Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at St. Jane De Chantal during CMS and state inspections, most recent first.
Kitchen staff failed to complete proper hand hygiene and prevent cross-contamination during meal prep. One cook handled food, soiled dishes, and then washed hands for only 12 seconds before using the same paper towel to shut off the water and dry hands; another handled French toast with soiled gloves and then used the same paper towel to wipe the sink and shut off the water; a third poked egg yolks with a soiled gloved finger. A cook also mixed meat by hand with forearms touching the food and visible tomato sauce on the arm. Facility policy required 15-second hand hygiene and not using the same paper towel to turn off faucets.
Failure to Obtain Informed Consent for Mitt Restraints: A resident with respiratory failure, heart failure, encephalopathy, a trach, catheter, and feeding tube was observed wearing bilateral mitt restraints while in bed. The chart showed restraint orders and a care plan calling for signed consent and education on risks and benefits, but there was no evidence that the resident or family was informed or that consent was obtained; the ADM confirmed the facility had no restraint consent form.
A resident with depression and later diagnoses of PTSD, IDD, and major depressive disorder did not have a new PASARR completed after the new diagnoses were received. The chart showed the diagnoses on psychiatric and diagnosis lists, but the care plan did not address moods, behaviors, IDD, or PTSD. Staff interviews confirmed there was no clear process for reporting new diagnoses or recognizing that the new PTSD/IDD findings required a new PASARR and care plan updates.
A resident was admitted without a completed PASARR level 1 screening, despite an admission MDS showing intact cognition, little depression, and dependence for all cares. The chart and care plan had no PASARR documentation at admission, and the level 1 PASARR was completed later after the resident went to the hospital and was readmitted; SS confirmed the resident entered the facility without the required screening.
Failure to complete a wheelchair screening for proper positioning. A resident with intact cognition, heart failure, depression, PTSD, and orthopedic conditions was repeatedly observed sitting on the edge of the WC cushion, leaning back, and secured by a tight seat belt for support. The resident said the WC was not comfortable and that they felt like they were sliding out of it. The WC arm rests were torn and the frame was dented, and staff confirmed the resident had not been evaluated in the weekly wheelchair clinic.
A resident with depression, PTSD, and a BIMS of 15 disclosed childhood sexual abuse and a traumatic family history, but the care plan did not address PTSD or trauma history. Psychiatry diagnosed ID and PTSD and recommended therapy, yet the record showed ongoing anxiety, sleep issues, agitation, and social isolation without the facility recognizing the updated diagnosis or reflecting it in the care plan.
A resident with depression, PTSD, and intellectual disability had ongoing anxiety, agitation, social isolation, and other behavioral concerns documented in the chart. A psych consult recommended therapy for PTSD, but the facility did not document that the therapy was implemented, and the resident’s PASARR and care plan were not updated after the new ID diagnosis. SS confirmed the trauma screen was never completed.
An RN, NA, and LPN failed to follow HH and PPE requirements during catheter care and wound care. During care for one resident on EBP with a Foley, feeding tube, wounds, and a trach, staff repeatedly changed gloves without HH, handled clean items after dirty tasks, and the NA wiped fecal-contaminated catheter tubing toward the resident's body. During wound care for another resident with multiple hip and coccyx wounds, an LPN performed dressing changes without a gown, moved the catheter without changing gloves, and moved between dirty and clean tasks without HH or glove changes.
A resident with a history of smoking-related risks and poor hand dexterity was left unsupervised while smoking, leading to repeated burns. Despite a care plan requiring supervision and the use of adaptive devices, the facility failed to ensure these measures were followed, resulting in multiple incidents of burns between the resident's fingers.
A resident with diabetes and incomplete quadriplegia received insulin after eating lunch, contrary to the facility's policy and physician's orders. The LPN confirmed the error, and the resident's Hemoglobin A1c was out of the normal range, indicating potential issues with diabetes management.
The facility failed to ensure proper hand hygiene and glove changes during wound care for two residents, and did not adhere to maintenance policies for a mechanical in-exsufflator and nebulizer kit for two other residents. Observations revealed lapses in hygiene practices and equipment maintenance, leading to potential cross-contamination risks.
Kitchen Hand Hygiene and Cross-Contamination During Meal Prep
Penalty
Summary
The facility failed to ensure kitchen staff completed hand hygiene for 15 seconds and failed to prevent cross contamination during meal preparation. During observation of meal preparation, one cook prepared the noon meal with gloves on, placed premeasured ingredients into a pot, mixed hamburger and ground turkey in another pot, and then took soiled dishes to the dirty dish room. After removing gloves, the cook completed hand hygiene for 12 seconds, wiped the sink, shut off the water, and continued drying hands with the same soiled paper towel. Additional observations showed another cook preparing French toast with gloves on, picking up utensils and other items, and then handling the French toast with the same soiled gloves. That cook removed gloves, completed hand hygiene, and then wiped the sink and shut off the water with the same paper towels used to dry hands. A third cook cracked eggs on the griddle, touched utensils, and poked egg yolks on several eggs with a soiled gloved finger. Later, a cook added dry ingredients to the cooked meat mixture, washed hands for 15 seconds, wiped the sink and shut off the water with a paper towel that was then used to dry arms, and mixed the meat mixture by hand with forearms touching the food and visible tomato sauce on the arm. Facility policy required hand hygiene for 15 seconds and stated not to dry hands with the same paper towel used to turn off faucets. The Production Manager and Dietary Manager confirmed the concerns with using soiled gloves on egg yolks and with handwashing and paper towel use.
Failure to Obtain Informed Consent for Mitt Restraints
Penalty
Summary
The facility failed to ensure informed consent was obtained before applying a physical restraint for one resident. Resident 2 was observed wearing mitten restraints on both hands during multiple observations while resting in bed. The resident’s record showed diagnoses of respiratory failure, heart failure, obesity, difficulty swallowing, and encephalopathy, and the resident had a tracheostomy, a catheter, and a feeding tube inserted into the stomach through the skin. Resident 2’s active orders included medical restraints for agitation, impulsive behaviors, impaired judgment, and interference with treatment devices, with mitts ordered for both hands. The comprehensive care plan addressed the need for a physical restraint to prevent the resident from pulling at the tracheostomy and included interventions to obtain signed consent before applying the restraint and to fully inform the resident or family member of the risks and benefits of all options being considered. However, the record contained no evidence that the resident or family member was educated on the risks and benefits of restraint use or that informed consent was obtained. The facility’s restraint procedure did not mention informed consent, and the Administrator confirmed the facility did not have a consent form for the restraint.
Failure to Complete New PASARR After New Mental Health and IDD Diagnoses
Penalty
Summary
The facility failed to complete a new PASARR for Resident 11 after new diagnoses of PTSD and IDD were received. Resident 11’s record showed an admission history and physical with depression, a PASARR in 2020 that identified Level 1 findings with no Level 2 required, and later psychiatric documentation dated 07/15/2022 listing mild intellectual disability, PTSD, and major depressive disorder. A diagnosis list dated 12/24/2025 also included PTSD, IDD, and major depressive disorder, but the quarterly care plan dated 12/26/2025 did not mention moods, behaviors, IDD, or PTSD. Interviews confirmed the facility did not know about the new PTSD and IDD diagnoses and did not have a process to report new diagnoses or determine when a new PASARR was needed. RN MDS A stated that office notes are obtained after provider appointments and diagnoses are added to the MDS and face sheet, but she was not aware that the new diagnoses would trigger a new PASARR or that they should have been care planned. SS-B confirmed a new PASARR should have been done and the diagnoses should have been added to the care plan, and LPN C stated that only new orders or follow-up appointments returned from appointments and that leadership could add diagnoses or objectives to the care plan.
PASARR Screening Not Completed at Admission
Penalty
Summary
The facility failed to complete a PASARR level 1 screening for one resident at the time of admission. Record review showed the resident was admitted on 10/24/2025, and the admission MDS dated 10/19/2025 documented a BIMS score of 15, indicating the resident was cognitively intact, and a PHQ-9 score of 1, indicating little depression. The MDS also showed the resident was dependent for all cares, and Section A did not contain a documented PASARR at that time. The resident’s diagnoses included arthritis, anorexia, HTN, CKD, and weakness, and the resident was receiving antibiotics, opioids, and an antiplatelet. The resident’s care plan dated 10/24/2025 had no documentation that a PASARR had been completed. A PASARR screening dated 12/07/2025 later showed a level 1 PASARR completed after the resident went to the hospital and was readmitted to the facility. The facility policy stated the admission team completes the PASARR prior to admission, and Social Service confirmed in interview that the resident was admitted with no completed PASARR.
Failure to Complete Wheelchair Screening for Proper Positioning
Penalty
Summary
The facility failed to complete a wheelchair screening for one resident to ensure proper positioning. Resident 11 had an MDS dated 10/08/2025 showing a BIMS score of 15, indicating intact cognition, along with diagnoses of heart failure, depression, PTSD, and orthopedic conditions. The MDS also showed the resident felt down, had trouble sleeping, little energy, poor appetite, and trouble concentrating, with a PHQ-9 severity score of 10. Functional status on the MDS showed the resident was independent with eating and rolling in bed, but required assistance or was dependent for sit to lie, sit to stand, transfers, and toileting. Observations showed Resident 11 repeatedly seated poorly in the wheelchair, with buttocks on the edge of the cushion, leaning back, and using a tightly secured seat belt for support. The resident stated the wheelchair was not comfortable and reported feeling like they were sliding out of it all the time. The wheelchair arm rests were torn and the metal wheel frame was dented. A PT evaluation from 02/18/2025 did not mention evaluating the resident for a new wheelchair, and facility records showed the seating procedure required a therapy consult before a wheelchair evaluation. Staff interviews confirmed the resident had complained about wheelchair issues, had not been seen in the wheelchair clinic, and had not been evaluated at the weekly wheelchair clinic.
Failure to Identify Trauma History and Follow PTSD Behavior Therapy
Penalty
Summary
Provide care or services that was trauma informed and/or culturally competent was not met for one resident. The resident told the surveyor that their father drank heavily and molested them as a child. The resident’s record showed diagnoses including bilateral knee pain, osteoarthritis, heart failure, depression, and PTSD, with a BIMS score of 15 and a PHQ-9 score of 10 indicating moderate depression. The quarterly care plan addressed mood and behavior concerns such as frustration, anger with a roommate, statements about being better off dead, temper tantrums, paranoia, delusions, agitation, and social isolation, but it did not mention PTSD or trauma history. Record review showed psychiatry diagnosed intellectual disability and PTSD and recommended therapy for PTSD, and later psychiatric visits documented ongoing anxiety related to past trauma and sleep problems. The facility’s social services staff stated they began asking about trauma on admission only in September 2023, after this resident had already been admitted, and confirmed they were not aware of the new intellectual disability and PTSD diagnosis. An RN stated that a new diagnosis of intellectual disability would trigger a new PASARR and that the care plan should have been updated.
Failure to Identify and Provide Behavioral Health Services for Resident with PTSD and ID
Penalty
Summary
The facility failed to identify and provide necessary behavioral health services for one resident with PTSD and intellectual disability. The resident was admitted with diagnoses including bilateral knee pain, osteoarthritis, and heart failure, and later reported a history of childhood sexual abuse by the resident’s father. The resident’s MDS showed a BIMS score of 15, moderate depression, and diagnoses of depression and PTSD, while the care plan documented mood and behavior concerns including frustration, anger, temper tantrums, paranoia, delusions, agitation, and social isolation. Record review showed that a psychiatric consultation identified a new diagnosis of intellectual disability and PTSD and recommended therapy for the resident’s PTSD. Subsequent psychiatric visits documented ongoing anxiety related to past trauma and sleep issues. Despite these findings, the facility did not document implementation of the recommended therapy for PTSD. The resident also had a history of behavioral concerns documented in progress notes and nursing behavior records, including anger, impulsivity, irritability, anxiety, verbal abuse, rejection of care, socially inappropriate behavior, and wandering. The resident’s PASARR from admission identified the resident as Level 1 with no serious mental illness or intellectual disability, and facility staff stated they were not aware that a new diagnosis of intellectual disability would trigger a new PASARR and care plan update. Social services confirmed that a new PASARR should have been completed and that the care plan should have been updated. Social services also confirmed that the trauma screen was never completed for the resident, despite staff stating that trauma screening had been added to admission practices and used when a new diagnosis was identified during the resident’s stay.
Hand Hygiene and PPE Failures During Catheter and Wound Care
Penalty
Summary
The facility failed to follow infection control practices related to hand hygiene and PPE use during catheter care and wound care. The report cites policies requiring alcohol-based hand rub or handwashing before and after resident contact, after handling catheters or used dressings, and after glove removal, as well as EBP guidance requiring gowns and gloves for high-contact care activities such as wound care and certain resident care tasks. During care for a resident with a history of MDRO who was on EBP and had orders for a feeding tube, Foley catheter, abdominal wound, wounds under the breast and in abdominal folds, and a tracheostomy, an RN and a NA were observed providing multiple cares while wearing gowns and gloves. The RN cleaned and dressed the feeding tube site and abdominal wound, and the NA provided skin care, peri-care, and catheter care. Throughout the observation, both staff members repeatedly changed gloves without performing hand hygiene, handled clean items after dirty tasks without hand hygiene, and continued care without changing PPE as required. The NA also cleaned catheter tubing by wiping it toward the resident's body after the resident had been incontinent of feces and the tubing had feces on it. The NA later removed gown and gloves, did not perform hand hygiene, and returned to the resident without a gown while leaning over the resident; the NA's clothing came into contact with the resident's gown. Both staff later confirmed they should have performed hand hygiene with glove changes and that the catheter tubing should have been wiped away from the resident's body. A separate wound care observation for another resident with left hip, right hip, and coccyx wounds showed an LPN preparing and performing dressing changes without a gown despite EBP guidance requiring gown and gloves for wound care. The LPN placed supplies on the bed without barrier protection, used washcloths and towels across multiple wounds, moved the catheter from one side of the bed to the other without changing gloves, and moved from dirty to clean tasks without hand hygiene or glove changes. The LPN also used the same towel and washcloths across the right hip, left hip, and coccyx wound care, and did not wash hands after removing soiled dressings or between dressing changes. The LPN later confirmed not changing gloves between dirty and clean portions of the dressing changes, not changing gloves after moving the catheter, and not washing hands between dressing changes. The DON also confirmed the LPN should have worn a gown and performed hand hygiene and glove changes between the dirty and clean portions of care.
Failure to Supervise Resident Smoking Leads to Repeated Burns
Penalty
Summary
The facility failed to ensure proper interventions were followed for Resident 22, who was at risk for injury due to smoking. Resident 22, who had a history of chronic diastolic congestive heart failure, osteoporosis, diabetes with polyneuropathy, and nicotine dependence, was cognitively aware but dependent on staff for most activities of daily living. The resident's care plan included interventions such as using a smoking apron, monitoring for proper disposal of cigarettes, and using a cigarette ring holder. However, these interventions were not consistently followed, leading to multiple incidents of burns. Observations revealed that Resident 22 was left unsupervised while smoking, despite the care plan indicating the need for supervision. On one occasion, the resident was observed struggling with an adaptive device and ended up holding the cigarette improperly, resulting in a burn between the index and middle fingers. The resident also dropped cigarettes on the ground and table, indicating a lack of proper supervision and assistance. Interviews with staff confirmed that the resident was allowed to smoke with minimal supervision, and there was insufficient staff to provide one-on-one supervision. The facility's failure to provide adequate supervision and ensure the use of assistive devices led to repeated incidents of burns for Resident 22. Despite the resident's known difficulty with hand dexterity and the need for adaptive devices, the facility did not ensure these were available and properly used. The lack of supervision and failure to adhere to the care plan interventions contributed to the resident's repeated injuries.
Insulin Administration Error for Resident with Diabetes
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, specifically in the administration of insulin to a resident with diabetes. The resident, who was cognitively intact and had a primary diagnosis of incomplete quadriplegia, was supposed to receive insulin based on a sliding scale before meals. However, on the day of observation, the Licensed Practical Nurse (LPN) administered the insulin after the resident had already eaten lunch, which was contrary to the facility's policy and the physician's orders. This error was confirmed by the LPN during an interview. The resident's blood glucose level was recorded at 225, and 4 units of insulin were administered according to the sliding scale. The resident's Hemoglobin A1c level was also noted to be out of the normal range, indicating potential issues with diabetes management. The unit coordinator confirmed that the expectation was for blood glucose checks and insulin administration to occur before meals, highlighting a deviation from the standard procedure in this instance.
Infection Control Deficiencies in Wound Care and Equipment Maintenance
Penalty
Summary
The facility failed to ensure proper hand hygiene and glove changes during wound care for two residents. For Resident 3, a Licensed Practical Nurse (LPN) did not change gloves or perform hand hygiene when transitioning from a contaminated process to a clean process while treating a wound on the resident's right anterior foot. Similarly, for Resident 77, a Registered Nurse (RN) did not perform glove changes or hand hygiene during wound care on the posterior neck wound, despite acknowledging the need for such practices. The facility also failed to adhere to its policy regarding the maintenance of a mechanical in-exsufflator (M.I.E.) for Resident 38. The M.I.E. circuit, which should have been changed monthly, was not changed since the resident went on hospice. Observations revealed that the circuit and filter were not dated, and the mask had facial oils on it, indicating a lack of proper maintenance and hygiene. Additionally, the facility did not follow its policy for nebulizer kit maintenance for Resident 56. The nebulizer kit, which should have been changed weekly and rinsed after each use, was not maintained as required. Observations showed that the kit had not been changed since the date marked on it, and liquid was left in the chamber, indicating it was not rinsed after use. The infection control bag was also not changed as per the facility's policy.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Lincoln
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ambassador Health Of Lincoln | 0.5 mi | ★★★★★ | 3 | 0 |
| Holmes Lake Rehabilitation & Care Center | 0.6 mi | ★★★★★ | 10 | 0 |
| Eventide Lincoln Care Center | 1.1 mi | ★★★★★ | 4 | 0 |
| Gateway Vista | 1.7 mi | ★★★★★ | 20 | 0 |
| Emerald Nursing & Rehab Brookside Llc | 1.7 mi | ★★★★★ | 27 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.