Highland Chateau Health And Rehabilitation Center
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
from her bed to her chair with the assistance of another staff. He did not transfer R1 often, because she refused to get out of bed on most days. He was not certain of what cares the staff assisted 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. R1's current Medical Provider stated he had not met 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 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 R1 was able to walk around the facility. R1 was noncompliant and no matter how much education she completed with R1 she would refuse to get out of bed.
She stated she did not 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.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
12/30/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Highland Chateau Health and Rehabilitation Center
2319 West Seventh Street Saint Paul, MN 55116
SUMMARY STATEMENT OF DEFICIENCIES
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.
Facility ID: