Highland Chateau Health And Rehabilitation Center
Inspection Findings
F-Tag F0657
F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
from her bed to her chair with the assistance of another staff. He did not transfer Resident R1 often, because she refused to get out of bed on most days. He was not certain of what cares the staff assisted Resident R1 with as her care plan indicated she was independent with her ADL's. Upon interview on 12/30/25 at 9:08 a.m. Resident R1's current Medical Provider stated he had not met Resident R1 yet and he was not the provider who wrote the orders to restart therapies. His expectations were if a provider writes an order that the facility follows the order and if there was a concern with an order to reach out and have a discussion with the provider.Upon interview on 12/30/25 at 12:36 p.m. licensed practical nurse (LPN)-A the RAI coordinator stated she did complete Resident R1's MDS on 11/1/25 however did not update the care plan. She stated she was new to her job and recently had started updating care plans when MDS's are completed and have any changes. Upon interview on 12/30/25 at 2:22 p.m. the assistant director of nursing, licensed practical nurse (LPN)-B stated she had worked at the facility for three months and she was not aware that upon admission Resident R1 was able to walk around the facility. Resident R1 was noncompliant and no matter how much education she completed with Resident R1 she would refuse to get out of bed. She stated she did not document the education and attempts to get Resident 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 Resident R1's noncompliance and deconditioning.
She stated the intradisciplinary team (IDT) converses about Resident R1 often and the NP is in the room. LPN-B believed the NP was aware that Resident R1 was not getting up and should have offer inventions since she heard them team talk about Resident R1 in the meetings. LPN-B stated Resident R1's current transfer status was via a mechanical lift. She denied awareness of Resident 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.
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Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
12/30/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Highland Chateau Health and Rehabilitation Center
2319 West Seventh Street Saint Paul, MN 55116
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0727
F 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many
FORM CMS-2567 (02/99) Previous Versions Obsolete
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.
Based on interview and record review the facility failed to designate a registered nurse to serve as the director of nursing (DON) on a full-time basis following the exit of the former DON. This practice had the potential to affect all 54 residents who resided at the facility. Findings include: Upon entrance 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.
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Highland Chateau Health And Rehabilitation Center in SAINT PAUL, MN inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
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.