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Complaint Investigation

Highland Chateau Health And Rehabilitation Center

December 30, 2025 · Saint Paul, MN · 2319 West Seventh Street
Citations 2
Beds 64
Provider ID 245028
Healthcare Facility
Highland Chateau Health And Rehabilitation Center
Saint Paul, MN  ·  View full profile →
Source Document
Official CMS Inspection Report (Medicare.gov)
Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.
Inspection Summary

HIGHLAND CHATEAU HEALTH AND REHABILITATION CENTER in SAINT PAUL, MN — inspection on December 30, 2025.

Found 2 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

Inspection Findings

FF0657
Resident Assessment and Care Planning Deficiencies

her job and recently had started updating care plans when MDS's are completed and have any

upon admission R1 was able to walk around the facility. R1 was noncompliant and no matter how

document the education and attempts to get R1 up.

Documentation was something all the nurses at the facility were currently working on.

She denied reaching out to therapy, the NP, the Pain clinic, or psychiatric services with R1's noncompliance and deconditioning.

She stated the intradisciplinary team (IDT) converses about R1 often and the NP is in the room. LPN-B believed the NP was aware that R1 was not getting up and should have offer inventions since she heard them team talk about R1 in the meetings. LPN-B stated R1's current transfer status was via a mechanical lift.

She denied awareness of R1 having home therapy orders following her therapy sessions in September and stated the facility must have missed the providers order on 11/18/25 because they were not initiated.

Upon interview on 12/30/25 at 3:46 p.m. the Administrator stated her expectation was when a change was made to the comprehensive assessment the care plan would be updated at the same time. A facility policy titled Care Plan, Comprehensive Person-Centered with a revision date of 10/2025 indicated:1.

Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making.2.

When possible, interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers.3.

Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change.4.

The interdisciplinary team reviews and updates the care plan:a. when there has been a significant change in the resident's condition.b. when the desired outcome is not met.c. when the resident has been readmitted to the facility from a hospital stay; andd. at least quarterly, in conjunction with the required quarterly MDS assessment.5.

The resident has the right to refuse to participate in the development of their care plan and medical and nursing treatments.

Such refusals are documented in the resident's clinical record in accordance with established policies.

245028 12/30/2025

Highland Chateau Health and Rehabilitation Center 2319 West Seventh Street Saint Paul, MN 55116

nurses on a full time basis.

the director of nursing (DON) on a full-time basis following the exit of the former DON.

This practice

interview on 12/29/25 at 9:39 a.m. licensed practical nurse, (LPN)-B stated she was the only administration staff on duty and had been acting as the DON for the last two weeks.

The former DON's human resource file indicated she was let go of her duties on 12/17/25.

Upon interview on 12/30/25 at 9:17 a.m. the Director of Human Resources stated he was not certain who was acting as the DON currently. He stated that he was not involved in the hiring process of a new DON as the corporate office had been taking care of new DON applications and interviews.

Upon interview on 12/30/25 at 3:46 p.m. the Administrator stated the facility did not have a DON.

The facility was using a team effort with the ADON, nursing staff and the [NAME] President of Clinical Services to cover the open role.

She was not certain where corporate was in the process of a new hire.

Upon interview on 12/30/25 at 4:25 p.m. the [NAME] President of Clinical Services stated the facility was working without a DON and she was not able to assume the role on a full-time basis. A facility policy regarding required nursing services was requested however none received.

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in SAINT PAUL, MN, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from HIGHLAND CHATEAU HEALTH AND REHABILITATION CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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About This Inspection Report

Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.

Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.

Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.