Highland Chateau Health Care Center

F-F677: The facility failed to ensure routine personal hygiene care (i.e., nail care) was provided for 1 of 1 resident (Resident R22) reviewed for activities of daily living (ADLs) who was dependent on staff for his care.

Refer to

F-F690: The facility failed to have comprehensive incontinence care plan and provide timely assistance with toileting for 1 of 1 residents (Resident R21) reviewed for bladder incontinence.

Refer to

F-F726: The facility failed to ensure agency nursing assistants (NA's) received appropriate orientation, training and supervision.

Refer to

F-F807: The facility failed to provide water, consistent with the resident needs and preferences, and sufficient to maintain hydration for 1 of 1 resident (Resident R31) reviewed for hydration.

RECORD REVIEW:

Resident R4's face sheet received on 4/24/25, indicated Resident R4 had diagnoses including morbid (severe) obesity, chronic pain, reduced mobility.

Resident R4's admission minimum data set (MDS) assessment dated [DATE REDACTED], indicated Resident R4 had intact cognition.

Resident R4's care plan dated 1/14/25, included functional performance requiring total assist of two persons for bed mobility, dressing and personal hygiene. Transfers required total assist using 600 pound full-body lift with 4 persons to transfer.

Resident R8's face sheet received on 4/24/25, included diagnosis of stroke affecting his non-dominate left side.

Resident R8's significant change MDS assessment dated [DATE REDACTED], indicated intact cognition, clear speech, could understand and be understood. Resident R8 was dependent upon staff for toileting and most ADL's. Resident R8 was always incontinent of urine and occasionally incontinent of bowel.

Resident R8's care plan dated 3/27/25, indicated Resident R8 required extensive physical assist for most ADL's.

Resident R12's face sheet received on 4/24/25, included diagnosis of stroke affecting his non-dominate left side.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of 67 245028 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245028 B. Wing 04/24/2025

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 0725 Resident R12's quarterly MDS assessment dated [DATE REDACTED], indicated intact cognition, clear speech, he could understand and be understood. Resident R12 required supervision with toileting transfers, and was dependent upon Level of Harm - Minimal harm or staff for toileting hygiene. Resident R12 was frequently incontinent of bowel and bladder. potential for actual harm Resident R12's care plan dated 3/28/25, indicated Resident R12 required extensive physical assist for most ADL's. Residents Affected - Many Resident R16's annual MDS assessment dated [DATE REDACTED], indicated Resident R16 was cognitively intact, had clear speech, could understand and be understood. Resident R16 required partial to substantial staff assist with dressing and substantial assist with toileting; was occasionally incontinent of urine and always incontinent of bowel. Diagnoses including renal insufficiency, amputation, diabetes, heart failure and atrial fibrillation.

Resident R16's care plan dated 4/25/25, indicated Resident R16 required extensive assistance with dressing, bed mobility, toileting and transfers. Resident R16's care plan also indicated risk for skin impairment and directed staff to apply barrier cream after each incontinent episode.

Resident R21's face sheet received on 4/24/25, included diagnoses of orthopedic aftercare for left hip replacement, pressure ulcer of right heel stage 3, and pressure ulcer of right buttocks stage 2.

Resident R21's admission MDS assessment dated [DATE REDACTED] indicated Resident R21 was cognitively intact, had clear speech, could understand and be understood. No behaviors or delirium; was always incontinent of bowel and bladder and required assistance of staff for toileting.

Resident R21's care plan dated 3/24/25 and updated 4/16/26 did not include a plan for bowel and bladder incontinence.

Resident R31's face sheet received on 4/24/25, included diagnosis of left below the knee amputation.

Resident R31's quarterly MDS assessment dated [DATE REDACTED], indicated Resident R31 was cognitively intact, had clear speech, could understand and be understood. Resident R31 was frequently incontinent of bowel and bladder, used briefs for toileting and was dependent upon staff for toileting hygiene.

Resident R31's care plan with revised date of 3/27/25, indicated Resident R31 was incontinent of bladder and bowel related to immobility and would remain free from skin breakdown due to incontinence and brief use. Care plan dated 10/29/24, indicated Resident R31 was a total assist/one-person physical assist.

Resident R33's face sheet received on 4/24/25, included chronic venous hypertension of bilateral lower legs (persistent high blood pressure in veins of legs).

Resident R33's quarterly MDS assessment dated [DATE REDACTED], was cognintively intact, had clear speech, could understand and be understood. Resident R33 was independent with activities of daily living

Resident R37's face sheet received on 4/24/25, included diagnoses of malignant cancer of the bladder, chronic pain due to cancer, anxiety, and insomnia.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of 67 245028 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245028 B. Wing 04/24/2025

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 0725 Resident R37's quarterly MDS assessment dated [DATE REDACTED], indicated Resident R37 had moderately impaired cognition, clear speech, could understand and be understood. Resident R37 was dependent upon staff for most activities of daily living Level of Harm - Minimal harm or (ADL's) and could walk short distances with the aid of a walker. Resident R37 was occasionally incontinent of bladder potential for actual harm and bowel. Resident R37 had pain almost constantly which interfered with sleep and day to day activities.

Residents Affected - Many Resident R37's care plan dated 9/24/24, indicated Resident R37 received hospice care, would be comfortable and would not have an interruption in normal activities due to pain. Resident R37's care plan with revised date of 3/27/25, indicated Resident R37 required one-person physical assist for most ADL's.

Resident R38's face sheet received on 4/24/25, included diagnosis of stroke affecting her non-dominate left side.

Resident R38's significant change MDS assessment dated [DATE REDACTED], indicated intact cognition, clear speech, could understand and be understood. Resident R38 was dependent upon staff assist for most ADL's including toileting. Resident R38 was always incontinent of bowel and bladder.

Resident R38's care plan with revised date of 3/27/25, indicated Resident R38 required extensive physical assist for most ADL's.

RESIDENT OBSERVATIONS:

Resident R4

On observation 4/23/25 at 11:30 a.m., nursing assistant (NA)-A entered Resident R4's room and Resident R4 told her she needed the bed pan and NA-A stated she needed to get more help. At 11:32 a.m. NA-B entered Resident R4's room and Resident R4 told her she needed to use the bed pan NA-B informed her she needed to get more assistance and left the room. Resident R4 called the front desk of the facility stating she needed help and to send some as I don't want anyone to have to clean up my mess. At 11:36 a.m. licensed practical nurse (LPN)-A went into Resident R4's room but was not able to locate NA-A or NA-B and told Resident R4 she couldn't get her on the bed pan alone and would have to wait until she could get help. LPN-A remained in the room until 11:41 a.m. At 11:37 a.m., social services (SS)-A entered the room. At 11:52 a.m., SS-A remained in the room with the door closed and NA-A entered the room and then exited the room. NA-B and NA-A both entered the room at 11:55 a.m., and LPN-A entered the room shortly after. At 12:10 p.m., all staff exited the room.

On interview and observation on 4/23/25 12:39 p.m., Resident R4 stated she needed to use the bed pan and they told me they needed more help. Resident R4 stated it took them over an hour to finally get her on the bed pan. Resident R4 stated

she was really worried she was going to soil herself so she called the front desk for help but that didn't help either. Resident R4 stated she was able to hold her bowel movement until they got her on the bedpan, but it was close. At 12:43 p.m., LPN-A entered the room and Resident R4 complained of how she was laying in her bed with her feet touching the bottom footboard and stated she is not comfortable. LPN-A stated she can't move Resident R4 alone and Resident R4 asked if they had a male NA working today. LPN-A stated no and added we can't always have a male NA on duty. Resident R4 then stated see, this is what happens all the time.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 40 of 67 245028 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245028 B. Wing 04/24/2025

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 0725 On observation and interview 4/23/25 at 1:21 p.m., Resident R4 continued to have her feet touching the foot board with head of bed elevated at 60 degrees. Resident R4 stated I am so uncomfortable, and someone needs to do Level of Harm - Minimal harm or something about it. Resident R4 put on her call light. potential for actual harm

On observation and interview 4/23/25 at 1:34 p.m., NA-H and NA-A entered Resident R4's room to boost Resident R4 up in her Residents Affected - Many bed. NA-H stated they called him from 2nd floor to assist. NA-H added it is just physics with putting her feet up and head down and then sliding her. NA-H stated he can boost Resident R4 up in bed himself when doing this.

On interview 4/23/25 at 1:35 p.m., NA-A stated it takes three staff to move Resident R4 and she has to call another NA from another wing or floor to come and assist her and then find the nurse also.

On interview 4/24/25 at 9:09 a.m., the director of nursing (DON) stated residents should not have to wait 30-45 minutes to be assisted onto a bedpan or to be repositioned. The DON stated the staff need better ways to communicate and coordinate patient care activities.

Resident R21

On observation 4/23/25 at 9:05 a.m., Resident R21 placed call light on. At approximately 9:10 a.m., nursing assistant (NA)-A entered the room. Resident R21 requested to be changed as his pad was wet. NA-A stated she would be back soon.

On observation on 4/23/25 at 10:44 a.m., Resident R21 placed his call light on, and licensed practical nurse (LPN)-A was in the hallway. Resident R21 was yelling at the nurse that he has been sitting in a wet pad for hours and no one comes and answers his call light. Resident R21 stated the NA said she would be back hours ago. LPN-A stated she would get him some help and Resident R21 stated he has been sitting in wet stuff for over 2 hours and that is ridiculous and was going to contact state senators to stop all funding for the facility. LPN-A stated she would help him shortly and Resident R21 stated this is ridiculous, you shouldn't have to, where are the aides? LPN-A entered Resident R21's shortly after and assisted with changing his wet pad.

On 4/23/25 at 11:53 a.m., Resident R21 placed call light on, and NA-A was walking past his room. Resident R21 told NA-A he needed to get dressed before lunch and NA-A stated she would be there soon. NA-A continued to walk down

the hallway towards the nurses station and then back towards Resident R21's room. Resident R21 again stated he needed to get dressed and has an appointment at 1:00, and NA-A stated she needed to help someone else and would be right back. Resident R21 stated all you are doing is wandering around.

On interview and observation on 4/23/25 at 11:59 a.m., Resident R21 stated he had been left lying in a wet pad for 2 hours this morning and that just isn't right. Resident R21 was in a hospital gown in his bed. Resident R21 stated this happened almost every day and gets nothing but excuses over and over. Resident R21 stated again, I laid in a wet pad for over 2 hours this morning and the nurse had to change that because the NA never did come into my room and I saw her wandering the halls. Resident R21 stated they never toilet him and he just has to go in his pad.

On interview 4/24/25 at 9:09 a.m., the DON stated staff should go into the room once a call light is activated and should not have conversations with them from the hallway. The DON stated residents should not have to wait over an hour to get assistance for toileting or dressing and should never lay in a wet pad for two hours.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 41 of 67 245028 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245028 B. Wing 04/24/2025

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 0725 CALL LIGHT RESPONSE INTERVIEWS AND OBSERVATIONS:

Level of Harm - Minimal harm or During an interview on 4/21/25 at 4:53 p.m., Resident R33 stated agency staff had no get up and go. Resident R33 stated there potential for actual harm were no standards; no one holding them accountable to make sure they were doing their job. Resident R33 stated for example, there were signs around the building indicating staff were not supposed to be on their cell phones, Residents Affected - Many but they were often seen on their cell phones. Resident R33 provided another example on 4/20/25, at around 7:00 p.m. , Resident R31 was screaming because her call light wasn't working - she was screaming for help - she needed to be changed. After about a half hour and no one helping her, Resident R33 walked to the dining room and saw the nursing assistant sitting at the nurses station on her phone. Resident R33 stated he told her to get off her phone and help Resident R31 and slapped the sign about not being on cell phones in front of her.

During observations during survey from 4/21/25, to 4/24/25, on both first and second floors, multiple staff, primarily NA's were observed on cell phones multiple times, both while at the nurses station and while in common areas on the units.

During document review, a written grievance filed by Resident R8 on 4/6/25, indicated he had turned his call light on at noon and someone came in and turned the light off saying they would get to him. No one came for 3.5 hours.

The DON's written response indicated, Call lights answered promptly. Staff reported they went to assist as soon as able. There was no indication in the review/response that Resident R8's call light log had been reviewed for

the date and time of Resident R8's complaint.

During an interview on 4/24/25 at 1:36 p.m., Resident R8's grievance was reviewed with the DON, including Resident R8's call light log data from 4/1/25, to 4/24/25. Resident R8 had two call light response times of 42 and 60 minutes on 4/6/25.

The DON stated that was not acceptable and would expect call lights to be answered sooner than that. The DON believed she received wrong call light data for Resident R8, otherwise would not have written on the grievance form that Resident R8's call lights had been answered promptly.

CALL-LIGHT RESPONSE REVIEW:

Call light response times were reviewed for a one-month time frame from 3/23/25, to 4/22/25, which indicated many call light response times greater than 20 minutes:

FIRST FLOOR:

Resident R21:

During an interview on 4/21/25 at 4:43 p.m., Resident R21 stated it was not uncommon for his call light to be on for 30 minutes and no one answered it. When his call light wasn't answered, Resident R21 stated he sometimes called the facility on his cell phone for help and half the time no one answered the phone. Resident R21 stated he thought the NA's were drastically understaffed.

Resident R21 had 474 activations with call light response times of:

> 20 minutes = 13 x

> 30 minutes = 22 x

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 42 of 67 245028 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245028 B. Wing 04/24/2025

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 0725 > 40 minutes = 5 x

Level of Harm - Minimal harm or > 50 minutes = 4 x potential for actual harm > 60 minutes = 10 x Residents Affected - Many Resident R4:

During an interview on 4/22/25 at 8:08 a.m., Resident R4 stated she has had to wait hours for her call light to be answered.

Resident R4 had 76 activations with call light response times of:

> 20 minutes = 8 x

> 30 minutes = 1 x

> 40 minutes = 1 x

> 50 minutes = 1 x

> 60 minutes = 11 x

SECOND FLOOR:

Resident R16:

During an interview on 4/21/25 at 3:34 p.m., Resident R16 stated he waited a long time for his call light to be answered, depending on the shift. Resident R16 stated about a week ago, around 9:00 p.m., he put his call light on, and no one took care of him until the next morning.

Resident R16 had 66 call light activations with call light response times of:

> 20 minutes = 5 x

> 30 minutes = 7 x

> 40 minutes = 1 x

> 50 minutes = 1 x

> 60 minutes = 7 x

Resident R37:

During an interview on 4/22/25 at 9:14 a.m., Resident R37 stated sometimes staff answered his call light in a few minutes and sometimes they didn't come at all. Resident R37 stated, What I'm scared about the most, is when my pain gets worse -- am I going to have to suffer?

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 43 of 67 245028 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245028 B. Wing 04/24/2025

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 0725 Resident R37 had 240 activations with call light response times of:

Level of Harm - Minimal harm or > 20 minutes = 17 x potential for actual harm > 30 minutes = 9 x Residents Affected - Many > 40 minutes = 1 x

> 50 minutes = 1 x

> 60 minutes = 7 x

Resident R12:

During an interview on 4/21/25 at 2:32 p.m., Resident R12 stated he had his call light on for four hours one night when

he had a bowel movement. Resident R12 stated his call light was on for 45 minutes most of the time before anyone responded.

Resident R12 had 72 activations with call light response times of:

> 20 minutes = 6 x

> 30 minutes = 3 x

> 40 minutes = 3 x

> 50 minutes = 3 x

> 60 minutes = 9 x

Resident R38:

During an interview on 4/21/25 at 5:36 p.m., Resident R38 stated it took a long time for someone answer her call light -- sometimes up to 3 hours.

Resident R38 had 23 activations with call light response times of:

> 20 minutes = 2 x

> 30 minutes = 3 x

> 40 minutes = 1 x

> 50 minutes = 0 x

> 60 minutes = 5 x

Resident R8

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 44 of 67 245028 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245028 B. Wing 04/24/2025

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 0725 During document review, a written grievance filed by Resident R8 on 4/6/25, indicated he had turned his call light on at noon and someone came in and turned the light off saying they would get to him. No one came for 3.5 hours. Level of Harm - Minimal harm or Call lights response log for 4/1/25, to 4/24/25, were reviewed. potential for actual harm Resident R8 had 36 activations with call light response times of: Residents Affected - Many > 20 minutes = 3 x

> 30 minutes = 1 x

> 40 minutes = 2 x (one occurred on 4/6/25)

> 50 minutes = 1 x

> 60 minutes = 2 x (one occurred on 4/6/25)

During an interview on 4/24/25 at 10:52 a.m., the assistant director of nursing (ADON) whose office was on second floor, stated she had been in her role for almost a year. ADON stated resident call light response times often came up in conversation. ADON stated she could hear when a call light was not being answered

in a timely manner due to the continued beeping sound outside of her office. The ADON stated sometimes

she got up to see what was going on, or staff or residents brought it to her attention. The ADON stated she typically touched base with residents when there were long call light response times to discuss circumstances. In addition, the ADON stated call light audits were done when a concern was identified by a resident. The ADON stated a manager conducted the audit by sitting in a residents room and activating the call light and waiting for staff to respond. The ADON stated she did not look at call light response time reports; that maybe the DON and/or administrator did. The ADON was informed by the surveyor that call light response time reports for multiple residents on second floor for the past month indicated many call lights were over 20, 30, 40, 50 and 60 minutes. The ADON stated she was not aware of that, and stated call lights should be answered within 10-15 minutes. The ADON stated licensed nursing staff on duty had accountability over the NA's to ensure they were doing their work in a timely manner. Further, the ADON stated staff cell phones were not permitted on the units - only when on break.

During an interview on 4/24/25 at 12:21 p.m., the DON stated call lights response times were discussed at QAPI (quality assurance and performance improvement) meetings. The DON stated call light response times were discussed in terms of average call light response times rather than looking at and investigating outliers.

The DON stated managers conducted call light audits where a manager went into a residents room and pressed the call light. The DON stated sometimes a call light could be long if staff went into the room and forgot to shut the light off. The DON stated it wasn't an issue of not having enough staff, adding they were adequately staffed for their census. The DON was informed by the surveyor of the call light response times noted on reports received from the administrator. The DON stated, That is not acceptable on any level. The DON stated she would expect licensed nursing staff on duty to hold NA's accountable for completing their work in a timely manner, but acknowledged staff nurses didn't have the time, and it could place them in an uncomfortable position. The DON stated the facility did not utilize walkie talkies to communicate with other staff across wings .adding that if a NA on one wing needed help, he/she would have to go look for someone to help.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 45 of 67 245028 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245028 B. Wing 04/24/2025

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 0725 During an observation on 4/24/25 at 2:47 p.m., three NA's were standing in the common area on the first floor all on their cell phones. NA-A immediately put her phone away when observed. The other two Level of Harm - Minimal harm or unidentified NA's did not. The ADON was informed. potential for actual harm

During an interview on 4/24/25, at 2:50 p.m., (LPN)-C stated staff came to her about NA's being on their cell Residents Affected - Many phones while on duty and stated she had told the ADON and DON, but nothing happened .I can only do so much.

40614

Facility Resident Call System policy dated 3/5/25, indicated calls for assistance were answered as soon as possible, but no later than 5 minutes. Urgent requests for assistance are addressed immediately. Call light response times were reviewed as part of the QAPI program.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 46 of 67 245028 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245028 B. Wing 04/24/2025

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 0726 Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 42073

Residents Affected - Many Based on interview and document review, the facility failed to ensure employed and agency nursing assistants (NA's) received appropriate orientation, training and supervision. In addition, the facility failed to ensure 2 of 5 nursing assistants (NA-A and NA-C) received and demonstrated required competency skills for resident cares. Further, NA-C had not completed all in-service trainings upon hire. This had potential to affect all 47 residents who resided in the facility.

Findings include:

Resident R33's quarterly Minimum Data Set (MDS) assessment dated [DATE REDACTED], indicated Resident R33 was cognitively intact.

Resident R47's quarterly MDS assessment dated [DATE REDACTED], indicated Resident R47 was cognitively intact.

During an interview on 4/21/25 at 4:53 p.m., Resident R33 stated agency staff had no get up and go. Resident R33 stated there were no standards; no one holding them accountable to make sure they were doing their job.

Reviewed binder provided by the administrator which was used for new employee and agency orientation.

Review of the binder indicated one or two pages on various topics, primarily focused on topics licensed nursing staff would need to know/utilize, and little job-specific for non-licensed nursing staff (NA's). The topics included: pharmacy, oxygen, the electronic medical record (EMR) Point Click Care with a screen shot of how to locate the Kardex and care plan, infection control, emergency procedures, wounds, new admissions, risk management and assistance scoring. The administrator indicated new employee and agency orientation was conducted by the assistant director of nursing (ADON). Via email on 4/22/25, at 4:23 p.m., when asked if the binder was used for NA's too, the administrator replied, yes, but rarely did they have any agency NA's. Via email on 4/23/25, at 8:29 p.m. when asked to see certain NA orientation checklists, the administrator replied agency staff did not have a checklist; they only reviewed and signed the orientation binder. An undated document titled Agency Orientation -- provided by the administrator, listed printed name, signature and title of 13 registered nurses and NA's, but unable to determine when this training had occurred.

A list of agency NA's for payroll cycle 4/14/25, through 4/27/25, provided by the director of nursing (DON) to identify agency staff working during survey week, identified 12 agency NA's having worked hours during that time period, working a total of 102.25 hours.

During an interview on 4/23/25 at 10:05 a.m., at resident council meeting, Resident R47 stated agency NA's needed proper training; That's my biggest concern. Resident R47 stated agency NA's were not doing their work, didn't know what to do when they come here; were not properly trained. Resident R47 stated agency NA's asked him what they were supposed to do and asked him where supplies were kept. Resident R47 stated they didn't know how to use the [mechanical] lifts. Residents at the resident council meeting stated they could not always tell who was agency versus employed staff, adding not all staff wore name tags or often name tags were backwards.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 47 of 67 245028 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245028 B. Wing 04/24/2025

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 0726 During an interview on 4/24/25 at 9:17 a.m., human resource director (HRD)-C stated he had been employed at the facility for one month. HRD-C stated a lot of money was going to agencies for staffing. HRD-C stated Level of Harm - Minimal harm or the ADON provided orientation for new employed and agency staff. HRD-C stated he was not able to find potential for actual harm documentation of agency or employed staff orientation/training.

Residents Affected - Many During an interview on 4/24/25 at 10:52 a.m., the ADON stated she had been in her role since June 2024.

The ADON stated she was responsible for new employee staff orientation, including agency staff, and utilized an orientation binder for guidance. ADON stated there were no orientation checklists or other such documentation tools to ensure employed or agency NA's received orientation and training consistent with resident care requirements and expectations of the facility. There were no documentation to ensure NA's were shown were resident supplies were kept, no documentation to ensure NA's were competent in the use of the facility mechanical lifts, no documentation to ensure NA's were informed of expectations about checking resident preferences and transfer status (e.g., level of assistance needed) prior to providing care, nothing to ensure NA's were informed of providing fresh water to residents, of expected call light response times, or expectations about personal cell phone use. The ADON stated the only orientation NA's received regarding individualized resident care was how to access the Kardex (a quick reference guide that provided

a summary of patient information) in the EMR which was one screen shot of how to access the Kardex. The ADON stated she did not ensure agency NA's had access to the Kardex, stating they should have the same access as employed NA's but did not follow up with agency NA's to ensure they had access and knew how to utilize the Kardex. The ADON stated licensed nursing staff on duty were accountable for ensuring NA's performed their job duties.

During an interview on 4/24/25 at 12:21 p.m., the director of nursing (DON) stated she expected NA's to know about the individual resident care needs and how a resident transferred before caring for the resident, and expected NA's to use the Kardex to determine this. The DON was informed of resident concerns regarding the perceived lack of orientation, training and oversight for NA's. The DON stated she expected licensed nursing staff on duty to hold NA's accountable for performing their job duties.

48299

NURSE AIDE TRAINING

NA-A was hired 5/26/21. NA-A's employee file lacked skill competencies completed within the past year.

NA-C was hired 2/4/25. NA-C's employee file contained undated competency exams related to HIPAA (The Health Insurance Portability and Accountability Act; federal stands to protect health information from disclosure without patient's consent), workplace emergencies, resident rights, abuse and neglect and elder justice, fire safety, and hazardous chemicals. NA-C's employee file lacked skill competencies.

NA-C's Relias (platform which provides online training) transcript printed 4/24/25, indicated NA-C completed

the following trainings:

-Emergency Preparedness Requirements with completion date of 4/10/25.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 48 of 67 245028 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245028 B. Wing 04/24/2025

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 0726 -Behavioral Management in the SNF (skilled nursing facility) with completion date of 4/8/25 and 4/10/25.

Level of Harm - Minimal harm or -Cultural Awareness and Humility with completion date of 4/8/25. potential for actual harm -Abuse, Neglect, and Exploitation with completion date of 4/8/25. Residents Affected - Many -Basics of Tuberculosis with completion date of 4/8/25.

-About Infection Control and Prevention with completion date of 4/8/25.

-The Facts on COVID-19 (respiratory illness caused by the SARS-CoV-2 virus, a type of coronavirus) with completion date of 4/8/25.

During interview on 4/24/25 at 1:59 p.m., HRD-C stated new hires completed general onboarding through a PowerPoint (software to create and deliver presentations using slides, texts, images, and multimedia elements) presentation and completed skill competencies during shadow shifts on the floor. HR stated new hires completed some Relias training upon hire and had more Relias trainings during annual training. HR stated employees received annual competency training through a skills fair directed by the assistant director of nursing (ADON) and director of nursing (DON).

During follow-up interview on 4/24/25 at 3:03 p.m., HRD-C reviewed NA-C's completed Relias trainings and was unsure if more training was required than what was completed. HRD-C expected Relias training to be completed within two weeks after orientation date.

During interview on 4/24/25 at 3:22 p.m., the DON reviewed NA-C's Relias training transcript and stated NA-C was not signed up for all the required new hire Relias trainings. The DON was given opportunity to look for NA-C's new hire skill competencies. DON stated staff completed an annual skills fair which included hand washing, infection control, abuse, and other specific skills. The DON stated the last skills fair was August 2024, and had sign-in sheets for the staff. The DON stated they were not sure where the sign-in sheets were located. The DON stated skill competencies were important to ensure staff understood and were able to effectively perform their necessary job duties.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 49 of 67 245028 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245028 B. Wing 04/24/2025

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 0726 The facility assessment dated [DATE REDACTED], indicated current strategies for recruitment and retention of nursing staff included competitive compensation and benefits by offering competitive salaries, comprehensive Level of Harm - Minimal harm or benefits, and incentives like bonuses or tuition reimbursement to attract and retain top talent. Replace potential for actual harm agency with full-time facility employees. The facility utilized a comprehensive educational program with the goal of having the most competent and satisfied care givers. All new staff attended a classroom experience Residents Affected - Many that covered the information all staff need to complete their jobs effectively. Completion of an extensive checklist (developed by the clinical leadership) in the care setting ensured the nursing staff had the opportunity to demonstrate knowledge and skill for required tasks. There was person centered care education via unit meetings, one to one with clinical managers or staff development. The facility provided annual education that covered required regulatory education as well as facility specific education which can occur in the classroom or online, depending on associate's preference, availability, and learning style. The agenda, power point, and checklist for General Orientation were available within the shared drive, located under Administration/General Orientation. The Facility Assessment indicated staff competencies included person-centered care, activities of daily living, disaster planning and procedures, infection control, vitals, caring for people with dementia, mental and psychosocial disorders, trauma, substance use disorder, and non-pharmacological management of responsive behaviors.

The facility's Orientation Program for Newly Hired Employees, Transfers, Volunteers policy dated 3/4/25, indicated the orientation program included a tour of the facility, instructions to be followed in an emergency, introduction to resident care procedures and administrative structure. The policy indicated orientation records included the date reviewed, participant's initials, subject matter reviewed, and other information deemed necessary or appropriate.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 50 of 67 245028 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245028 B. Wing 04/24/2025

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 0730 Observe each nurse aide's job performance and give regular training.

Level of Harm - Potential for 48299 minimal harm Based on interview and document review, the facility failed to complete annual performance reviews for 2 of Residents Affected - Many 5 nursing assistants (NA-A, NA-B) whose employee files were reviewed. This had the potential to affect all 47 residents who resided at the facility.

Findings include:

Review of NA-A and NA-B employee files contained counseling forms with verbal and written warnings. Both files lacked documentation of an annual performance review in the last year. NA-A was hired on 5/26/21, and NA-B was hired on 12/6/23.

During interview on 4/24/25 at 3:03 p.m., the human resources manager (HR) stated were not sure of the process for performance reviews. HR further stated recently started role and planned to implement a process to ensure performance reviews were completed during employees' work anniversary month.

During interview on 4/24/25 at 3:14 p.m., the director of nursing (DON) stated they referenced the performance review policy to know how often performance reviews were required. The DON stated they (NA-A and NA-b) held their role for approximately two years, and performance reviews were not completed

in the past year. The DON stated performance reviews were important, so staff knew how well or not they performed their job duties and gave staff an opportunity to voice their concerns about education.

Facility Job Descriptions and Performance Evaluations policy dated 9/2020, indicated performance evaluations measured the standards against job performance. The policy indicated the director of human resources and/or respective department director reviewed with each employee a copy of the employee's job description prior to or upon employment, or upon assignment of duties, to determine if the essential functions of the job can be performed, or if modification of the job position needs to be made. The policy lacked time frame for further performance reviews.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 51 of 67 245028 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245028 B. Wing 04/24/2025

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 0761 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately Level of Harm - Minimal harm or locked, compartments for controlled drugs. potential for actual harm 40614 Residents Affected - Few Based on observation and interview, the facility failed to maintain safe storage of medications when over the counter stock medications were left unlocked and unattended in an office.

Findings include:

On observation and interview on 4/21/25 at 3:31 p.m., through an open door, observed bottles/containers of over the counter (OTC) medications spread out on a table in an office located at the end of 1 [NAME] wing, a resident hallway. At the end of the hallway by the office was a vending machine for soda pop and snacks for staff and residents. There was no exit or entry located in this area. Medications included vitamins, acetaminophen, probiotics, lidocaine patches and ibuprofen. Some medications were still in boxes, and some were unpackaged and on the table. Medical Records Director (MRD)-O was present in the room and stated she was also central supply and ordered supplies including OTC medications. MRD-O stated she was

in the process of unpacking the medications to refill the medication closet on the nursing unit. MRD-O stated

she locked the door when she left her office.

On observation 4/21/25 at 6:30 p.m., the MRD office door was open and MRD-O was not in the office. At 6:34 p.m., MRD-O returned to her office and said she left it open as she just had to run to the second floor and wasn't gone long.

On observation and interview on 4/22/25 at 12:37 p.m., MRD office door was closed, but not locked. At 2:23 p.m., MRD-O office door remained closed but unlocked. At 3:23 p.m., MRD office door was closed but remained unlocked. At 3:26 p.m., MRD-O returned to her office and opened the door without a key. MRD-O stated she was on a unit that was close by, so she did not lock the door.

During an observation and interview on 4/22/25 at 3:24 p.m., during a tour with the administrator, the MRD office door was open. The OTC medications were still on the table and unattended. The administrator confirmed this was a potential safety issue and the medication should not be left unattended.

On observation and interview 4/24/25 at 11:02 a.m., a tour of the 2nd floor medication room (only medication room in the building) was completed with licensed practical nurse (LPN)-C. Multiple boxes of tube feeding solutions were present on the counter and multiple other non-medication supplies were stored on the shelves and counters. LPN-C stated they don't have a lot of room to store anything else in the medication room.

On interview 4/24/25 at 12:03 p.m., the director of nursing (DON) stated medications should not be stored in

a room that is not locked including over the counter stock medications. The DON stated she would expect MRD-O to lock the door when leaving with medications present even if she is gone for a short time.

A policy on medication storage was requested and none received.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 52 of 67 245028 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245028 B. Wing 04/24/2025

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 0801 Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 46885

Residents Affected - Many Based on interview and document review the facility failed to employ either a full-time registered dietician (RD) or a qualified dietary manager (DM) to carry out the functions of the food and nutrition service, which had the potential to affect 44 of 44 residents who received food from the kitchen.

Findings include:

During interview on 4/21/25 at 2:39 p.m., the dietary manager (DM) stated she had a food safety certification and an MDH certification, but did not have her qualifications on hand.

During interview on 4/22/25 at 12:16 p.m., DM stated, the administrator told DM to bring her certifications in

on Thursday, 4/24/25. DM stated the registered dietician (RD)-I worked every day.

During interview on 4/23/25 at 7:53 a.m., RD-I stated he was the dietician for the facility, was contracted, and had been with the facility for 5 or 6 years and worked on Mondays. When asked about RD-I's FTE status, RD-I stated he had to look at his hours report and stated he worked 10 to 12 hours per week and again stated he usually only came in on Mondays.

During interview on 4/23/25 at 2:38 p.m., DM came into the kitchen and stated the internet was poor and the HR director instructed her to email her qualifications and he would provide the qualifications to the surveyor. DM could not show or verify her certifications and qualifications and stated she tried to pull the certification up on her phone but the internet was bad.

During interview on 4/23/25 at 2:18 p.m., human resources (HR)-C stated his role consisted of interviewing new staff, conducting background checks, and verifying licenses. HR-C stated personnel files were kept in his office and he tries to digitize them. HR-C further stated he had worked at the facility about a month and stated there were problems with employee files being incomplete and stated DM's personnel file was incomplete and stated DM had certifications and licenses but HR-C did not have them and expected DM's file be in the HR department. HR-C further stated did not know what DM's certifications were, and stated DM was a director or manager for a previous facility. HR-C verified there was nothing in smart links and verified DM did not have an employee file.

During interview on 4/23/25 at 3:57 p.m., DM stated she had a food safety certificate, but did not have a certified dietary manager certificate. DM stated she was not a certified food service manager, but stated it is part of her course. DM stated she had a food safety certification from another nursing facility she worked at for [AGE] years. DM further stated she did not have an associate's degree or higher, was a manager at a facility for [AGE] years and stated she consulted with the dietician every day. DM did not provide any evidence of her certifications and qualifications.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 53 of 67 245028 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245028 B. Wing 04/24/2025

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 0801 During interview on 4/23/25 at 4:03 p.m., the administrator stated a CDM was a certified dietary manager and added they had a certified dietician that superceded the CDM and verified their dietician was not full Level of Harm - Minimal harm or time. The administrator stated she knew the DM was a CDM and stated their dietician was a consultant. potential for actual harm DM's personnel file was requested and the administrator stated HR-C noticed a lot of employees were without personnel files. A policy was requested for the dietician and dietary manager qualifications and Residents Affected - Many verification of the dietician's qualifications or certifications.

An unsigned and dated job description, Certified Dietary Director, indicated the purpose of the position was to plan, organize, develop and direct the operations of the food and nutrition services department in accordance with current federal, state and local standards. the job description further identified requirements for the position included: preferred, as a minimum, a bachelor's degree in nutrition, dietary management or related field from an accredited college or university, must be a certified dietary manager or comparable certification in the state.

The facility provided the dietary manager's (DM) resume on 4/24/25, at 11:04 a.m., that indicated DM was a kitchen manager from February 2019, to October 2023, at a senior living, and identified the following responsibilities: cooked, ordered food, cleaned the kitchen, and completed staff training and prep. Under a heading, Certifications and Licenses, indicated DM had ServSafe from June 2012 to present, was a Certified Dietary Manager from February 2018 to February 2028, had Food Handler Certification from September 2019 to present.

Evidence of DM's qualifications including certifications was requested, on 4/24/25 at 12:59 p.m., however no additional information was provided.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 54 of 67 245028 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245028 B. Wing 04/24/2025

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 0806 Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 48065

Residents Affected - Few Based on observation, interview, and document review, the facility failed to ensure identified preferences for menu selection were honored for 1 of 1 resident (Resident R16) reviewed for choices.

Findings include:

Resident R16's 5-day Minimum Data Set (MDS assessment dated [DATE REDACTED], indicated Resident R16 had intact cognition with no behaviors and diagnoses included end stage renal disease, dependence on renal dialysis, diabetes, paroxysmal atrial fibrillation, and essential hypertension. Resident R16 was independent with eating, required substantial assistance from staff for toileting, lower body dressing and transfers, and required moderate assistance for bed mobility.

Resident R16's Order Summary Report printed 4/23/25, indicated an order for renal diet, regular texture and thin liquids.

Progress note dated 3/18/25, authored by registered dietician (RD) indicated resident states that he has no questions or concerns regarding nutrition with the exception that he would like larger portion sizes . Dietician provided education regarding weights and encouraged him to continue with regular portions, but resident was adamant that he wanted larger portions, Dietician notified manager of a preference for larger portions.

Progress note dated 4/17/25, authored by RD indicated RD spoke with dialysis RD who spoke with this resident [Resident R16 ] regarding his diet and nutritional concerns. Resident and dialysis RD discussed switching to a regular diet, and both agreed this is acceptable. Dialysis RD states all labs look good with the exception of phosphorus, but that is d/t [due to] resident running out of Tums per his statement. Resident is able to return back to a renal diet at his request. DON and NP notified of resident diet order change to a regular diet.

During an interview on 4/21/25 at 3:44 p.m., Resident R16 stated he got white rice twice a day and he had requested multiple times to stop giving him rice with every meal. Resident R16 stated I don't eat the rice. Resident R16 added he was not supposed to have bananas or milk which he received three times day. Resident R16 stated he had never talked to the facility's RD.

During observation and interview on 4/22/25 at 12:53 p.m., Resident R16 was eating lunch, and his tray had a piece of ham, white rice, steam vegetables, a piece of cake, and apple juice. Resident R16's meal card indicated renal diet, assorted juices (cran, apple or grape juice), regular protein-smaller portions, no potato, steamed rice, seasonal vegetables, strawberries and decaf coffee with creamer. Resident R16 stated he was supposed to get strawberries but instead they gave a piece of cake rich in sugar. Resident R16 added last night they gave me white rice, and milk.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 55 of 67 245028 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245028 B. Wing 04/24/2025

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 0806 During interview on 4/22/25 at 1:44 p.m., licensed practical nurse (LPN)-C stated for two days Resident R16 received mashed potatoes and today he got rice. LPN-C stated for weeks Resident R16 had complained about receiving rice Level of Harm - Minimal harm or white, he never eats the rice. LPN-C stated Resident R16 told her for months he had complained and talked to the potential for actual harm dietary staff about the rice and his diet. LPN-C stated during a RD's visit to the facility, she informed RD about Resident R16's request to visit with him. LPN-C stated later that day, Resident R16 told her RD never talked to him. Residents Affected - Few LPN-C suggested to Resident R16 to talk to the dialysis dietician to discuss his concerns.

During interview on 4/23/25 at 1:01 p.m., RD stated the dietary manager stated the last dietary manager had

a paper version of residents' food likes and dislikes, but he wasn't sure what the current dietary manager used. RD stated he met the resident in February 2025, and he didn't recall talking to Resident R16 about his dislike for rice. RD stated on 4/17/25, the dialysis dietician contacted him and agreed to change Resident R16's diet to a regular diet.

During interview on 4/23/25 at 2:20 p.m., dietary manager (DM) stated she looked at all the trays returned to

the kitchen and if residents didn't eat their meals, she talked to the residents to find out if they were not hungry, maybe they were sick, or didn't like the food. DM stated the resident's likes and dislikes were added to the residents' meal cards. DM stated she didn't recall talking to Resident R16 or hearing bout his dislike of rice. Resident R16's meal card dated 4/22/25, still indicated Renal diet and white rice. DM stated today she received an order, and she updated Resident R16's meal card indicating a regular diet, double portions and no rice.

During interview on 4/24/25 at 2:59 p.m., director of nursing (DON) stated we need to offer choices. DON stated she talked to the floor staff and dietary department to offer him (Resident R16) choices. Not following Resident R16's choices is a dignity and respect issue. We need to change his diet, document risk and benefits and educate

the resident about his food choices.

Facility Resident Food Preferences policy dated 12/9/21, indicated individual food preferences will be assessed upon admission and communicated to the interdisciplinary team. The policy also indicated, if the resident refuses or is unhappy with his diet, the staff will create a care plan that the resident is satisfied with.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 56 of 67 245028 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245028 B. Wing 04/24/2025

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 0807 Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 42073

Residents Affected - Few Based on observation, interview, and document review the facility failed to provide water, consistent with the resident needs and preferences, and sufficient to maintain hydration for 1 of 1 resident (Resident R31) reviewed for hydration. In addition, 2 of 2 resident (Resident R18 and Resident R33) voiced concern of not receiving clean water mugs.

Findings include:

Resident R31's face sheet received on 4/24/25, included diagnoses of left below the knee amputation, diabetes, and protein calorie malnutrition.

Resident R31's quarterly Minimum Data Set (MDS) assessment dated [DATE REDACTED], indicated Resident R31 was cognitively intact, had clear speech, could understand and be understood. Resident R31 was independent in her ability to transfer from bed to wheelchair and to self-propel her wheelchair.

Resident R31's physician order dated 1/7/25, indicated consistent carbohydrate diet regular texture, thin liquids consistency.

Resident R31's care plan dated 4/26/23, indicated the facility would encourage good nutrition and hydration in order to promote healthier skin. Resident R31's care plan with revised date of 1/7/25, indicated Resident R31's preferences would be considered when providing care.

During an interview and observation on 4/22/25 at 8:47 a.m., no water mug or cup was visible in Resident R31's room. Resident R31 stated staff did not provide fresh water, that she had to get it herself. Resident R31 stated she knew she should drink water throughout the day. Further, Resident R31 stated they no longer had access to ice for their water, stating

the facility just removed the ice machines.

During an observation on 4/23/25 at 12:45 p.m., there was no water mug/cup visible in Resident R31's room.

Observations and interviews in the same hallway included:

--Resident R18: quarterly MDS assessment dated [DATE REDACTED], indicated intact cognition, clear speech, could understand and be understood. Was independent with mobility via wheelchair. Resident R18 stated he replenished his water mug with water from his bathroom sink; no one brought him fresh water. In addition, Resident R18 stated he never received

a clean water mug; he reused the same one.

--Resident R33: quarterly MDS assessment dated [DATE REDACTED], indicated intact cognition, clear speech, could understand and be understood. Resident R33 was independent with ambulation. Resident R33 stated no one brought him fresh water - he refilled his cup himself. In addition, Resident R33 stated he never received a clean water mug; he reused the same one.

During observations on 4/21/25 through 4/23/25, while on second floor, did not observe staff pass water to resident rooms.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 57 of 67 245028 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245028 B. Wing 04/24/2025

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 0807 During an interview on 4/23/25 at 1:11 p.m., dietary manager (DM)-J stated kitchen staff had nothing to do with water pass for residents, other than supplying the mugs. DM-J was not aware of a process to ensure Level of Harm - Minimal harm or residents received received a clean water mug and fresh water daily. potential for actual harm

During an interview on 4/23/25 at 1:14 p.m., licensed practical nurse (LPN)-C stated she had never seen Residents Affected - Few nursing assistants (NA's) formally pass water to residents; had only seen staff refill a residents cup if requested. LPN-C stated there used to pitchers of ice water near the nurses station for nurses to use to fill water for residents, but it was removed this week - she did not know why. LPN-C stated she did not know how residents were supposed to get fresh water now.

During an interview on 4/23/25 at 3:10 p.m., (NA)-A stated most of the residents on this floor (2nd floor) were independent and could get their own water; that staff did not go around with a cart and provide fresh water. NA-A stated there used to be a pitcher of water for residents to access but now that was gone. NA-A stated

she did not know how residents were supposed to get fresh water now.

During an interview on 4/24/25 at 10:46 a.m., assistant director of nursing (ADON), who's office was on the second floor, stated NA's were supposed to pass water on the day and evening shifts, was aware it was not happening consistently, but did not know why.

During an interview on 4/24/25 at 12:50 p.m., the director of nursing stated she expected staff to pass water daily and provide residents with a clean mug daily.

Facility Bedside Water Containers policy dated 4/23/25, indicated the facility would provide residents with fresh drinking water at their bedside daily. The night shift would be responsible for collecting used water containers and replacing clean water containers, filled with fresh water and ice on a daily basis.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 58 of 67 245028 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245028 B. Wing 04/24/2025

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 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm 46885

Residents Affected - Some Based on observation, interview, and document review, the facility failed to ensure kitchen food items were labeled and dated, scoops were not stored in the dry bins, opened foods were properly wrapped or stored, outside food containers were cleaned. In addition the facility failed to ensure resident meals brought from outside were labeled and dated in the 1 of 1 kitchenettes. This had the potential to affect all residents who consumed food from the kitchen.

Findings include:

See also

F-F812 related to food storage.

A Paffy's pest control inspection report dated 4/22/25 at 2:45 p.m., indicated the facility staff reported seeing mice activity with droppings in the kitchen, but no rodents were found. Additionally, the facility provided the following inspection reports:

1/9/25, a comment indicated nothing was entered on the pest log.

1/23/25, a comment indicated nothing had been entered on the pest log, however the kitchen had seen activity and exterior bait stations had varying degrees of activity.

2/7/25, a comment indicated the logbook was checked and nothing was added to the logbook, minor activity was found in the kitchen.

2/20/25, a comment indicated nothing was added to the logbook and minor activity was found in the kitchen.

3/6/25, a comment indicated nothing new was entered to the logbook, however kitchen staff reported seeing

a mouse run into a wall void and light activity was found upon an exterior inspection.

3/20/25, a comment indicated nothing was entered to the logbook and no activity was found in the facility.

4/3/25, a comment indicated in unit 210 activity was not found other than old green mouse droppings. The kitchen was inspected, and kitchen staff reported seeing a mouse run under the steam table 2 days prior and RTU was moved near the back door since they opened that door a lot.

4/17/25, a comment indicated no issues were reported and moderate activity was identified on an exterior inspection on the east side and light activity was identified on a bait station across from staff's office.

A report log provided by the facility, Pest Sighting Report Facility Deficiency Report indicated mice sightings

in various locations in the facility on 3/12/24, 3/21/24, 4/19/24, 4/24/24, 5/3/24, 5/9/24, 5/15/24, 6/3/24, 6/11/24, 6/13/24, 6/17/24, 6/16/24, 6/20/24, 6/22/24, 6/23/24, 6/24/25, 7/23/24, 7/29/24, 8/5/24, 8/11/24, 8/13/24, 8/14/24, 8/19/24, 8/20/24, 9/3/24, 9/9/24, 9/10/24, 9/17/24, 9/22/24, 9/23/24, 9/25/24, 10/24/24, and

on 10/30/24. No other mouse sightings were logged after 10/30/24.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 64 of 67 245028 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245028 B. Wing 04/24/2025

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 0925 During interview and observation 4/21/25 between 2:16 p.m., and 2:31 p.m., a Plunkett's pest trap was in the kitchen on the floor. At 2:17 p.m., on the way to the dumpster located through the door that went to the Level of Harm - Minimal harm or outside from the kitchen, the dietary manager (DM) was going to prop the door open and stated they potential for actual harm propped the door open to bring the trash outside and leave the door open to come back inside. The dumpster was uncovered, and the DM stated they kept the dumpster covers opened because the nurses Residents Affected - Many also disposed of trash. The dumpster contained bags in the bottom of the bin and briefs were visible in the bags. At 2:21 p.m., a Plunkett's pest trap was in the dry storage room and next to the trap were several black particles. The DM stated, it looks like mouse turds and further stated it would be mopped that evening. The DM further stated there were three traps in the dry storage area. DM stated she had been at the facility 5 months and had not seen mice in the kitchen. At 2:25 p.m., a 3.79-liter jug of molasses was located on the shelf in the kitchen and the DM verified there was molasses around the outside of the container and stated staff didn't wipe it down. At 2:26 p.m., a 138-ounce jar of salsa was in the dry storage that the DM verified had dried salsa on the outside of the jar and the lid had not been securely closed. At 2:28 p.m., five 16-ounce opened and unsecured bags of Tostitos tortilla chips were in the dry storage and DM stated the bags should have been wrapped in plastic and took the bags off the shelf. At 2:31 p.m., the sugar and flour storage bins contained sugar and flour on top of the lids and was verified by the DM who instructed staff to wipe down the lids. At 2:37 p.m., the underside of the coffee machine contained brown flaky material the DM stated was dried coffee along with some white chunks the DM could not identify and stated it was a build up from not being cleaned.

During observation on 4/22/25 at 7:52 a.m., the last table on the first floor towards the East hall had a whitish chalky material on the table.

During observation on 4/22/25 between 7:53 a.m. and 7:56 a.m., the table on the first floor by the window and closest to the [NAME] Hall and the table across from the table by the window had crumbs on the table and on the floor next to the table.

During observation on 4/22/25 at 7:59 a.m., the food cart was going towards the west hall on the first floor.

During interview and observation on 4/22/25 at 8:00 a.m., housekeeping (H)-A stated tables were wiped down in the a.m., and in the afternoon before housekeeping left at 2:30 p.m. H-A stated the nursing assistants were supposed to wipe down the tables at night and stated housekeeping did not vacuum at night because housekeeping didn't work at night and observed the tables and floor and stated the crumbs were cookies on the tables and floor and wiped down the tables.

During interview on 4/22/25 at 8:04 a.m., nursing assistant (NA)-I stated no residents eat in the dining area

on the first floor for breakfast and stated they were just passing meal trays at this time and no residents had eaten in the dining area.

During observation on 4/22/25 at 8:23 a.m., meal trays were being passed out on the East hallway.

During observation on 4/22/25 at 8:52 a.m., staff took a meal out of room [ROOM NUMBER]E and did not wipe down the table. A plastic lid with a white cream substance was located on the floor in room [ROOM NUMBER]E with the cream substance also on the floor.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 65 of 67 245028 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245028 B. Wing 04/24/2025

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 0925 During interview and observation on 4/22/25 at 12:16 p.m., the DM stated pest control was coming today.

The area around the Plunkett's trap in the dry storage area contained little black particles and stated they Level of Harm - Minimal harm or swept and mopped the floor last night and stated they had a pest problem and verified the particles were potential for actual harm mouse droppings and stated food items needed to be closed and secured. The DM further stated the aides were responsible for wiping down the dining room tables and stated propping the door open can be a Residents Affected - Many problem for pests and further stated the cook will open the door if it was smoky in the kitchen or hot. The dumpster outside was uncovered with several garbage bags and the DM verified it was opened and stated

she thought it should be closed but stated that was maintenance's responsibility and verified the dumpster contained food items and several garbage bags.

During interview on 4/22/25 at 12:59 p.m., maintenance (M)-A stated for mouse prevention they utilized mouse traps, but the mice didn't seem to want food and traveled through the registers. He further stated it would be important for food to be in containers. Mice were more prevalent in the fall and spring and the doors should not be propped open. M-A further stated the dumpster should be closed and were approximately 25 feet from the kitchen door. M-A and M-B denied seeing mice.

During interview on 4/22/25 at 1:47 p.m., licensed practical nurse (LPN)-C stated she found a dead baby mouse in a room two weeks ago and was busy and forgot to log it in the pest control book.

During interview and observation on 4/22/25 at 2:06 p.m., Paffy's pest control staff (PPC)-N stated there were droppings in the kitchen, but no rodents in the traps. PPC-N stated they used mouse poison and metal traps or bait stations. PPC-N stated the mice eat the poison and they had several traps in the property and about a year prior there had been ground movement which created a huge influx of mice, and the administrator called this week due to droppings. PPC-N stated food, and warmth could attract mice and added propping doors open was the worse thing in the world and kitchens loved to leave the doors open which invited critters and stated mice lived in a 10-foot radius if they had warmth, food, and water. The door to the outside on the second floor where residents went to smoke contained a gap on the bottom and the door opened automatically to a small room with another door that went to the outside of the building. Both doors opened and closed automatically, the door to the outside did not have a gap.

During interview on 4/22/25 at 2:14 p.m., the administrator stated the kitchen got hot and has directed staff to shut the door and further stated the dumpster had been uncovered since she had been at the facility and added 99% of their staff were short making it difficult to shut. The administrator stated housekeepers left at 2:30 p.m., and added that was probably why food was on the tables and floors in the a.m. and the aides were supposed to clean the tables after dinner. The administrator stated Paffy's used to come twice a week and then went down to once a week and a few months ago went down to every other week because there was no activity and no complaints from staff or residents and stated the mice that are here were only coming out at night and added it was a known fact that anywhere food was not stored properly would attract something and stated the kitchen door should always be shut and if the door was propped open should be fast. The administrator further stated if residents kept food in the room they talked to residents and asked families to bring in sealable containers to keep goodies to avoid mice from going into rooms and stated anyone going into the rooms could monitor this. If no family, the facility would purchase them for the resident.

The administrator stated she was not aware of mice sightings and stated Paffy's started coming to the facility every other week in January.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 66 of 67 245028 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245028 B. Wing 04/24/2025

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 0925 During further interview on 4/22/25 on 2:15 p.m., the administrator stated if there was of an uptick in sightings of mice, the pest control agency was contacted immediately to come to the facility. A logbook was Level of Harm - Minimal harm or established for staff and residents to report sighting and were instructed to report each time a mouse was potential for actual harm sighted to ensure appropriate follow up. (The last entry in this logbook was 10/30/24. The administrator was informed of a dead mouse sighting by a nurse two weeks ago and stated, That's the first I'm hearing this. Residents Affected - Many

During an interview and observation on 4/22/25 at 3:24 p.m., together with the administrator, toured the facility for upkeep/maintenance. In Resident R31's room, observed multiple candies and snacks on Resident R31's overbed table and a loaf of bread on the dresser. These items were not in covered containers. Observed many items

on the floor around the perimeter of the room and in the closet. Across the hall in Resident R27's room, concern was expressed for the amount of clutter on the floor and bed which could potentially attract and conceal mice.

The administrator stated she was well aware of Resident R27's room and stated staff went through the mounds of clothing and items on the floor to ensure there were no mice.

During an observation on 4/23/25 at 8:44 a.m. and again at 3:00 p.m., Resident R31's snacks and bread were still not

in covered containers.

During an interview on 4/23/25 at 10:05 a.m., at resident council meeting, Resident R16 stated LPN-C had been doing morning medication rounds in his room and said, Oh my gosh, there is dead mouse on the floor. Resident R16 said that was about two weeks ago.

During observation and interview on 4/23/25 at 2:37 p.m., the door to the outside from the kitchen was propped open with a plastic pink wet floor sign. At 2:40 p.m., the door remained propped open approximately seven inches. At 2:43 p.m., the door remained propped open. At 2:46 p.m., the door was still opened. At 2:48 p.m., the door remained open. At 2:49 p.m., a staff person opened the door and stepped over the pink wet floor caution sign and went out the door which was still propped open. The DM verified the door was propped open and stated they needed water and were going back and forth so she monitored the door to make sure nobody came in. At 2:50 p.m., the door remained propped open.

42073

During an interview on 4/24/25 at 1:44 p.m., the director of nursing (DON) was informed of the dead mouse finding and stated the facility had not had a mouse sighting in over 90 days or longer but would put a plan in place.

Facility Pest Control policy dated 9/6/23, indicated on-going measures are taken to prevent, contain and eradicate common household pests such as roaches, ants, mosquitoes, flies, mice and rats. General measures to decrease pests include elimination of cracks and crevices, proper lighting and ventilation, use of screen on windows and doors, and the use of self-closing doors. All food stored in the dietary area is kept in

a designated area in securely covered containers, is off the floor and away from walls. All food items kept in resident rooms are stored in covered containers, with the exception of uncut fruits such as bananas and oranges, a contract with a pest control company will be elected to assure regular inspection and application of chemical pesticides. Staff will report all sightings of pest to the maintenance and or environmental services director for pest control intervention.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 67 of 67 245028

F-F925 related to pest control.

During the tour of the kitchen on 4/21/25 from 2:01 p.m., to 2:15 p.m., with the dietary manager (DM), observed the following:

The kitchen refrigerator:

A sponge cake that was opened, unlabeled and undated and the DM asked to have it labeled.

A container of dried milk dated 1/11, DM verified was dated 1/11 and stated dried milk was good for a week and it wasn't kept because it could grow yeast inside the bag.

The kitchen freezer:

1 box containing gluten free pasta shells was stored on the floor and packages of vegetables were located

on top of the box and DM stated the box should not be stored on the floor. At 2:12 p.m., DM picked up the box and placed it on the shelf.

3 packages of waffles with 10 in each package were undated and without a label. 1 of the bags was opened.

1 opened bag of egg omelets that was undated and unlabeled.

1 more package of waffles was stored on another shelf and the DM stated they were bad and instructed staff to throw them out the previous week and stated they would go in the garbage.

1 bag of opened chicken sitting in a box. The DM stated the chicken bag should have been closed.

1 bag of chicken strips that were unlabeled and undated.

Dry Storage:

One 3.79 liter jug of molasses opened 10/9/23, had a brown substance on the outside of the jug. DM stated

it was molasses and staff just didn't wipe it down and stated it should have been discarded.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 59 of 67 245028 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245028 B. Wing 04/24/2025

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 0812 One 138 ounce jar of salsa that the DM stated contained dried salsa on the outside of the jar. DM verified

the lid was not secured tightly. Level of Harm - Minimal harm or potential for actual harm Five 16 ounce opened bags of Tostitos tortilla chips not tied closed. The DM stated the chips should be wrapped in plastic and took the bags off the shelf. Residents Affected - Some

A dry bin marked, Sugar contained two scoops in the bin. DM stated scoops should not be stored in the sugar. Additionally, the top of the lids of the sugar and flour contained flour and sugar on each and DM instructed kitchen staff to wipe down the lids and stated it was important to wipe down because of germs and food debris.

During interview and observation on 4/21/25 at 2:37 p.m., the coffee machine contained debris on the under side of the machine. The DM stated it looked like coffee debris and stated it was dried up coffee and stated there was some white chunks she could not identify what it was and stated it looked like buildup from not being cleaned every day.

During interview and observation on 4/21/25 at 2:44 p.m., the DM looked in the kitchenette refrigerator on the first floor that contained a salad in a Wendy's bag that was unlabeled and undated and the DM removed the item from the refrigerator.

During interview on 4/22/25 at 12:16 p.m., the DM stated she would be concerned with opened food items because they have pests in the kitchen and food was supposed to be closed right away.

During interview on 4/22/25 at 2:14 p.m., the administrator stated it was a known fact that improperly stored food would attract something. Additionally, the administrator stated when food is delivered, it is placed on the floor in the cooler and the team puts the food away.

Facility Foods Brought by Family/Visitors, dated 12/20/21, indicated food brought by family/visitors that is left with the resident to consume later will be labeled and stored in a manner that it is clearly distinguishable from facility prepared food. Perishable foods must be stored in re-sealable containers with tightly fitting lids in a refrigerator. Containers will be labeled with the resident's name, the item and the use by date.

Facility Food Storage, dated 7/13/23, indicated food would be stored in an area that is clean, dry and free from contaminants. Plastic containers with tight-fitting covers must be used for storing cereals, cereal products, flour, sugar, dried vegetables, and broken lots of bulk foods. All containers must be legible and accurately labeled and dated. Scoops are not to be stored in food or ice containers, but are kept covered in a protected area near the containers. Leftover food will be stored in covered containers or wrapped carefully and securely. Each item will be clearly labeled and dated before being refrigerated. Leftover food is used within 7 days or discarded as per the 2013 Federal Food Code. All foods should be covered, labeled and dated. All foods will be checked to assure that foods including leftovers will be consumed by their safe use by dates, or frozen where applicable, or discarded. All foods will be stored off the floor.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 60 of 67 245028 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245028 B. Wing 04/24/2025

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 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 48065 potential for actual harm Based on observation, interview and document review, the facility failed to ensure enhanced barrier Residents Affected - Few precautions (EBP) were followed for 1 of 1 resident (Resident R22) reviewed for EBP. In addition, facility failed to ensure proper use of gloves while providing personal cares for 1 of 1 resident (22) observed for personal cares.

Findings include:

EBP

Resident R22's quarterly Minimum Data Set (MDS) assessment dated [DATE REDACTED], indicated Resident R22 was severely cognitively impaired, had no behaviors and did not refuse personal cares. Resident R22's MDS indicated diagnoses of cerebral infarction, quadriplegia, essential hypertension, and seizure disorders.

Resident R22's Clinical Profile printed 4/23/25, indicated Resident R22 was on enhanced barrier precautions (EBP).

Resident R22's Clinical Orders report printed 4/23/25, indicated orders for care of gastrostomy tube and wound care orders for his buttocks and left great toe.

Resident R22's care plan printed 4/23/25, indicated Resident R22 had a risk for infection related to gastrostomy tube placement and directed staff to initiate appropriate isolation precautions.

During observation on 4/21/25 at 4:10 p.m., an EBP sign was taped to Resident R22's room door directing staff to wash their hand before entering the room, and to wear gloves and gown to provide personal cares. Also, a bin was located next to the door, containing personal protection equipment (PPE).

During observation on 4/22/25 at 12:38 p.m., nursing assistants (NA)-E and NA-F were giving a sponge bath and providing pericare for Resident R22 without using gowns.

During interview on 4/22/25 at 12:45 p.m., NA-E stated she had worked at facility for 8 years and today she was oriented NA-F to the facility. NA-E stated she knew Resident R22 was on EBP, but she forgot to put on a gown because the nurse was rushing her to complete cares for other residents. NA-E stated Resident R22 was on precautions because he had an infection on his foot and had a tube feeding. NA-E stated the staff needed to wear gowns to prevent contamination.

Glove Change

During observation on 4/23/25 at 9:18 a.m., NA-H and NA-G put on PPE prior entering Resident R22's room. NA-H provided most of the personal cares and NA-G primarily assisted with turning and repositioning Resident R22. NA-G changed her gloves after each discrete area of the body as listed was washed; Resident R22's face, upper body, genital area, buttocks and before dressing for a total of 5 glove changes. NA-H changed his gloves once while personal cares were given to Resident R22. NA-H and NA-G did not wash their hands after removing each pair of dirty gloves and before putting on new gloves.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 61 of 67 245028 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245028 B. Wing 04/24/2025

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 0880 During interview on 4/23/25 at 9:48 a.m., NA-H stated he needed to wash his hands before putting on clean gloves and added I forgot. Level of Harm - Minimal harm or potential for actual harm During interview on 4/23/25 at 9:51 a.m., NA-G stated, I forgot I needed to wash my hands after removing

Residents Affected - Few my dirty gloves and put on clean gloves. NA-G she needed to wash her hands for infection control issues.

During interview on 4/23/25 at 2 p.m., licensed practical nurse (LPN)-C stated nursing assistants needed to wear proper PPE before providing cares for any resident on EBP. LPN-C stated we (nursing staff) need to wash their hands after removing dirty gloves and before putting on clean gloves to prevent infections. There are signs of the door, directing staff to wear PPE. Failure to follow precautions represented a risk to transmit infections.

During interview on 4/23/25 at 3:02 p.m., director of nursing (DON) stated there were signs on the doors and carts by the resident's doors directing staff to wear PPE to prevent spread of infections. DON stated she expected nursing staff to follow infection control measures.

Facility Enhanced Barrier Precautions policy dated 10/8/22, indicated EBP were utilized to prevent the spread of multi drug-resistant organisms (MDRO) to residents. The Policy also indicated EBP were indicated for residents with wounds and/or indwelling medical device regardless of MDRO colonization.

Facility Using Gloves Personal Protective Equipment policy dated 4/24/25, indicated the objectives to use gloves were to prevent spread of infections, prevent wounds from contamination, to protect hands from potentially infectious material . The policy directed staff to wash their hands after removing gloves.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 62 of 67 245028 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245028 B. Wing 04/24/2025

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 0919 Make sure that a working call system is available in each resident's bathroom and bathing area.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 42073 potential for actual harm Based on observation, interview and document review, the facility failed to ensure resident call lights were Residents Affected - Few functioning for 1 of 1 resident (Resident R31) reviewed for call lights.

Findings include:

Resident R31's facesheet received on 4/24/25, included diagnosis of left below the knee amputation.

Resident R31's quarterly Minimum Data Set (MDS) assessment dated [DATE REDACTED], indicated Resident R31 was cognitively intact, had clear speech, could understand and be understood. Resident R31 was frequently incontinent of bowel and bladder, used briefs for toileting and was dependent upon staff for toileting hygiene.

Resident R31's care plan with revised date of 3/27/25, indicated Resident R31 was incontinent of bladder and bowel related to immobility and would remain free from skin breakdown due to incontinence and brief use. Care plan dated 10/29/24, indicated Resident R31 was a total assist/one-person physical assist.

During an interview on 4/21/25 at 4:53 p.m., Resident R33 who resided in the same hallway as Resident R31, stated that on 4/20/25, at about 7:00 p.m., Resident R31 was hollering for help because she needed to be changed, and her call light did not work. Resident R33 stated after 30 minutes, he walked to the dining room to inform staff. Resident R33 stated that was not the first time Resident R31 had hollered out for help.

During an interview and observation on 4/22/25 at 8:34 a.m., Resident R31 stated her call light did not work. Both Resident R31 and surveyor attempted to activate the call light by pressing the red button on the end of the white call cord.

The small red light on the call station located on the wall at the head of the bed did not illuminate to indicate

the call light had been activated, nor did her room number appear on the electronic scrolling sign in the hallway. Resident R31 could not recall when she first noticed her call light not working, but had been given a tap bell to use. A metal tap bell was observed on her overbed table. Resident R31 stated staff did not always hear the bell and stated she had to call out for help sometimes.

During an interview and observation on 4/22/25 at 3:24 p.m., together with the administrator, entered Resident R31's room and attempted to activate the call light by pressing the red button on the end of the white call card. The small red light did not illuminate on the call station located on the wall at the head of the bed, nor did Resident R31's room number appear on the electronic scrolling sign in the hallway. Using her cell phone, the administrator immediately informed maintenance. The administrator did not know why this had not been addressed sooner and expected call lights to be functioning at all times.

Facility Call System, Resident policy dated 3/6/25, indicated each resident was provided a means to call staff directly for assistance; the call system would remain functional at all times. The call system would be routinely maintained and tested by the maintenance department. Calls for assistance would be answered as soon as possible, but no later than 5 minutes. Urgent requests for assistance would be addressed immediately.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 63 of 67 245028 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245028 B. Wing 04/24/2025

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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 46885 potential for actual harm Based on interview, observation, and document review, the facility failed to implement interventions to Residents Affected - Many maintain an effective pest control program to eliminate mice in the facility. This had the potential to affect 47 of 47 residents who resided at the facility.

Findings include:

See also