ElderGrade

Inspection citations at St. Johnsbury Health & Rehab

71 citations on record, 9 of which inspectors scored at actual harm or immediate jeopardy. Each one is the state surveyor's own finding, not our summary.

Reading the scope & severity code

A–C

No harm, minimal potential

D–F

No harm, potential for harm

G–I

Actual harm to a resident

J–L

Immediate jeopardy

The letter also encodes how many residents were affected — isolated, a pattern, or widespread. Full explainer.

Citations by survey year

Year Citations Involving harm or jeopardy
2026 10 0
2025 27 5
2024 17 0
2023 17 4
D May 4, 2026 Tag F0657 Complaint investigation Corrected Jun 2026

Resident Assessment and Care Planning Deficiencies

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

No actual harm, potential for more than minimal harm

D May 4, 2026 Tag F0550 Complaint investigation Corrected Jun 2026

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

No actual harm, potential for more than minimal harm

D January 28, 2026 Tag F0880 Corrected Feb 2026

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

No actual harm, potential for more than minimal harm

D January 28, 2026 Tag F0761 Corrected Feb 2026

Pharmacy Service Deficiencies

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.

No actual harm, potential for more than minimal harm

D January 28, 2026 Tag F0756 Corrected Feb 2026

Pharmacy Service Deficiencies

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

No actual harm, potential for more than minimal harm

D January 28, 2026 Tag F0628 Corrected Feb 2026

Resident Rights Deficiencies

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

No actual harm, potential for more than minimal harm

D January 28, 2026 Tag F0578 Corrected Feb 2026

Resident Rights Deficiencies

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

No actual harm, potential for more than minimal harm

D January 28, 2026 Tag F0552 Corrected Feb 2026

Resident Rights Deficiencies

Ensure that residents are fully informed and understand their health status, care and treatments.

No actual harm, potential for more than minimal harm

E January 28, 2026 Tag F0689 Corrected Feb 2026

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

No actual harm, potential for more than minimal harm

F January 28, 2026 Tag F0812 Corrected Feb 2026

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

No actual harm, potential for more than minimal harm

D July 24, 2025 Tag F0712 Complaint investigation Corrected Aug 2025

Nursing and Physician Services Deficiencies

Ensure that the resident and his/her doctor meet face-to-face at all required visits.

No actual harm, potential for more than minimal harm

D July 24, 2025 Tag F0710 Complaint investigation Corrected Aug 2025

Nursing and Physician Services Deficiencies

Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.

No actual harm, potential for more than minimal harm

D July 24, 2025 Tag F0689 Complaint investigation Corrected Aug 2025

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

No actual harm, potential for more than minimal harm

D July 24, 2025 Tag F0686 Complaint investigation Corrected Aug 2025

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

No actual harm, potential for more than minimal harm

E July 24, 2025 Tag F0773 Complaint investigation Corrected Aug 2025

Administration Deficiencies

Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.

No actual harm, potential for more than minimal harm

E July 24, 2025 Tag F0657 Complaint investigation Corrected Aug 2025

Resident Assessment and Care Planning Deficiencies

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

No actual harm, potential for more than minimal harm

E July 24, 2025 Tag F0656 Complaint investigation Corrected Aug 2025

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

No actual harm, potential for more than minimal harm

E July 24, 2025 Tag F0655 Complaint investigation Corrected Aug 2025

Resident Assessment and Care Planning Deficiencies

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

No actual harm, potential for more than minimal harm

E July 24, 2025 Tag F0609 Complaint investigation Corrected Aug 2025

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

No actual harm, potential for more than minimal harm

F July 24, 2025 Tag F0865 Complaint investigation Corrected Aug 2025

Administration Deficiencies

Have a plan that describes the process for conducting QAPI and QAA activities.

No actual harm, potential for more than minimal harm

F July 24, 2025 Tag F0835 Complaint investigation Corrected Aug 2025

Administration Deficiencies

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

No actual harm, potential for more than minimal harm

F July 24, 2025 Tag F0770 Complaint investigation Corrected Aug 2025

Administration Deficiencies

Provide timely, quality laboratory services/tests to meet the needs of residents.

No actual harm, potential for more than minimal harm

F July 24, 2025 Tag F0760 Complaint investigation Corrected Aug 2025

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

No actual harm, potential for more than minimal harm

F July 24, 2025 Tag F0727 Complaint investigation Corrected Aug 2025

Nursing and Physician Services Deficiencies

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.

No actual harm, potential for more than minimal harm

F July 24, 2025 Tag F0725 Complaint investigation Corrected Aug 2025

Nursing and Physician Services Deficiencies

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

No actual harm, potential for more than minimal harm

L July 24, 2025 Tag F0841 Complaint investigation Corrected Aug 2025

Nursing and Physician Services Deficiencies

Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility.

Immediate jeopardy to resident health or safety

L July 24, 2025 Tag F0600 Complaint investigation Corrected Aug 2025

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Immediate jeopardy to resident health or safety

D May 28, 2025 Tag F0761 Complaint investigation Corrected Jun 2025

Pharmacy Service Deficiencies

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.

No actual harm, potential for more than minimal harm

D May 28, 2025 Tag F0628 Complaint investigation Corrected Jun 2025

Resident Rights Deficiencies

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

No actual harm, potential for more than minimal harm

D May 28, 2025 Tag F0554 Complaint investigation Corrected Jun 2025

Resident Rights Deficiencies

Allow residents to self-administer drugs if determined clinically appropriate.

No actual harm, potential for more than minimal harm

J May 28, 2025 Tag F0658 Complaint investigation Corrected Jun 2025

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

Immediate jeopardy to resident health or safety

J May 28, 2025 Tag F0600 Complaint investigation Corrected Jun 2025

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Immediate jeopardy to resident health or safety

F April 8, 2025 Tag F0882 Complaint investigation Corrected Apr 2025

Infection Control Deficiencies

Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

No actual harm, potential for more than minimal harm

F April 8, 2025 Tag F0880 Complaint investigation Corrected Apr 2025

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

No actual harm, potential for more than minimal harm

F April 8, 2025 Tag F0841 Complaint investigation Corrected Apr 2025

Nursing and Physician Services Deficiencies

Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility.

No actual harm, potential for more than minimal harm

G March 28, 2025 Tag F0689 Complaint investigation Corrected Mar 2025

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Actual harm to a resident

C January 22, 2025 Tag F0842 Complaint investigation

Resident Assessment and Care Planning Deficiencies

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

No actual harm, minimal potential

D December 11, 2024 Tag F0773 Corrected Jan 2025

Administration Deficiencies

Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.

No actual harm, potential for more than minimal harm

D December 11, 2024 Tag F0686 Corrected Jan 2025

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

No actual harm, potential for more than minimal harm

D December 11, 2024 Tag F0677 Corrected Jan 2025

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

No actual harm, potential for more than minimal harm

Citations are published by CMS from state survey agency findings. A citation describes what an inspector observed on a specific date; homes are required to submit a correction plan, and many findings are resolved long before you read them. Ask the administrator what happened and what changed.