Y |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2023-05-17 | 2023-06-12 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-04-07 | 2023-05-10 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-04-07 | 2023-05-10 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-04-07 | 2023-05-10 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-04-07 | 2023-05-10 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-01-31 | 2023-02-28 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-01-31 | 2023-02-28 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-08-24 | 2022-12-13 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-08-24 | 2022-12-13 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-08-23 | 2022-11-25 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-10-17 | 2022-11-18 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-10-17 | 2022-11-18 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-08-24 | 2022-09-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-08-24 | 2022-09-30 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-07-06 | 2022-07-15 | Y |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2022-07-06 | 2022-07-15 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-06-15 | 2022-07-08 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-06-15 | 2022-07-08 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2022-05-10 | 2022-06-07 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-05-10 | 2022-06-07 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2022-04-27 | 2022-05-24 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-04-27 | 2022-05-24 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-04-27 | 2022-05-24 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-04-27 | 2022-05-24 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-05-05 | 2022-05-18 | Y |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2022-05-05 | 2022-05-18 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-03-21 | 2022-04-13 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-08-11 | 2021-09-15 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2021-08-11 | 2021-09-15 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2021-08-11 | 2021-09-15 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2021-08-11 | 2021-09-15 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-08-11 | 2021-09-15 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-08-11 | 2021-09-15 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-08-11 | 2021-09-15 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2021-08-11 | 2021-09-15 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2021-05-13 | 2021-06-23 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-05-13 | 2021-06-23 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-05-13 | 2021-06-23 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2021-04-28 | 2021-05-11 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-04-28 | 2021-05-11 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-04-28 | 2021-05-11 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-10-25 | Not Fixed | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-25 | Not Fixed | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-10-25 | Not Fixed | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-10-25 | Not Fixed | Y |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2023-06-21 | Not Fixed | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-08-30 | Not Fixed | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2023-08-30 | Not Fixed | N |
| Provide doctor's orders for the resident's immediate care at the time the resident was admitted. | Health | 2023-08-30 | Not Fixed | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-08-30 | Not Fixed | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-08-30 | Not Fixed | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-08-30 | Not Fixed | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-08-30 | Not Fixed | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2023-08-30 | Not Fixed | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-08-30 | Not Fixed | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-08-30 | Not Fixed | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-08-12 | Not Fixed | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2021-08-12 | Not Fixed | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2021-08-12 | Not Fixed | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2021-08-12 | Not Fixed | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-08-12 | Not Fixed | N |
