St. Jane de Chantal

Licensed Reference Number 175 NAC 12-006.11(E)Based on observations, record reviews and interviews, the facility failed to ensure that the kitchen staff completed hand hygiene for 15 seconds and failed to ensure no cross contamination to prevent foodborne illness during meal preparation. This had the potential to affect 67 residents in the facility. The facility census was 80.Findings are:Observation of meal preparation on 01/06/2026 from 7:30 AM to 8:40 AM revealed the following:At 7:35 AM an observation of [NAME] D preparing the noon meal with gloves on puts all premeasured ingredients into a pot to cook and then mixes the hamburger, ground turkey into another pot and then takes soiled dishes to the dirty dish room. [NAME] D removed gloves and completed hand hygiene for 12 seconds, wipes sink, shuts off water and continued to dry hands with the same soiled paper towel. At 7:45 AM [NAME] F while preparing French toast with gloves on, picked up utensils and other items, then picked up French toast with the same soiled gloves on. [NAME] F removed gloves, completed hand hygiene and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.05(G)Based on observation, record review, and interviews, the facility failed to ensure informed consent was obtained before applying a physical restraint for 1 resident (Resident 2) of 1 sampled for restraints. The facility census was 80.Findings are:An observation on 01/06/2026 at 10:42 AM revealed Resident 2 wearing mitten restraints (padded, soft gloves used in healthcare to prevent patients-usually with a mental deficit-from pulling out vital tubes, such as tracheostomy [a surgically created hole in the neck to create an airway], catheter [a flexible tube inserted into the body to drain fluid, such as into the bladder to drain urine], or feeding tubes) on both hands.An observation on 01/06/2026 at 2:50 PM revealed Resident 2 resting on their back in bed with mitten restraints on both hands.An observation on 01/07/2026 at 7:25 AM revealed Resident 2 resting on their back on bed with mitten restraints on both hands.A record review of Resident 2's undated demographics…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the facility failed to complete a new Preadmission Screening and Resident Review (PASARR- a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) for Resident 11 when new diagnoses were received. This affected 1 of 2 residents reviewed for PASARR completion. The facility reported a census of 80. Findings are:A record review of Resident 11's Face Sheet dated 01/08/2026 revealed the resident was admitted on [DATE].A record review of Resident 11's admission history and physical (H&P) dated 04/07/2020 revealed the resident had a diagnosis of depression. There was no mention of Post Traumatic Stress Disorder (PTSD)-a mental health condition triggered by experiencing or witnessing a traumatic event) or Intellectual Developmental Disabilities (IDD)- involves significant limitations in both intellectual functioning and adaptive behavior.A record review of Resident 11's Minimum Data Set (MDS - a standardized,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews the facility failed to complete a Preadmission screening and resident review(PASARR)- that is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care. A level 1 screening is a mandatory preliminary assessment for anyone entering a Medicaid certified nursing facility to quickly identify if they have a serious mental illness, Intellectual Disability, or Developmental Disability as defined by Medicaid. The facility failed to complete a PASARR for one (Resident 20) of two sampled residents. The facility census was 80.The findings are: Record review Resident 20's face sheet revealed admission date of 10/24/2025. Record Review of Resident 20's admission minimum data set (MDS) (is a standardized federally mandated assessment tool used in nursing homes to comprehensively evaluate the resident's health, functional abilities and needs) dated 10/19/2025 revealed the following: Section C showed a Brief Interview for Mental…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Licensure Reference Number 175 12-006.09(H)Based on observations, record review and interviews the facility failed to complete a wheelchair screening to ensure proper positioning for one (Resident 11) of one sampled resident. The facility identified a census of 80.Findings are: Record Review of Resident 11's Minimum Data System (MDS) (is a standardized, federally mandated assessment tool used in nursing homes to comprehensively evaluate resident's health, functional abilities and needs) dated 10/08/2025 reveled Section C Brief Interview for Mental Status (BIMS) (a quick 15-point cognitive screening tool used in healthcare to assess orientation, short-term memory and recall) Resident 11's score was a 15, indicating the residents cognition was intact. Section D of MDS revealed Resident 11 feels down, trouble sleeping, little energy, poor appetite, and trouble concentrating. The MDS also revealed a severity score of 10 on a Patient Health Questionnaire-9(PHQ-9) (which is a brief self-administered tool used for screening, diagnosing, and monitoring depression severity by asking for nine…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to identify a history of trauma and failed to follow the recommended behavior therapy for 1 (Resident 11) of 1 sampled resident. The facility identified a census of 80.Findings are: An interview with Resident 11 on 1/05/2026 at 11:40 AM revealed that when the resident was asked if they had a history of trauma, the resident stated that the resident's father drank a lot and molested the me as a child. Record review of Resident 11's face sheet revealed the resident was admitted [DATE] with the following diagnosis, bilateral knee pain, osteoarthritis, heart failure. There was no mention of post-traumatic stress disorder (PTSD). Record review of Resident 11's admission history and physical dated 4/07/2020 revealed no diagnosis or mention of PTSD. Record review of Resident 11's preadmission screening and resident review (PASARR) (a process which requires that all applicants to Medicaid-certified nursing facilities be given a preliminary assessment to determine…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to identify or provide recommended behavioral health services for 1 (Resident 11) of 1 sampled resident with a diagnosis of Post Traumatic Stress Disorder and Intellectual Disability. The facility identified a census of 80. Findings are: An interview with Resident 11 on 1/05/2026 at 11:40 AM revealed that when the resident was asked if they had a history of trauma, the resident stated that the resident's father drank a lot and molested me as a child. Record review of Resident 11's face sheet revealed the resident was admitted [DATE] with the following diagnosis, bilateral knee pain, osteoarthritis, and heart failure. There is no mention of post-traumatic stress disorder (PTSD). Record review of Resident 11's admission history and physical dated 4/07/2020 revealed no diagnosis or mention of PTSD. Record review of Resident 11's preadmission screening and resident review (PASARR) (a process which requires that all applicants to Medicaid-certified nursing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure reference Number 175 NAC 12-006.18Based on observations, record reviews, and interviews, the facility failed to ensure infection control practices related to hand hygiene (HH-cleaning the hands with soap and water or the use of an alcohol-based hand rub [ABHR] to help prevent the spread of infection) and use of personal protective equipment (PPE-special equipment, including gloves, gown, masks, and eye protection, worn to prevent exposure to hazards such as infectious materials) were followed during catheter (a flexible tube inserted into the body to drain fluid, such as into the bladder to drain urine) care for 1 (Resident 2) of 5 sampled residents for catheter care, and during wound care for 2 (Resident 2 and Resident 61) of 8 residents sampled for wound care. The facility census was 80.Findings are: A record review of the facility's Infection Prevention: Hand Hygiene policy last reviewed 06/04/2025 revealed that staff should use alcohol-based hand rub (ABHR) or wash their hands under the following…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12.006.09(I) Based on observation, interview, and record review; the facility failed to ensure interventions were followed for 1 (Resident 22) of 1 sampled resident to prevent potential accidents. The facility census was 83. Findings are: A record review of Resident 22's Clinical Summary Report dated 9/12/2024 revealed the resident was admitted to the facility on [DATE]. The resident had diagnoses of chronic diastolic congestive heart failure (CHF), age-related osteoporosis (weak bones), Post COVID-19, Type 2 diabetes mellitus with diabetic polyneuropathy (uncontrolled blood sugar that affects the nerves in the arms, hands, kegs, and feet), weakness, and cigarette nicotine dependence. A record review of Resident 22's Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to develop a resident's care plan) dated 7/30/2024 revealed the resident had a Brief Interview for Mental Status (BIMS, a score of a residents cognitive abilities) of 15 of 15 which…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Licensure Reference Number 175 NAC 12-006.10 Based on observation, record review, and interview; the facility failed to ensure that residents were free of significant medication errors while administering insulin (a medication used to reduce the amount of blood sugar in the blood of residents with diabetes) to 1 (Resident 56) of 1 residents sampled. The facility census was 83 at the time of survey. Findings are: Record review of the facility's policy titled Medication Safety with a last reviewed date of 7/22/24 revealed that the short acting insulin administration schedule was based around meal delivery times. Record review of undated admission Record revealed that Resident 56 was admitted into the facility on 6/19/2020. Record review of Resident 56's list of diagnoses revealed a primary diagnosis of incomplete quadriplegia (paralysis that affects all of a person's limbs) due to spinal cord lesion between 1st and 4th cervical vertebra. Also listed were respiratory failure and Type 2 Diabetes Mellitus (a condition that occurs when the body does not produce enough insulin or doesn't…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12.006.18(B) and (D) Based on observation, interview, and record review, the facility failed to ensure staff performed hand hygiene (cleaning) and glove changes when going from a contaminated process to a clean process during wound care for 2 (Residents 3 and 77) of 5 sampled residents, failed to ensure 1 (Resident 38) of 6 sampled resident's mechanical in-exsufflator (a machine used to help produce a cough) circuit was changed monthly, and failed to rinse the nebulizer (neb)(a machine used to deliver liquid medication to the lungs) kit after each use and change weekly for 1 (Resident 56) of 6 sampled residents to prevent cross-contamination. The facility census was 83. Findings are: A. A record review of Resident 3's Transfer/Discharge/Active Orders dated 9/12/2024 revealed the resident had a wound care order on the right anterior (in front) foot wound for staff to apply a Mepilex (border dressing); Xeroform (petroleum-based gauge wound dressing) dressing on Mondays,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.