Highland Chateau Health and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Highland Chateau Health and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Feb 13, 2026

  The facility failed to ensure appropriate interventions to prevent elopement for 1 of 3 residents (R1) who was assessed to be an elopement risk. This resulted in an Immediate Jeopardy (IJ) when R1 was able to leave the facility, get on a city bus where she was found three hours and 15 minutes later at the Mall of America (5.8 miles away). The immediate jeopardy began on 2/10/26 at approximately 2:30 p.m. when R1 was able to leave the facility after demonstrating exit seeking behaviors without appropriate individualized interventions to prevent elopement. The immediate jeopardy was identified on 2/13/26, and the administrator and director of nursing were notified of the immediate jeopardy at 2/13/26 at 4:10 p.m. […]

• Immediate jeopardy, isolatedF689Sep 19, 2025

  Based on observation, interview and document review, the facility failed to ensure smoking safety interventions were identified, implemented, and monitored for 1 of 1 resident (R29) reviewed who used oxygen and smoked. The facility also failed to provide adequate supervision to ensure oxygen was not taken into the designated smoking area, which resulted in an immediate jeopardy (IJ) when R29, who had oxygen present and was observed smoking and in close proximity to others who were smoking and present in the smoking patio, which posed a serious safety risk of fire or explosion and endangering R29 and others.The IJ began on 9/15/25 at 6:46 p.m., when R29 was observed on the outdoor smoking patio with a portal oxygen tank and in close proximity to other residents smoking. […]

• Immediate jeopardy, isolatedF600Mar 5, 2025

  Based on observation, interview, and record review the facility failed to protect the residents' rights to be free from neglect when the facility did not provide care, comfort, and safety. This resulted in immediate jeopardy (IJ) for 3 of 4 residents (R1, R2, R3) who experience mental anguish, and emotional distress when care and services were not provided to assist these dependent residents to get out of bed. In addition, the facility failed to provide care and services for R5 who was dependent on staff to get out of bed. The immediate jeopardy began on 2/28/25, when the facility failed to provide care, comfort, and safety. This resulted in mental anguish, and emotional distress when care and services were not provided to R1, R2, and R3 to get out of bed. […]

• Immediate jeopardy, isolatedF805Jan 25, 2024

  Based on interview and document review, the facility failed to follow dietary orders for a resident who was NPO (nothing by mouth) for 1 of 3 residents (R1) reviewed for diet modifications. This resulted in an immediate jeopardy (IJ) when R1 received a regular textured meal on [DATE], which caused R1 to choke, lose consciousness, require the Heimlich maneuver, cardiopulmonary resuscitation (CPR), and resulted in death. The facility immediately implemented corrective action so the deficient practice was issued at past non-compliance. The IJ began on [DATE], when R1 received a regular textured meal, which caused R1 to choke, lose consciousness, require the Heimlich maneuver, CPR, and died as a result of choking. […]

• Immediate jeopardy, isolatedF689Jul 9, 2021

  Based on interview and document review, the facility failed to comprehensively assess, reassess and develop interventions to minimize the risk of harm for 1 of 1 resident (R2) who was consuming alcohol in an unsafe manner. This resulted in an immediate jeopardy (IJ) situation for R2 who remained at risk of serious injury, impairment or death related to unsafe alcohol use in the community. The IJ began on 7/1/21, when R1 was observed to be alone in the street outside of the facility in a median area between two busy roads. R2 slid out of his wheelchair as he tried to get back to the facility. R2 was noted to be intoxicated. […]