SAINT PAUL, MN - A state health inspection at Highland Chateau Health Care Center identified widespread violations affecting resident care, including extended wait times for basic assistance, inadequate staff training, and failures in medication storage and food service management.
Extended Call Light Response Times Documented Across Facility
State inspectors documented numerous instances where residents waited excessive periods for assistance with basic needs during their April 2025 inspection. The facility's own call light response data from March 23 through April 22, 2025, revealed systematic delays far exceeding the facility's stated five-minute response time policy.
One resident with morbid obesity requiring four-person assistance waited over an hour to use a bedpan on April 23, despite multiple requests for help starting at 11:30 a.m. The resident called the facility's front desk stating she needed help and "didn't want anyone to have to clean up my mess." Staff members entered and exited the room multiple times, each stating they needed additional assistance, before finally providing care at 12:10 p.m.
Another resident reported being left in a wet incontinence pad for over two hours on the morning of April 23. When the resident activated his call light at 9:05 a.m. requesting to be changed, a nursing assistant stated she would return soon but never did. By 10:44 a.m., the resident was yelling in the hallway that "he has been sitting in a wet pad for hours and no one comes and answers his call light."
Call light response data revealed a pattern of delays across both floors of the facility. Multiple residents experienced response times exceeding 60 minutes, with some waiting over three hours. One resident had 474 call light activations during the review period, with 10 instances exceeding 60 minutes, 4 exceeding 50 minutes, and 22 exceeding 30 minutes.
Critical Gaps in Staff Training and Supervision
The inspection revealed that both employed and agency nursing assistants lacked proper orientation, training documentation, and demonstrated competency skills. The facility could not provide evidence that nursing assistants had received training on mechanical lift operation, location of resident supplies, or individual resident care requirements.
Residents at a council meeting on April 23 reported that agency nursing assistants frequently asked them what tasks they were supposed to perform and where supplies were located. One resident stated agency staff "didn't know how to use the mechanical lifts" and regularly asked residents for guidance about their job duties.
The assistant director of nursing, responsible for staff orientation, acknowledged there were no orientation checklists or documentation tools to ensure nursing assistants received training consistent with resident care requirements. The only orientation provided regarding individualized resident care was a single screenshot showing how to access patient information in the electronic medical record system.
Two nursing assistants reviewed lacked required annual performance reviews, and one newly hired assistant had not completed mandatory training modules including emergency preparedness and infection control protocols within the required timeframe.
Medication Storage Violations Create Safety Risks
Inspectors observed multiple instances where over-the-counter medications were left unsecured in an unlocked office. On April 21, bottles and containers of medications including acetaminophen, ibuprofen, lidocaine patches, and vitamins were spread across a table in an office with an open door. The medical records director responsible for the office stated she locked the door when leaving, but was observed leaving it unlocked on multiple occasions, including when she "just had to run to the second floor."
The facility's medication room on the second floor was found to contain non-medication supplies including tube feeding solutions and other materials, limiting proper medication storage space. The director of nursing confirmed that medications should never be stored in unlocked rooms and that doors should be locked whenever staff leave areas containing medications, even briefly.
Food Service Management Lacks Qualified Oversight
The facility could not provide documentation verifying that their dietary manager possessed required certifications. Despite claiming to have food safety certification and certified dietary manager credentials on her resume, the dietary manager was unable to produce evidence of these qualifications during the inspection period.
The facility's registered dietician worked only 10-12 hours per week, typically on Mondays, rather than providing full-time coverage as required. This limited oversight contributed to failures in honoring resident dietary preferences and ensuring proper food handling procedures.
Medical Significance of Care Delays
Prolonged wait times for toileting assistance pose serious health risks for elderly residents. Extended contact with urine and feces can lead to skin breakdown, pressure ulcers, and urinary tract infections. For residents with existing wounds or compromised skin integrity, these delays significantly increase infection risk and can impede healing of existing conditions.
The psychological impact of waiting extended periods for basic assistance cannot be understated. Loss of dignity, increased anxiety, and feelings of helplessness contribute to depression and decreased quality of life. For residents with intact cognition who understand they are being left in soiled conditions, the emotional distress compounds physical discomfort.
Inadequate staff training directly correlates with increased risk of resident injuries. When nursing assistants lack competency in mechanical lift operation, residents face fall risks and potential injuries during transfers. Without proper knowledge of individual resident needs and transfer requirements, staff may attempt unsafe maneuvers that could result in fractures, skin tears, or other traumatic injuries.
Additional Issues Identified
The inspection also documented failures in providing adequate hydration to residents. Multiple residents reported never receiving fresh water or clean water mugs, with staff confirming that water distribution was not occurring consistently despite facility policy requiring daily fresh water service.
Food service violations included unlabeled and undated food items in the kitchen, improper food storage, and failure to honor documented dietary preferences. One resident on a renal diet repeatedly received rice despite multiple requests to stop serving it, and received foods inconsistent with dietary restrictions including milk and bananas.
The facility demonstrated inadequate oversight of staff cell phone use, with multiple nursing assistants observed using personal phones while on duty despite posted policies prohibiting this practice. This distraction contributed to delayed response times and reduced attentiveness to resident needs.
Documentation failures were widespread, including incomplete employee files, missing orientation records for agency staff, and lack of annual performance evaluations. The human resources director, employed for only one month, acknowledged finding numerous employee files were incomplete or missing entirely.
Quality assurance processes failed to identify or address the systematic call light delays. While the facility discussed average response times at quality meetings, they did not investigate outliers or extended response times. The director of nursing acknowledged she had reviewed incorrect call light data when responding to a resident grievance about a 3.5-hour wait for assistance.
These violations represent fundamental breakdowns in basic care provision and facility management. The patterns documented suggest systemic organizational failures requiring comprehensive corrective action to ensure resident safety and dignity.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Highland Chateau Health Care Center from 2025-04-24 including all violations, facility responses, and corrective action plans.
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