Inspection Reports for
Highland Chateau Health + Rehabilitation Clinic
2319 7th St W, St Paul, MN 55116, United States, MN, 55116
Back to Facility Profile18 CMS Surveys
Inspection Report — Dec 30, 2025
Routine
Date: Dec 30, 2025
Visit Reason
MDH assisted living licensing survey.
Findings
Survey identified 2 correction orders addressing care plan revision and failure to designate a full-time Director of Nursing. The orders relate to revising a resident's care plan and ensuring a registered nurse serves as DON.
Deficiencies (2)
F0657 Develop the complete care plan within 7 days of the comprehensive assessment: The facility failed to revise resident R1's care plan after a change in condition and did not process ordered therapy.
F0727 Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis: The facility failed to designate a full-time Director of Nursing after the former DON left and was operating without a DON.
Report Facts
residents_reviewed: 3
residents_affected_in_sample: 1
Inspection Report — Sep 19, 2025
Routine
Date: Sep 19, 2025
Visit Reason
MDH assisted living licensing survey
Findings
Survey findings: Maltiple correction orders (27 tags) were issued covering care quality (wound care, ADL care and care planning), medication management (including missed/incorrect routes and timing), infection prevention and control (including enhanced barrier precautions, glucometer cleaning, Legionella program), nutrition and tube-feeding issues, dialysis coordination, smoking/oxygen safety, staffing and long call-light response times, food safety and kitchen sanitation, dental access, pest control (mice), and an ineffective QAPI program. No civil monetary fines are stated in this document.
Deficiencies (27)
F0550 Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.: Surveyors found residents waited prolonged periods for basic ADL care (soiled briefs, delayed toileting and showering) and staff documentation inconsistent with residents' reported experiences, indicating failures to ensure dignified, timely care.
F0554 Allow residents to self-administer drugs if determined clinically appropriate.: The facility failed to assess and document safe self-administration for multiple residents who had medications at bedside; staff found personal medications on bedside tables without proper orders/assessments.
F0584 Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.: Observed feeding pump and bag left in a resident's room after tube removal and residents reporting items left in rooms making environment un-homelike.
F0641 Ensure each resident receives an accurate assessment.: The facility's MDS assessments were inaccurately coded for multiple residents (examples: hearing and insulin administration coding errors documented), indicating systemic assessment inaccuracies.
F0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.: Care plans lacked required detail and monitoring for antipsychotic use, dialysis care specifics, oxygen therapy, and other resident-specific interventions.
F0657 Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.: Care plans were not updated to reflect current orders or functional changes for multiple residents (examples: dialysis, oxygen, diet texture and supervision needs), and interdisciplinary updates were missing.
F0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.: Residents requiring supervision or assistance (e.g., supervision at meals, ROM/splinting) were not consistently provided interventions or the facility lacked documentation and follow-through to preserve function.
F0677 Provide care and assistance to perform activities of daily living for any resident who is unable.: Observations and interviews documented repeated delays answering call lights and missed scheduled showers/ADL cares (residents left in soiled briefs, missed showers documented as completed when residents reported otherwise).
F0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals.: Wound care orders for residents with venous ulcers were not transcribed/implemented timely, leg circumference measurements and admission weights were not documented as ordered, and other ordered treatments were delayed or missed.
F0688 Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.: A resident with right-sided hemiplegia lacked expected splint use and documentation; staff did not consistently apply or document splint provision or refusals, risking contracture.
F0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.: Immediate jeopardy (later removed) occurred when a resident on oxygen was observed with a portable oxygen tank in the outdoor smoking area in close proximity to other smokers; facility lacked adequate supervision and smoking/oxygen safety compliance prior to corrective action.
F0692 Provide enough food/fluids to maintain a resident's health.: A dietitian-recommended nutritional supplement (Glucerna/TID) for a resident with severe malnutrition was not ordered/implemented by nursing as documented, leaving the resident without recommended supplements.
F0693 Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.: Enteral feedings and tube-feeding timing were not followed per orders; enteral medication administration was given by the jejunal (J) port rather than the gastric (G) port per orders, and feeding bags lacked proper labeling and timely start/stop per schedule.
F0695 Provide safe and appropriate respiratory care for a resident when needed.: A resident's CPAP equipment arrived without mask/tubing/power cord and the supplies were not replaced in a timely manner, preventing appropriate CPAP use.
F0697 Provide safe, appropriate pain management for a resident who requires such services.: A resident prescribed buprenorphine experienced missed doses when the facility did not have the medication available and follow-up/alternative therapy was not timely arranged.
F0698 Provide safe, appropriate dialysis care/services for a resident who requires such services.: The facility failed to ensure ongoing assessment/monitoring of the AV graft site and coordination/communication with the dialysis provider; EMR lacked dialysis-specific documentation and phone contacts.
F0725 Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.: Call-light response logs, resident and staff interviews, and grievances documented frequent long waits (many >30 minutes and multiple >60–180 minutes); staff reported insufficient communication tools and heavy reliance on agency staff.
F0759 Ensure medication error rates are not 5 percent or greater.: Observed medication administration errors (route/timing/delays) contributed to an overall medication error rate above 5% for observed opportunities.
F0760 Ensure that residents are free from significant medication errors.: An antibiotic substitution/transcription issue led to missed/delayed antibiotic doses; medication ordering/receiving/transcription processes were not reliably completed.
F0791 Provide or obtain dental services for each resident.: A resident's missing dentures were not replaced in a timely fashion; documentation and timeliness of dental referral/replacement were inadequate despite speech/dietary changes and risk for choking.
F0805 Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.: A resident remained on a regular diet ticket despite SLP and physician orders downgrading diet to mechanical soft; the kitchen meal tickets and point-of-care did not reflect ordered diet changes, resulting in residents receiving inappropriate textures (e.g., donuts).
F0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.: Kitchen observations found wet/dirty pans stored stacked, lack of routine dishmachine temperature documentation, missing documentation of food temperatures at service, and lack of ice-machine manufacturer-recommended cleaning/sanitizing procedures and training documentation.
F0867 Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.: The facility's QAPI lacked evidence of ongoing, sustained corrective action addressing repeat deficiencies (care planning, staffing, infection control, nutrition, etc.); audits and PIPs were not documented or maintained.
F0880 Provide and implement an infection prevention and control program.: Multiple infection control gaps: glucometer not disinfected per manufacturer between residents, lack of enhanced barrier precautions for residents with infected wounds (dirty cups present, inconsistent gowning), lift equipment not cleaned between uses, and the Legionella program lacked monitoring parameters/diagrams/action thresholds.
F0881 Implement a program that monitors antibiotic use.: The facility's antibiotic stewardship program lacked consistent monitoring/documentation of antibiotic-associated assessments (no standardized monitoring/time-outs for residents started on antibiotics).
F0883 Develop and implement policies and procedures for flu and pneumonia vaccinations.: Records and interviews showed residents were not consistently offered/presented pneumococcal vaccine education/offers per CDC guidance (examples: residents not offered pneumococcal vaccine during the prior year).
F0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.: Repeated resident and staff reports of mice (multiple sightings, droppings, sticky-trap catches, dead mice) and pest-control logs documenting ongoing sightings; facility pest control efforts had not eliminated rodent sightings and staff/residents reported sightings inside rooms and common areas.
Inspection Report — Sep 19, 2025
Routine
Date: Sep 19, 2025
Visit Reason
MDH assisted living licensing survey
Findings
The licensing survey identified 1 correction order addressing an ineffective pest control program and mice infestations throughout the facility.
Deficiencies (1)
F0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests: Based on observation, interview and document review, the facility failed to implement an effective pest control program to eliminate mice in the building, with sightings documented in resident rooms, hallways, and common areas.
Report Facts
documented pest sightings: 35
Inspection Report — Jun 6, 2025
Routine
Date: Jun 6, 2025
Visit Reason
MDH assisted living licensing survey
Findings
The survey resulted in 2 correction orders addressing pain management and blood glucose monitoring, and medication administration errors involving oxycodone dosing and the facility e-kit supply.
Deficiencies (2)
F0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals: Based on interview and document review, the facility failed to appropriately monitor and comprehensively assess complaints of pain for 1 of 3 residents (R1) and failed to assess or monitor blood glucose for R1; R1 waited approximately nine hours for prescribed pain medication, called 911, and was transported to the hospital.
F0760 Ensure that residents are free from significant medication errors: The facility failed to ensure oxycodone HCl was administered per physician orders for 1 of 3 residents (R1), including doses given outside the ordered frequency and instances where the e-kit lacked the prescribed medication leading to delays and medication errors.
Report Facts
residents reviewed for pain management: 3
residents reviewed with blood glucose monitoring: 1
Inspection Report — Apr 24, 2025
Routine
Date: Apr 24, 2025
Visit Reason
MDH assisted living licensing survey.
Findings
Licensing survey issued 26 correction orders addressing resident dignity and respect, mail delivery and communication, notification of change in condition, investigation of missing personal property, MDS and care plan deficiencies, pressure ulcer prevention and wound care, incontinence/toileting care, nutrition and dietary implementation, respiratory and oxygen care, infection prevention and pest control.
Deficiencies (27)
0550 Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.: Based on observation, interview and record review the facility failed to provide a dignified experience for two residents (R30 and R1) who lacked adequate clothing and who were spoken to in an undignified manner.
0576 Ensure residents have reasonable access to and privacy in their use of communication methods.: Based on interview and document review the facility failed to ensure mail was delivered to residents on Saturdays for 4 residents, which could affect all 47 residents.
0580 Immediately tell the resident, the resident's doctor, and a family member of situations that affect the resident.: Based on interview and record review the facility failed to provide timely notification to a family member about a resident's change in condition and hospitalization (R22).
0584 Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.: Based on observation, interview and document review the facility failed to investigate a report of missing clothing for R30 when the resident reported items missing to staff.
0641 Ensure each resident receives an accurate assessment.: Based on interview and record review the facility failed to ensure an MDS was accurately coded for R16 (an anticoagulant was not coded).
0655 Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted.: Based on interview and record review the facility failed to offer or provide a baseline care plan summary to R36 or the resident representative as required.
0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.: Based on observation, interview and record review the facility failed to ensure comprehensive care plans for residents reviewed (examples: R7 for pressure ulcer prevention, R4 for respiratory care).
0657 Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.: Based on interview and record review the facility failed to ensure care conferences and timely care plan reviews were conducted for several residents (R31, R3, R36).
0677 Provide care and assistance to perform activities of daily living for any resident who is unable.: Based on observation, interview and record review the facility failed to ensure routine personal hygiene (nail care) for R22 who was dependent on staff.
0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals.: Based on observation, interview and record review the facility failed to properly transcribe and implement physician orders for edema management and wound/incision care for R36 (ted stocking and dressing orders were not processed into the nurses' assignment system).
0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing.: Based on observation, interview and record review the facility failed to implement interventions to prevent new pressure ulcers for R7, including failure to consistently reposition and offload pressure.
0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.: Based on observation, interview and record review the facility failed to comprehensively assess and document safe vaping practices and supervise/assess use of medical cannabis for R37 (vaping in room was found and not appropriately assessed/documented).
0690 Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.: Based on observation, interview and record review the facility failed to have a comprehensive incontinence care plan and provide timely toileting assistance for R21, who was found waiting in a wet pad for hours.
0692 Provide enough food/fluids to maintain a resident's health.: Based on observation, interview and record review the facility failed to ensure R46 received dietitian-recommended ice cream three times daily to address weight loss; the RD recommendation was not implemented.
0693 Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.: Based on observation and interview the facility failed to maintain the head-of-bed elevation during tube feeding for R22 (bed was flat while continuous tube feeding was infusing).
0695 Provide safe and appropriate respiratory care for a resident when needed.: Based on observation, interview and record review the facility failed to ensure R4's noninvasive ventilator was used and supplied per orders and failed to have an oxygen order in place while R4 was using continuous oxygen via concentrator.
0725 Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.: Based on observation, interview and call-light logs the facility failed to provide sufficient staffing and oversight of nursing assistants resulting in lengthy call-light response times and delayed care for multiple residents.
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.: Based on interview and record review the facility failed to ensure employed and agency nurse aides received appropriate orientation, training and competency verification and lacked documentation of orientation for agency staff.
0730 Observe each nurse aide's job performance and give regular training.: Based on personnel record review the facility failed to complete annual performance reviews for selected nurse aides (NA-A and NA-B).
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 locked, compartments for controlled drugs.: Based on observation and interview the facility left over-the-counter stock medications unpacked and unattended on an unlocked office table and medication storage areas were not consistently secure.
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.: Based on interview and document review the facility failed to employ a full-time registered dietitian or verify qualifications for the dietary manager; the contract dietitian worked limited hours and dietary manager credentials were not documented.
0806 Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.: Based on observation, interview and record review the facility failed to honor resident meal preferences for R16 (continued provision of foods he refused despite RD/dialysis RD discussion and requests).
0807 Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.: Based on observation and interviews the facility failed to provide fresh water and clean bedside cups consistently (examples R31, R18 and R33 reported not receiving clean water mugs or staff-passed water).
0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.: Based on observation and interview the facility failed to ensure opened foods were labeled/dated, scoops were stored properly, opened packages were secured, and some outside/visitor foods in kitchenettes were not labeled/dated.
0880 Provide and implement an infection prevention and control program.: Based on observation, interview and record review the facility failed to ensure enhanced barrier precautions were followed for R22 and failed to ensure proper glove use and hand hygiene during personal cares (staff changed gloves but did not perform hand hygiene between glove changes).
0919 Make sure that a working call system is available in each resident's bathroom and bathing area.: Based on observation and interview the facility failed to ensure a resident's call light was functional (R31's call light did not operate when tested).
0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.: Based on inspection reports, observation and interviews the facility failed to maintain effective pest control measures (mouse droppings and activity documented in kitchen/dry storage, open doors and uncovered dumpster and ongoing sightings).
Report Facts
residents_at_facility: 47
Inspection Report — Apr 24, 2025
Routine
Date: Apr 24, 2025
Visit Reason
MDH assisted living licensing survey.
Findings
The licensing survey resulted in 4 correction orders addressing resident dignity and clothing, failure to investigate missing personal property, a nonfunctioning call light system, and inadequate pest control for mice.
Deficiencies (4)
F0550 Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights: The facility failed to provide a dignified experience for two residents who lacked clothing and were spoken to in an undignified manner by staff.
F0584 Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely: The facility failed to investigate a report of missing clothing for one resident (R30).
F0919 Make sure that a working call system is available in each resident's bathroom and bathing area: The facility failed to ensure resident call lights were functioning for one resident (R31).
F0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests: The facility failed to implement interventions to maintain an effective pest control program, evidenced by mouse droppings, traps, an uncovered dumpster, and improperly stored food.
Report Facts
residents_residing: 47
Inspection Report — Mar 7, 2025
Routine
Date: Mar 7, 2025
Visit Reason
MDH assisted living licensing survey.
Findings
The licensing survey resulted in 2 correction orders addressing care planning (missing bathing preferences and bathing assistance) and failure to provide weekly baths/showers (bathing/ADL care).
Deficiencies (2)
F0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured: This Minnesota requirement is not met as evidenced by the facility's care plans did not include residents' bathing preferences or bathing assistance for 2 of 3 residents (R1, R3).
F0677 Provide care and assistance to perform activities of daily living for any resident who is unable: This Minnesota requirement is not met as evidenced by the facility failed to ensure minimum weekly baths/showers for 2 of 3 residents (R1, R2), with missing bathing documentation on multiple dates.
Inspection Report — Mar 5, 2025
Routine
Date: Mar 5, 2025
Visit Reason
MDH assisted living licensing survey.
Findings
This licensing survey resulted in 8 correction orders addressing resident neglect/immediate jeopardy and multiple care failures: failure to protect residents from neglect and provide safe transfers, incomplete care plans and unspecified lift/sling information, failure to provide ADL care and bathing, lack of activities, failure to obtain weekly weights, inadequate bedrail assessments, failure to update the facility assessment/restorative nursing program, and insufficient medical director involvement. No fines are stated in the document.
Deficiencies (8)
F0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.: Based on observation, interview and record review the facility failed to protect residents from neglect when three bariatric residents (R1, R2, R3) were not assisted out of bed; this situation resulted in an immediate jeopardy that began 02/28/25 when staff were unable to safely transfer R1, R2 and R3 due to equipment and sling issues.
F0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.: The facility's care plans for R1, R2 and R3 did not specify which mechanical lift or sling size to use for transfers, and contradictory transfer instructions were present for R3, leaving staff unsure how to safely transfer these residents.
F0677 Provide care and assistance to perform activities of daily living for any resident who is unable.: The facility failed to carry out required ADL care for R3 (no documentation that ordered every-other-day bathing occurred), indicating dependent residents did not receive required bathing and hygiene assistance.
F0679 Provide activities to meet all resident's needs.: The facility failed to support facility-sponsored and individual activities for R1, R2 and R3 who were dependent on staff; residents had little to no activity involvement and staff were unable to get dependent residents out of bed for group activities.
F0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals.: The facility did not obtain weekly weights per standing orders for R1 and R2 (multiple weekly weights missing or undocumented), and staff reported inability to weigh these residents given equipment limitations.
F0700 Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.: Bedrail/assist-bar evaluations were blank or missing for multiple residents (R1, R2, R3, R6, R7) yet bilateral 1/4 rails permanently affixed to beds were observed; the facility lacked documented interdisciplinary assessments, consent or ongoing evaluation of entrapment/other risks.
F0838 Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.: The facility failed to update the facility assessment after discontinuing restorative nursing; PT and staff indicated R1 and R2 would have benefited from restorative nursing and the lack of that program affected facility ability to maintain resident function (document states this had potential to affect all 56 residents).
F0841 Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility.: The medical director was not involved in admissions or oversight for bariatric residents and did not provide guidance on admission or care capability for R1, R2 and R3; facility staff reported not consulting the MD about admission suitability or equipment needs.
Inspection Report — Jan 24, 2025
Routine
Date: Jan 24, 2025
Visit Reason
MDH assisted living licensing survey.
Findings
Two correction orders were issued related to self-administration of medications and inadequate staffing, including delayed call light response and missed baths.
Deficiencies (2)
F0554 Allow residents to self-administer drugs if determined clinically appropriate: The facility failed to perform a self-administration of medications (SAM) assessment and lacked interdisciplinary team review for R5, who kept an antiseizure medication in her bedside drawer and self-administered it without the required staff witness.
F0725 Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift: The facility failed to ensure adequate staffing to answer call lights timely and to provide scheduled baths, with numerous prolonged call light wait times and documented staffing shortages on multiple days.
Report Facts
residents reviewed for medication administration: 3
residents reviewed for call light response: 3
facility units: 100
Inspection Report — Jun 27, 2024
Routine
Date: Jun 27, 2024
Visit Reason
MDH assisted living licensing survey.
Findings
Five correction orders were issued addressing medication self-administration, baseline/admission care planning, treatment and monitoring including wound care and vital signs, respiratory/oxygen orders, and medication administration errors. No fines are stated in the document.
Deficiencies (5)
F0554 Allow residents to self-administer drugs if determined clinically appropriate: This Minnesota requirement is not met as evidenced by the facility failed to assess and determine safety for 1 of 1 resident (R3) reviewed for self-administration of medication.
F0655 Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted: This Minnesota requirement is not met as evidenced by the facility failed to develop a baseline care plan for 2 of 3 residents (R1, R3) reviewed for wounds, pain, and respiratory concerns.
F0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals: This Minnesota requirement is not met as evidenced by the facility failed to assess and monitor 2 of 3 residents (R1, R3) reviewed for monitoring, including incomplete wound assessments and missing vital sign documentation.
F0695 Provide safe and appropriate respiratory care for a resident when needed: This Minnesota requirement is not met as evidenced by the facility failed to properly assess and obtain orders for oxygen for 1 of 1 resident (R1) receiving oxygen therapy.
F0760 Ensure that residents are free from significant medication errors: This Minnesota requirement is not met as evidenced by the facility failed to obtain a blood pressure reading prior to administering Metoprolol for 1 of 1 resident (R3), after which the resident became hypotensive and fell.
Report Facts
residents reviewed for self-administration: 1
residents reviewed for baseline care plans: 2
residents reviewed for monitoring: 2
residents receiving oxygen referenced: 1
residents reviewed for medication administration: 1
Inspection Report — May 15, 2024
Routine
Date: May 15, 2024
Visit Reason
MDH assisted living licensing survey
Findings
Survey identified 22 correction orders addressing medication management and storage, wound care and infection prevention, nutrition and snacks, dialysis coordination, staff competencies, safety/supervision (smoking and walker), CLIA waiver, and vaccination processes.
Deficiencies (22)
F0554 Allow residents to self-administer drugs if determined clinically appropriate: The facility failed to ensure a resident (R352) was assessed for safe self-administration of a nebulized medication; staff left the resident while medication aerosolized and the resident was not inhaling.
F0577 Allow residents to easily view the nursing home's survey results and communicate with advocate agencies: The facility failed to ensure residents had access to survey results and plans of correction; the binder in the lobby lacked signage and was missing survey/complaint reports for multiple years.
F0610 Respond appropriately to all alleged violations: The facility failed to ensure incidents of potential abuse were thoroughly investigated and records maintained for residents R2 and R101; investigations lacked documentation of staff and resident interviews and required records.
F0641 Ensure each resident receives an accurate assessment: The facility miscoded Minimum Data Set items (examples: R27's weight/labelling of antibiotic use; R47's discharge status), resulting in inaccurate resident assessments.
F0655 Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted: Baseline care plans for newly admitted residents (R352, R353) were incomplete or lacked specific interventions (pain, oxygen use, ADLs) to meet immediate needs.
F0657 Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals: The facility failed to ensure timely quarterly care conferences and complete care plan review for R37 (no documented care conference since January).
F0660 Plan the resident's discharge to meet the resident's goals and needs: The facility failed to provide ongoing, comprehensive discharge planning for R37; relocation services stalled and coordination with county/relocation resources was inadequate.
F0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason: The facility failed to implement communication interventions for R2 (hearing impairment), limiting the resident's ability to participate in activities and causing social isolation.
F0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals: The facility failed to comprehensively assess and monitor developed skin conditions and non-pressure wounds (R353, R37), and nursing staff did not adequately cleanse a surgical wound prior to dressing changes (R30).
F0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents: The facility failed to provide required supervision while smoking for R42 despite that requirement in the care plan/Kardex, and failed to promptly provide/repair a safe walker for R37.
F0692 Provide enough food/fluids to maintain a resident's health: Resident R27 did not receive ordered between-meal deli sandwich supplements and double portions per diet orders; dietary and nursing processes failed to ensure supplements were delivered and documented.
F0698 Provide safe, appropriate dialysis care/services for a resident who requires such services: The facility failed to consistently perform and document post-dialysis access-site monitoring and post-dialysis assessments, did not reliably coordinate/obtain paperwork from the dialysis clinic, and lacked a signed dialysis services care coordination agreement.
F0726 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: The facility lacked documented competency verification/return-demonstration for wound care for licensed staff (RN-D) and had no checklist requirement for agency/licensed staff skills.
F0757 Ensure each resident’s drug regimen must be free from unnecessary drugs: PRN opioid (oxycodone) administrations for R352 lacked documented assessment rationale and lacked documentation that non-pharmacologic interventions were attempted prior to giving narcotic doses.
F0759 Ensure medication error rates are not 5 percent or greater: Observation and record review identified medication practice errors (example: attempt to give R11 morning medications before breakfast), contributing to a reported medication error rate in the record.
F0761 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: The medication refrigerator lacked a thermometer and temperature log; items were frozen and insulin pens were covered in ice crystals, risking reduced efficacy.
F0770 Provide timely, quality laboratory services/tests to meet the needs of residents: The facility's posted CLIA waiver was expired and there was not evidence of a current valid waiver for point-of-care testing.
F0806 Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences: Provider ordered a regular diet for R2 (4/23/24) per resident preference, but nursing failed to transcribe the order and the diet was not changed.
F0809 Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests: The facility did not provide consistent nutrient/ calorie substantive bedtime snacks to residents and staff/dietary lacked a reliable process to distribute evening/bedtime snacks.
F0880 Provide and implement an infection prevention and control program: The IPC program lacked accurate outcome and process surveillance (in-house infections misclassified, missing audits), and the facility's water management/Legionella program had no facility-specific diagrams, control limits or monitoring documentation.
F0883 Develop and implement policies and procedures for flu and pneumonia vaccinations: Residents R43 and R23 had no documented seasonal influenza vaccination in the medical record despite signed consents or indication they consented; the vaccination documentation process was deficient.
F0887 Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status: Resident R43 signed consent for COVID-19 vaccination but there was no documentation the vaccine was administered.
Report Facts
facility_resident_count_mentioned: 45
medication_error_rate_percent: 5.88
Inspection Report — Apr 8, 2024
Routine
Date: Apr 8, 2024
Visit Reason
MDH assisted living licensing survey.
Findings
Survey found the facility failed to ensure monitoring and treatment according to physician orders for a resident's hypertension. One correction order was issued addressing failure to provide appropriate treatment and monitoring.
Deficiencies (1)
F0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals: The facility failed to ensure monitoring and treatment of a resident's hypertension per physician orders; required blood pressure monitoring was not consistently performed.
Inspection Report — Feb 13, 2024
Routine
Date: Feb 13, 2024
Visit Reason
MDH assisted living licensing survey.
Findings
1 correction order was issued addressing pest control related to mice observed in multiple areas of the facility.
Deficiencies (1)
F0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests: The facility failed to ensure adequate pest control as evidenced by surveyors observing mice in multiple locations and resident reports of mice.
Inspection Report — Feb 2, 2024
Routine
Date: Feb 2, 2024
Visit Reason
MDH assisted living licensing survey
Findings
Survey identified failures in behavioral health care planning and staff competencies. Two correction orders were issued addressing (1) lack of a comprehensive, person-centered behavioral health care plan for a resident with alcohol/substance use disorder and related safety risks, and (2) insufficient staff training/competencies to manage behavioral health and substance use disorders.
Deficiencies (2)
F0740 Ensure each resident must receive and the facility must provide necessary behavioral health care and services: The facility failed to develop a comprehensive, person-centered care plan with appropriate services, treatments, prevention interventions, and reevaluation for a resident with substance use disorder; the resident had alcohol in his room, repeated intoxication, and falls related to alcohol use.
F0741 Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents: Staff lacked appropriate training and competencies to respond to active substance use disorder and history of trauma (examples include multiple nursing and direct care staff unaware of withdrawal protocols, monitoring, or individualized interventions).
Inspection Report — Jan 25, 2024
Routine
Date: Jan 25, 2024
Visit Reason
MDH assisted living licensing survey.
Findings
One correction order was issued for failure to ensure meals were provided in the correct form and to follow dietary/meal ticket procedures; the citation involved an incident where a resident who was NPO received a regular textured meal that resulted in choking and death, and the deficient practice was cited at past non-compliance after corrective actions were implemented.
Deficiencies (1)
F0805 Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs: This Minnesota requirement is not met as evidenced by the facility's failure to follow dietary orders for 1 of 3 residents reviewed (R1), who was NPO but received a regular textured meal on 1/23/24 which led to choking, cardiopulmonary resuscitation, and death; staff did not verify the resident's diet or meal ticket.
Report Facts
residents_reviewed_for_diet_modifications: 3
residents_currently_NPO: 0
Inspection Report — Jun 7, 2023
Routine
Date: Jun 7, 2023
Visit Reason
MDH assisted living licensing survey.
Findings
The survey identified a failure to protect residents from abuse (2 of 4 residents); one correction order was issued addressing resident-to-resident abuse and inadequate implementation of care plans. No fines were stated.
Deficiencies (1)
F0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect: This Minnesota requirement is not met as evidenced by the facility failing to ensure residents were free from abuse for 2 of 4 residents when R1 hit R2 and held R2 on the ground in the elevator, and care plan interventions were not implemented to keep them apart.
Report Facts
residents affected: 2
residents reviewed: 4
Inspection Report — Mar 8, 2023
Routine
Date: Mar 8, 2023
Visit Reason
MDH assisted living licensing survey.
Findings
The licensing survey resulted in 2 correction orders addressing failures in bathing/grooming and failures to assess and treat wounds/skin. No fines are stated in the document.
Deficiencies (2)
0677 Provide care and assistance to perform activities of daily living for any resident who is unable: This Minnesota requirement is not met as evidenced by the facility failing to ensure bathing and grooming were completed for 1 of 3 residents reviewed (R4), including missed showers and unshaved facial hair noted on observation.
0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals: This Minnesota requirement is not met as evidenced by failure to assess and complete appropriate wound care and lack of weekly skin assessments for residents (R1, R4), including an unassessed open area on R1.
Report Facts
residents reviewed for activities of daily living: 3
residents reviewed for wounds: 2
residents reviewed for skin: 2
Inspection Report — Feb 23, 2023
Routine
Date: Feb 23, 2023
Visit Reason
MDH assisted living licensing survey.
Findings
The survey identified 7 correction orders addressing resident dignity and rights, care planning, activities of daily living (hygiene and grooming), fall prevention, nutrition and swallowing, pain management, and the resident environment/housekeeping.
Deficiencies (7)
F0550 Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights: This Minnesota requirement is not met as evidenced by the facility's failure to comprehensively identify and address a resident's dignity needs (R2), including repeated observations of R2 being left unclothed, poor grooming (long toenails, untrimmed facial hair), and staff actions that embarrassed or demeaned the resident.
F0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured: This Minnesota requirement is not met as evidenced by R2's care plan lacking person-centered interventions for bladder incontinence and communication needs (no alternate communication tools specified and incomplete SPECIFY REQ for incontinence checks).
F0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason: This Minnesota requirement is not met as evidenced by failure to monitor, assess, and intervene for long, thick toenails and facial hair growth for R2, documented missed hygiene days, and care that left R2 in pain from toenails.
F0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents: This Minnesota requirement is not met as evidenced by repeated falls for R2 since 11/17/22 (multiple witnessed and unwitnessed falls with injuries and hospitalizations) and lack of updated, effective fall-prevention interventions or re-evaluation of interventions.
F0692 Provide enough food/fluids to maintain a resident's health: This Minnesota requirement is not met as evidenced by failure to comprehensively assess, monitor, and re-evaluate R2's weight loss, swallowing/diet consistency and shellfish allergy, and failure to provide adaptive equipment or consistent prescribed mechanical-soft diet, contributing to significant weight loss.
F0697 Provide safe, appropriate pain management for a resident who requires such services: This Minnesota requirement is not met as evidenced by inconsistent/conflicting Tylenol orders over several months, lack of timely communication to the medical provider about R2's ongoing pain, and staff not escalating requests for additional pain medication after falls.
F0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public: This Minnesota requirement is not met as evidenced by R2's room and bathroom condition (dirt and items under the bed, dried urine and basin under bed, missing/malfunctioning doorknob and trim, damaged furniture, dried food in mini-fridge, and other cleanliness/repair issues).
Report Facts
weight_loss_lbs: 11
pain_rating: 7
days_hygiene_both_shifts: 15
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