Highland Chateau Health And Rehabilitation Center

sometimes and was unaware of her preference for clothing and getting up to her wheelchair. NA-A

was wearing a hospital gown. R46 stated she was happy to be up in a wheelchair and she enjoyed

clinical services, stated she would expect resident preferences for getting dressed and getting up during the day to be known and honored.Facility Dignity policy printed 3/4/26, indicated: The facility culture supports dignity and respect for residents by honoring resident goals, choices, preferences, values and beliefs.

This begins with the initial admission and continues throughout the resident's facility stay.

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

and the provider should have been notified with the first low pressure.

stated the expectation would to be follow the orders, hold the medication and call the physician.

Facility Acute Condition Changes-Clinical Protocol policy updated 3/16/25, indicated: the nursing staff will contact the physician based on the urgency of the situation.

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

resident's ability to function.

observation, interview and document review the facility failed to monitor for resident specific target

antipsychotic medications.Findings include: R3's admission Minimum Data Set (MDS) dated [DATE], indicated R3 had moderately impaired cognition with no hallucinations, delusions, no behaviors, wandering or rejection of care. MDS indicated R3 was on an antipsychotic, antidepressant, and hypnotic along with opioid medications.R3's medical diagnosis report, printed 3/5/26, included the following relevant diagnoses: schizoaffective disorder (chronic mental health condition that is characterized by combination of schizophrenia symptoms such as hallucinations or delusions along with a major mood disorder including depression or mania), dementia (cognitive decline in memory, language, and problem solving that impairs daily life), restlessness and agitation and dislocation of right hip. R3's care plan, printed 3/2/26, identified the R3 at risk for depression with the following interventions: if depression screen is positive, contact provider for suggestion, and perform depression screening evaluation.

Furthermore, the care plan identified the resident uses psychotropic medication with the following interventions: administer psychotropic medications as ordered by physician.

Monitor for side effects and effectiveness every shift, and monitor/document/report any adverse reason of psychotropic medications: unsteady gait, tardive dyskinesia, EPS (shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps nausea, vomiting, behavior symptoms not usual to the person.The care plan lacked mention of target behaviors for antipsychotic use or identification of what, if any, target behaviors R3 exhibited for the use of either olanzapine or fluoxetine.R3's Order Summary Report, printed 3/5/26, included the following orders:-fluoxetine (psychotropic medication used to treat depression) 20 mg oral tablet- give one (1) tablet by mouth one time a day for depression with a start date of 12/22/25. -lamotrigine (psychotropic medication) 25 mg oral tablet - give two (2) tablets by mouth one time a day related to unspecified dementia without behavioral disturbance with a start date of 12/22/25.-olanzapine (antipsychotic medication) 2.5 mg oral tablet - give one (1) tablet by mouth two time a day related to schizoaffective disorder and unspecified dementia with a start date of 1/22/26.The Physician Order Report lacked documentation or any direction to monitor target behaviors or identification of target behaviors.R3's February and March Medication and Treatment Administration Records (MARs) reviewed and indicated medications listed above (fluoxetine, and olanzapine were administered as ordered.

The document lacked evidence of target behaviors identified or monitored.During an observation and interview on 3/3/26 at 8:22 a.m., R3 was observed lying in bed and had just finished eating breakfast. R3 stated he had not gotten ready for the day yet.

During an interview on 3/3/26 at 11:43 a.m., nursing assistant (NA)-H stated they are not very familiar with R3 and unsure if they have any behaviors.

During an interview on 3/3/26 at 1:24 p.m., registered nurse (RN)-A stated they are not very familiar with R3, and they are not sure if R3 has any behaviors or target behaviors. RN-A stated if a resident has aggressive behaviors would be monitored for this.

During an interview on 3/4/26 at 1:22 p.m., director of nursing (DON) stated all psychotropic medication should have side effect monitoring and target behaviors identified. DON verified R3 did not have any target behaviors identified for olanzapine or fluoxetine.

During an interview on 3/5/26 at 9:23 a.m., RN-F also known as vice president of clinical services stated if target behaviors can be identified they would be put in the order and in the care plan. A policy on psychotropic medication was requested and not received.Facility Antipsychotic Medication Use policy reviewed 4/26/25, indicated The attending physician and other staff will gather and document information to clarify a resident's behavior, mood, function, medical condition, specific symptoms, and risks to the resident and others.

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

was not made aware of R57's discharge until he heard from FM-A on 1/10/26. FM-C stated he did not

admitted to the facility. FM-C stated he expected to be notified of a resident discharge so services

services, dated 1/8/26, indicated Nightingale (home health agency) denied R57 for services. No other evidence of attempted arrangements for services by the facility was provided.

The email provided by RN-F further stated R57 was a resident driven discharge, and I (RN-F) and the team did not complete the dc assessment. An email thread provided by administrator on 3/5/26, indicated conversations between redeemerservices.com (Hennepin County Contracted Case Managers) and allhomehealth.org discussing R57's care and staffing needs, but did not indicate the facility had made them aware of R57's discharge or that the facility was involved in any of the conversations.

The email thread indicated on 1/10/26, All Home Health was contacted via phone by FM-A and made aware of R57's return to her home the previous day 1/9/26.Facility provided document from M Health Fairview Southdale emergency department dated 1/10/26 at 10:48 a.m., indicated R57 presented on 1/10/26 with concerns for generalized weakness, recurrent falls, and failure to thrive and was admitted under observation status. M Health Fairview Southdale note further indicated R57 returned home from nursing facility on 1/9/26, continued to fall and called emergency medical services (EMS) on two occasions prior to presentation. R57 admitted to sleeping on the floor prior to calling EMS. R57 denied acute injury or pain.Facility Discharge Summary and Plan policy undated, indicated the following: When a resident's discharge is anticipated, a discharge summary and post-discharge plan will be developed to assist the resident to adjust to his/her new living environment.

Every resident will be evaluated for his or her discharge needs and will have an individualized post-discharge plan.

The post-discharge plan will be developed by the interdisciplinary team with the assistance of the resident and his or her family and will include: Arrangements that have been made for follow-up care and services, the degree of caregiver/support person availability, capacity, and capability to perform required care, what factors may make the resident vulnerable to preventable readmission, and how those factors will be addressed.

The resident/representative will be involved in the post-discharge planning process and informed of the final post-discharge plan. A member of the interdisciplinary team will review the final post-discharge plan with the resident and family at least 24 hours before the discharge is to take place.

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

assistant (PCA) service provider was contacted. An email provided by RN-F dated 1/8/26, indicated

R57 was a resident driven discharge and RN-F and the team did not complete the discharge

discharge was not found in the electronic health record (EHR) and when requested, was not provided by facility staff.Facility Discharge Summary and Plan policy undated, indicated the discharge summary will include a recapitulation of the resident's stay at this facility and a final summary of the resident's status at the time of the discharge in accordance with established regulations governing release of resident information and as permitted by the resident.

The discharge summary shall include a description of the resident's current diagnosis, medical history, course of illness, treatment, and therapy at the facility, current diagnostic results, physical and mental functioning status, ability to perform activities of daily living, mental and psychosocial status, discharge potential, dental condition, activities potential, rehabilitation potential, cognitive status, medication reconciliation.

The resident or representative will be provided with an evaluation of resident's discharge needs, the post-discharge plan, and the discharge summary.

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

Review of pain scores for February and March 2026, indicated variable pain scores of 0 to 8/10.

During various observations over the course of four days from 3/2/26 to 3/5/26, R48 was primarily seen in his wheelchair on the smoking patio with other residents.

During an interview on 3/5/26 at 10:08 a.m., nursing assistant (NA)-D stated R48 had complained of pain more often lately - he was stiff all over when getting up in the morning and when changing his clothes. NA-D stated R48 received pain medications, but she did not know about non-medication measure for his pain, such as ice or massage, adding she did not do that.

During an interview on 3/5/26 at 10:49 a.m., registered nurse (RN)-A stated R48 had pain and saw pain-clinic providers twice a week, who adjusted R48's pain medication up or down. RN-A stated R48's pain medications were scheduled, rather than as needed; to keep on top of his pain and felt they were effective for him. RN-A was not aware of non-medication measure utilized for pain, stating R48's non-medication pain relief was smoking. RN-A verified R48's care plan did not include a focus area for pain.

During an interview on 3/5/26 at 12:13 p.m., RN-F also know as vice president of clinical services verified R48 experienced pain and had been seen by providers from the pain clinic on an on-going basis. VPCS verified R48's care plan did not include a focus area for pain. VPCS stated she would expect to see pain interventions including non-pharmacological interventions.

Facility Comprehensive Care Plans policy with revised date of 3/4/22, indicated the comprehensive care plan was based on a thorough assessment that included but was not limited to, the MDS.

Each resident's comprehensive care plan was designed to incorporate identified problem areas, incorporate risk factors associated with identified problems and reflect the resident's expressed wishes regarding care, treatment goals and preferences.

The care plan would identify the professional services that were responsible for each element of care and reflect currently recognized standards of practice for problem areas and conditions.

Areas of concern that were triggered during the resident assessment were evaluated using specific assessment tools (including Care Area Assessments) before interventions were added to the care plan.

Care plan interventions were designed after careful consideration of the relationship between the resident's problem areas and their causes.

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

During an interview on 3/2/26 at 12:36 p.m., R2 stated that she had not had a care conference in a long time. R2 stated she would like to have a care conference, would attend the care conference and had attended care conferences in the past.

During an interview on 3/4/26 at 8:32 a.m., social services (SS)-A stated she was unsure how often care conferences for long term residents should be held as she was new to the position but would find out. SS-A stated care conference notes would be documented in the progress notes or assessment section of the electronic medical record (EMR). SS-A verified the last documented care conference for R2 was 10/1/25. SS-A requested to follow up with supervisor for additional information. No additional information was provided to surveyor.

During an interview on 3/4/26 at 1:19 p.m., director of nursing (DON) stated the expectation would be care conferences are held quarterly and as needed for change of condition.

During an interview on 3/4/26 at 1:41 p.m., registered nurse (RN)-A stated floor nurses do not attend or participate in care conferences. RN-A stated she had not attended any care conferences.

During an interview on 3/5/26 at 9:24 a.m., RN-F also known as vice president of clinical services stated the expectation was care conferences are completed at least quarterly and as needed. RN-F reviewed R2's EMR and verified via email on 3/5/26 at 1:19 p.m., we are a bit behind on care plan meetings.

Her care plan was reviewed on 2/22/2026.

She should have one coming up soon. We also lost our social services designee which delayed our care plan schedule.Facility Resident Care Conference/Care Plan Review policy, reviewed 6/27/22, was provided.

The policy indicated The purpose of the care conference is to develop a plan of care and to ensure that the resident goals and preferences are discussed and established with one of processes being: For quarterly care conference, social services will utilize the social service care conference assessment.

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

During an interview on 3/4/26 at 8:16 a.m., registered nurse (RN)-D verified she completed the weekly bath audit for R3 on 3/2/26. RN-D stated she could not remember if he was shaved or not when she completed the weekly bath audit.

During an interview on 3/3/26 at 11:43 a.m., nursing assistant (NA)-H stated that morning care includes washing a resident up, changing their brief, combing their hair, and changing their clothes. NA-H stated shaving facial hair would typically be done on shower days unless a resident wanted it done daily or if it is long and bothering them. NA-H verified they were working with R3. NA-H stated R3 need assistance of 1 staff with all cares. NA-H stated they helped R3 with some cares this AM but did not offer to shave R3. NA-H verified R3 had longer facial hair and should have asked him.

During an interview on 3/03/26 at 1:31 p.m., registered nurse (RN)-A stated shaving facial hair should be offered during morning cares based on resident preferences (whether they want facial hair). RN-A stated the facility had razors for residents if residents do not have their own. RN-A stated they are not very familiar with R3.

During an interview on 3/3/26 at 1:53 p.m., director of nursing (DON) stated shaving facial hair would be based on resident preference which would be on their care plan. DON stated the expectation would be that if residents needed assistance with shaving, staff would be offering assistance with cares.

During a follow up interview on 3/4/26 at 8:14 a.m., DON stated she followed up with R3 and updated his care plan per his preference of shaving. DON stated that she requested staff shave him yesterday after meeting with surveyor. DON did not know when R3 was last offered to be shaved or last shaved. A facility policy on activities of daily living was requested but not received.

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

During observation on 3/3/26 at 8:45 a.m., R46 was alone in her room with no music or TV on.During observation and interview on 3/4/26 at 9:38 a.m., R46 was alone in her room with no music or TV on. R46 stated she would like to listen to the TV, but no one had offered to turn the TV on for her.During interview on 3/3/26 at 9:15 a.m., licensed practical nurse (LPN)-A stated she was aware R46 liked music and enjoyed listening to crime shows on the TV. LPN-A stated she knew that because she worked often but was not sure how other staff would know R46's activity preferences.

LPN-A stated R46's activity preference was not on her care plan.During interview on 3/3/26 at 4:35 p.m., LPN-B stated he was not aware of any specific activity preferences for R46 and did not see any preferences documented in her electronic health record (EHR).During observation on 3/4/26 at 1:48 p.m., R46 was in her room with no music or TV on.During interview on 3/4/26 at 1:53 p.m., NA-F stated R46 sometimes asked her to turn on her music or TV. NA-F stated she would not know that was an activity R46 enjoyed if R46 did not ask. NA-F stated she was unsure how to know residents' activity preferences.During interview on 3/4/26 at 2:25 p.m., NA-A stated she was not aware of R46's activity preferences and did not locate her preferences in the EHR. NA-A stated she could ask the activity director about R46's activity preferences.During interview on 3/5/26 at 10:18 a.m., registered nurse (RN)-F, also known as vice president of clinical services, stated she would expect resident activity preferences to be available to all staff in the EHR so resident preferences could be honored for activities. RN-F stated due to R46's dependence on staff, she would expect staff to offer R46 her activities.Facility Activity Programs policy printed 3/4/26, indicated: Activities offered are based on the comprehensive resident-centered assessment and the preferences of each resident.

Our activity programs are designed to encourage maximum individual participation and are geared to the individual resident's needs.

Activities are not necessarily limited to formal activities being provided only by activities staff.

Other facility staff, volunteers, visitors, residents and family members may also provide the activities.

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

checked the medication administration record (MAR)/orders, but did not see that an order was in for

stated she would expect nursing staff to be receiving forms from dialysis so his weights at dialysis

resident's weights on the days he was not at dialysis.

The NP stated that these weights were important, given his dialysis treatment as well as his diagnosis of congestive heart failure, to ensure timely provider notification and treatment in the case of weight gain that could be caused by fluid.

During an interview on 3/5/26 at 9:28 a.m., RN-F stated she expected dialysis to take weights at dialysis and those forms to be sent over after treatment. RN-F stated that if the provider wanted more frequent weights than the ones that were taken at dialysis, she would expect the provider to put an order in for this.Facility Dialysis Care- External Facility policy dated 11/3/21, indicated that shared communication between the dialysis center and the nursing home would be coordinated by the director of nursing and/or the designee.

The policy indicated this communication should include post-weight, blood pressure, and dialysis site.

The policy did not include the expected frequency of weight measurement at the facility for residents receiving dialysis treatments.

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

During an interview on 3/5/26 at 9:28 a.m., RN-F also know as vice president of clinical services stated she would expect nursing staff to attempt non-pharmacological pain interventions prior to administering as-needed pain medications.

Facility Pain- Clinical Protocol policy dated 6/9/25, indicated the provider would order non-pharmacological and medication interventions to address an individual's pain.

The policy indicated that generally and to the extent possible, the pain regimen should utilize the simplest regimen and lowest risk medications before using more problematic or higher risk approaches.

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

During an interview on 3/3/26 at 2:05 p.m., nurse practitioner (NP)-A stated she would expect to be notified with each low blood pressure so she can make the appropriate changes if needed. NP-A stated she had not been notified of any low blood pressure reading for R1 and stated she should have been. NP-A stated she would see R1 during rounds tomorrow (3/4/26). NP-A stated there are risks involved with giving antihypertensive medications to a person with low blood pressure such as dizziness, cognitive changes, increased risk of falls, syncope and altered level of consciousness.During a follow up interview on 3/4/26 at 8:14a.m., DON verified the provider had not been notified about the low blood pressures for R1. DON stated she talked to NP-A yesterday, after talking to surveyor about R1 blood pressure and medication. DON stated the medication should have been held and the provider should have been notified with the first low pressure. DON stated she had started providing re-education to the nurses on the floor, in light of the error, on holding blood pressuring medications when the parameters are not met, notifying the provider and the steps that need to be taken.

During an interview on 3/5/26 at 9:26 a.m., RN-F also known as vice president of clinical services stated the expectation would to be follow the orders, hold the medication and call the physician.

Facility Medication Errors policy, updated 8/13/22, identified the policy was to To provide guidance for identifying and reporting medication errors. A root cause analysis will be identified and changes to the policy and procedure will be reviewed and implemented as needed to prevent future errors.

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

completed for 1 of 2 residents (R57) reviewed for discharge.

Findings include: R57's face sheet

nervous system (cancer), repeated falls, muscle weakness, and schizoaffective disorder.R57's care plan revised 1/13/26, indicated risk for falls, limited to extensive assistance for dressing, independent for eating, extensive assistance for personal hygiene and toilet use.R57's discharge return not anticipated Minimum Data Set (MDS) dated [DATE], indicated intact cognition, no rejection of care, independent with eating, dependent for toileting hygiene, partial/moderate assistance for upper body dressing, lower body dressing, footwear, set up or clean up assistance for personal hygiene, partial/moderate assistance for going from sitting to lying, lying to sitting, sit to stand, and transfer to and from wheelchair, substantial/maximal assistance for tub/shower transfer.Facility electronic health record (EHR) nursing note dated 1/5/26, indicated R57 was found going up a hill in her scooter (motorized wheelchair), appeared to be very confused, and did not know where she was.

People (unknown) driving by helped her back to the facility.Provider order by nurse practitioner (NP)-A dated 1/5/26 at 5:48 p.m., indicated urinalysis (UA) with culture per new onset change in level of consciousness (LOC)/confusion.

Provider order by NP-A dated 1/6/26 at 9:35 a.m., indicated: Labs: collect urine sample for UA/Culture.

Diagnosis: Rule out urinary tract infection (UTI).Facility was unable to confirm urine was collected per order and did not provide results. In an email provided by RN-F, also known as vice president of clinical operations, on 3/5/26, stated It appears that it wasn't collected.

The lab has no record either. RN-F then provided urinalysis results from R57's M Health Fairview Southdale hospital encounter note dated 1/10/26, the time of her arrival to the emergency department following her discharge home.During interview on 3/5/26 at 10:18 a.m., registered nurse (RN)-F also known as vice president of clinical services stated she would expect provider orders to be followed promptly to ensure proper treatment for residents.Facility Acute Condition Changes-Clinical Protocol policy undated, indicated: The staff and physician will discuss possible causes of the condition change based on factors including resident/patient history, current symptoms, medication regimen, and diagnostic test results. If necessary, the physician will order diagnostic tests and evaluate the patient directly. In addition, the nurse shall assess and document/report the following baseline information: Recent labs.

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

During an interview on 3/4/26 at 8:08 a.m., HUC-A verified she was the health unit coordinator for the facility and was responsible for appointments for residents. HUC-A stated she was new to the position. HUC-A stated following any appointment, including dental appointments, the notes would be uploaded into the resident's medical record. HUC-A stated she was going to follow up with supervisor regarding any dental appointments for R2.

During a follow up interview on 3/4/26 at 9:35 a.m., HUC-A stated residents are referred out for dental visits as the facility does not have a dental provider that comes to the facility. HUC-A stated residents are seen on individual needs and requests. HUC-A stated the facility was unaware that R2 wanted to go the dentist or had dental concerns. HUC-A stated they would schedule an appointment for her. HUC-A stated was not able to locate any documentation when R2 was last seen by a dentist.

During an interview on 3/4/26 at 1:20 p.m., director of nursing (DON) stated the facility does not have a dentist that comes to the facility and residents are referred to the community for dental appointments. DON stated the expectation would be residents are seen annually for dental appointments and more frequent if there are concerns. DON reviewed R2's care conference note and verified R2 was to be referred to be seen be a dentist. DON stated it would be expected that R2 would seen by a dentist at the appointment and should have been done by this time as the care conference was dated 10/1/25 which was 5 months ago. DON stated she would follow up to see if she could find additional information. No additional information was provided.During a follow up interview on 3/4/26 at 1:42 p.m., RN-A stated she was not aware of any dental pain complaints from R2. RN-A was unsure of any recent dental appointments for R2.

During an interview on 3/5/26 at 9:24 a.m., RN-F also known as vice present of clinical services stated the expectation would have be a resident would be seen within a couple of months if they expressed a desire to see a dentist at a care conference.

Facility Dental Services policy, revised 12/2016, indicated the following: Routine and 24-hour emergency dental services are provided to our residents through:a contract agreement with a licensed dentist that comes to the facility monthly;referral to the resident's personal dentist;referral to community dentists; orreferral to other health care organizations that provide dental services.

Furthermore, all dental services provided are recorded in the resident's medical record. A copy of the resident's dental record is provided to any facility to which the resident is transferred.

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

During an interview on 3/5/26 at 8:41

generally include fewer carbohydrates than a regular diet, and could help assist a resident in

necessary, the facility would provide a therapeutic diet that was individualized to the resident's needs and desires to assist the resident in achieving their goals of care.

The policy indicated that the therapeutic diets should coincide with the therapeutic diets on the facility's menu extensions.