Average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Chateau Girardeau during CMS and state inspections, most recent first.
Failure to obtain informed consent for psychotropic medications: Five residents with diagnoses including dementia, MDD, anxiety, and behavioral symptoms were started on multiple psychotropic medications, including antipsychotics, antidepressants, benzodiazepines, and other mood-related drugs, but the record lacked documentation that the residents and/or their representatives were informed in advance of the risks and benefits. An LPN stated psychotropic consents were known but not thought to be done at the facility, and the DON and Administrator said they expected informed consent to be obtained.
Inconsistent and missing code status documentation affected two residents. One resident had conflicting records showing both full code and DNR, while the resident and responsible party were confused about the correct status. Another resident had a paper chart code status sheet showing full code, but no code status order in the EMR and no status on the clinical dashboard; staff said they relied on the paper chart as the most accurate source.
Failure to issue SNF ABN when Medicare skilled services ended. Based on record review and interview, the facility did not provide the required SNF ABN for a resident whose Medicare-covered skilled services had ended and who remained in the facility. The Community Nurse Navigator said he/she was responsible for giving residents the SNF ABN and NOMNC forms and had missed the ABN for the resident.
Psychotropic medication management was deficient for multiple residents. One resident had aripiprazole ordered for dementia without an appropriate diagnosis, another resident had several psychotropic medications with no documented pharmacy recommendation for an appropriate diagnosis for trazodone and no documented GDRs for multiple meds, and a third resident had mirtazapine without an appropriate diagnosis plus a PRN lorazepam order with no stop date. Staff interviews confirmed the resident had not had recent behaviors, and the DON and Administrator stated psychotropic meds should have an appropriate diagnosis and PRN orders should have a 14-day stop date.
Late Comprehensive MDS Assessments: The facility failed to complete required comprehensive MDS assessments within the mandated timeframe for three residents. Records showed each resident had quarterly MDSs completed, but no comprehensive MDS was completed within 366 days of the prior comprehensive assessment. The Administrator expected timely MDS completion, and the MDS Coordinator stated he/she was new, still learning the process, and knew some assessments had been missed or completed late.
The facility failed to complete a significant change MDS for a resident after hospice was elected. The resident had dementia with anxiety and agitation and COPD, and although a quarterly MDS was completed, the required SCSA was not completed within the required timeframe. The DON and Administrator said MDSs should be timely and reflect the resident’s condition, while the MDS Coordinator said he/she was new to the role, still learning the requirements, and knew some MDSs had been missed or done late.
Failure to follow physician orders and obtain catheter orders: one resident with COPD and respiratory failure had a daily weight order, but weights were missed repeatedly over several months while staff used assignment sheets and paper lists to track weights and nurses charted the results. Another resident with a urinary catheter had UTI, pseudomonas, and BPH, but the chart had no catheter or catheter-care order even though the baseline care plan documented the catheter and the DON said such orders were expected.
Failure to use EBP and proper hand hygiene during resident care: Two residents with indwelling urinary catheters and one with MDRO-related risk factors were observed during high-contact care without consistent gown use, glove changes, or hand hygiene. An LPN and CMT provided incontinent and catheter care to one resident without gowns and with missed glove changes and hand hygiene, and a CNA provided catheter care and dressing assistance to another resident while handling soiled items and the resident’s clothing with bare hands without hand hygiene. Staff interviews and facility policy confirmed that gowns, gloves, and hand hygiene were required during these care activities.
A resident with a urinary catheter was observed multiple times in common areas with the catheter drainage bag uncovered, compromising their dignity. Staff interviews confirmed the expectation for the bag to be covered, yet it was not, indicating a failure to maintain the resident's dignity.
The facility failed to provide written notification to two residents and/or their representatives about their transfers to a hospital. An LPN indicated that nurses were responsible for completing transfer paperwork, but documentation was missing. The Administrator expected proper forms to be filled out and given to residents or their representatives during transfers.
The facility failed to inform two residents and/or their legal representatives of the bed hold policy during hospital transfers. An LPN indicated that nurses were responsible for completing and distributing the necessary paperwork, while the Administrator expected these forms to be provided at the time of transfer.
The facility failed to provide an RN for eight consecutive hours per day, seven days a week, as required. The facility's assessment required an RN during both day and night shifts, but staffing data showed multiple days with no RN hours. The Administrator acknowledged the absence of an RN, explaining that an LPN filled the position after an RN quit, and an RN was only available by phone on weekends.
The facility exceeded the acceptable medication error rate due to improper insulin administration for two residents. Insulin pens were not primed before each use, contrary to the manufacturer's instructions and facility policy. Interviews revealed a misunderstanding among nursing staff regarding the priming procedure, contributing to the errors.
The facility failed to maintain proper infection control practices during catheter and gastrostomy tube care, and while delivering meal trays. Staff did not perform hand hygiene after touching contaminated surfaces or between tasks, contrary to facility policies. A CNA did not follow hand hygiene protocols during catheter care, and an LPN did not wear a gown during gastrostomy tube care, despite Enhanced Barrier Precautions (EBP) requirements.
The facility failed to provide the required twelve hours of in-service education per year for CNAs, as evidenced by CNA F's record showing only seven hours of training completed. The facility's policy mandates annual in-services of no less than twelve hours, but the Administrator admitted that not all education provided by the DON was documented, resulting in the deficiency.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to inform residents and/or their responsible parties, in advance, of the risks and benefits of proposed psychotropic medications before starting treatment for five sampled residents. The facility policy titled, Informed Consent for Treatment, stated that informed consent must be obtained prior to initiating treatment, except in emergencies, and documented in the medical record, including the nature and purpose of the treatment, expected benefits and potential risks, alternatives, and the option to refuse treatment. Resident #7 had diagnoses of unspecified dementia and anxiety disorder and orders for aripiprazole and sertraline, but there was no documentation of consent or education regarding risks and benefits for either medication. Resident #8 had diagnoses of major depressive disorder and dementia with psychotic disturbance and orders for Cymbalta, Effexor XR, lamotrigine, mirtazapine, trazodone, and Vraylar, with no documentation of consent or education for those medications. Resident #38 had diagnoses including cerebral infarction, falls, dementia with behavioral disturbance, sedative/hypnotic/anxiolytic dependence, anxiety disorder, MDD, and Alzheimer's disease, and had orders for clonazepam, escitalopram, lorazepam, and Seroquel without documentation of consent or education. Resident #55 had diagnoses of unspecified dementia with mood disturbance, anxiety, agitation, and insomnia, and had orders for Cymbalta, lorazepam, mirtazapine, morphine sulfate, brexpiprazole, and trazodone without documentation of consent or education. Resident #66 had diagnoses of MDD, anxiety, and depression and an order for duloxetine, with no documentation of consent or education. During interviews, an LPN said he/she knew about psychotropic medication consents but did not think they were done at the facility, and the Administrator and DON said they expected residents and/or their representatives to be informed of risks and benefits and to have informed consent for psychotropic medications.
Inconsistent and Missing Code Status Documentation
Penalty
Summary
The facility failed to initiate a code status order for one resident and failed to ensure that another resident’s code status was documented consistently throughout the medical record. For Resident #24, the face sheet and physician order sheet showed full code status, but the resident also had a DNR form signed by the resident’s responsible party and the physician. During interviews, the resident was confused and did not know what the code status should be, and the responsible party/spouse was also confused about the resident’s code status. For Resident #49, the medical record showed a paper chart code status sheet indicating full code, but there was no code status order in the electronic medical record and no code status documented on the clinical dashboard. Staff interviews showed that nurses relied on the paper chart front sheet and chart stickers to identify code status, and the DON stated staff would be expected to look at the paper chart because it was most accurate. The DON also stated the nurse completing admission was responsible for obtaining a code status order or the nurse on duty when the code status changed.
Failure to Issue SNF ABN When Medicare Skilled Services Ended
Penalty
Summary
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Based on interview and record review, the facility failed to issue a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when a resident's Medicare-covered services had ended for 1 resident out of 3 sampled residents. Review of the resident's Notice of Medicare Non-Coverage showed the resident was discharged from skilled services and remained in the facility, but the facility did not issue the SNF ABN. The facility policy stated that an ABN must be issued before services are provided when services are expected to be denied as not reasonable and necessary under Medicare guidelines. During interview, the Community Nurse Navigator stated he/she was responsible for giving residents the SNF ABN and NOMNC forms and said he/she just missed the SNF ABN for the resident. The Administrator stated the appropriate SNF ABN and NOMNC forms should be given to the resident or representative prior to discharge from Medicare skilled services in a timely manner.
Psychotropic Medication Orders Lacked Appropriate Diagnoses, PRN Limits, and GDRs
Penalty
Summary
The facility failed to have an appropriate diagnosis for psychotropic medications for three residents, failed to limit a PRN psychotropic medication order to 14 days for one resident, and failed to attempt gradual dose reductions for one resident. The deficiency involved review of facility policy, resident records, MDS assessments, and interviews with nursing and administrative staff. The facility policy required psychotropic medications to be tied to a specific diagnosed and documented condition, required GDRs unless clinically contraindicated, and limited PRN psychotropic orders to 14 days unless the prescriber documented a rationale for extending use. For one resident with diagnoses of unspecified dementia and anxiety disorder, the record showed an order for aripiprazole 15 mg daily related to dementia, but no appropriate diagnosis for the medication. The MD later stated dementia was not an appropriate diagnosis for aripiprazole and that the diagnosis should be mood disorder. For another resident with diagnoses including MDD and dementia with psychotic disturbance, the record showed multiple psychotropic medications, including Cymbalta, Effexor XR, lamotrigine, mirtazapine, trazodone, and Vraylar. The record did not contain a pharmacy recommendation for an appropriate diagnosis for trazodone, and there were no documented pharmacy recommendations for GDRs for Cymbalta, mirtazapine, lamotrigine, trazodone, and Vraylar. The quarterly MDS showed intact cognition, routine use of antipsychotic, antidepressant, and hypnotic medications, and that GDR was not attempted and not documented as contraindicated. For a third resident with multiple dementia-related diagnoses, the record showed lorazepam concentrate ordered PRN every four hours for anxiety with no stop date and mirtazapine ordered at bedtime for agitation. There was no appropriate diagnosis for mirtazapine and no pharmacy recommendations regarding a stop date for the PRN lorazepam or an appropriate diagnosis for mirtazapine. Nursing staff stated the resident had not had behaviors recently and had not had behaviors in the last couple of months. The Administrator and DON stated they would expect psychotropic medications to have an appropriate diagnosis and PRN psychotropic medications to have a 14-day stop date.
Late Comprehensive MDS Assessments
Penalty
Summary
The facility failed to complete comprehensive MDS assessments within the required time frames for three residents out of a sample of 14. For Resident #8, the record showed a comprehensive annual MDS with an ARD of 08/17/24 and completion on 08/26/24, followed by quarterly assessments, but no comprehensive MDS was completed within 366 days of the last comprehensive assessment. For Resident #38, the record showed a comprehensive annual MDS with an ARD of 12/15/24 and completion on 12/18/24, followed by quarterly assessments, but no comprehensive MDS was completed within 366 days of the last comprehensive assessment. For Resident #55, the record showed a comprehensive admission MDS with an ARD of 08/26/24 and completion on 08/29/24, followed by quarterly assessments, but no comprehensive MDS was completed within 366 days of the last comprehensive assessment. The facility policy required assessments to be completed and submitted according to federal and state timeframes, and the RAI Manual required the next comprehensive assessment within 366 days of the prior comprehensive assessment. During interview, the Administrator said MDS assessments were expected to be done timely and reflect the resident's current condition, and the MDS Coordinator said he/she was new to the job, still learning the requirements and computer system, and knew some MDS assessments had been missed recently or completed late.
Failure to Complete Significant Change MDS After Hospice Election
Penalty
Summary
The facility failed to complete a comprehensive MDS assessment after a significant change in condition for one resident who elected hospice services. The resident was admitted on 08/20/24 and had diagnoses of moderate unspecified dementia with anxiety, moderate unspecified dementia with agitation, and COPD. An order to admit to hospice was entered on 02/04/26, and a quarterly MDS was completed on 03/01/26, but no significant change in status assessment was completed within 14 days of the hospice admission. Facility policy required assessments to be submitted according to federal and state guidelines, and the RAI Manual required a significant change in status assessment when a resident elects the hospice benefit. During interviews, the Administrator and DON stated they would expect MDS assessments to be completed timely and to reflect the resident’s condition at the time of assessment. The MDS Coordinator stated he/she was new to the job, was still learning the requirements and timeframes, had never done the job before, had never used the facility computer system before, and knew some MDS assessments had been missed recently or completed late.
Failure to Follow Weight Orders and Obtain Catheter Orders
Penalty
Summary
The facility failed to follow physician orders for one resident who had COPD and respiratory failure. Resident #22 had an order for daily weights, but the record showed multiple missed weights across October 2025 through February 2026, including missed weights on several days in October, all of November, most of December, most of January, and most of February. Staff interviews showed that both CNAs and nurses were involved in obtaining weights, with weights written on assignment sheets or a paper list and then charted by nurses, and an RN stated the resident was a daily weight and did not refuse to be weighed. The facility also failed to obtain urinary catheter orders for another resident. Resident #67 was admitted with UTI, pseudomonas, and BPH, and the baseline care plan documented that the resident had a urinary catheter, but the medical record contained no order for a urinary catheter and no order for catheter care. A progress note showed a fax was sent to the urologist’s office for urinary catheter care, and the resident stated the catheter had been inserted before coming to the facility. The Administrator/DON stated they would expect an order for a urinary catheter and catheter care for all residents with urinary catheters, and the DON said the admitting nurse was responsible for getting urinary catheter orders from the physician.
Failure to Use Enhanced Barrier Precautions and Proper Hand Hygiene During Resident Care
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) for two residents who had conditions requiring EBP. Resident #24 had an order dated 04/08/26 to ensure EBP was being utilized with direct contact care. During observation of transfer and incontinent and urinary catheter care, LPN H and CMT D entered the room, performed hand hygiene, and put on gloves but did not put on gowns. They assisted the resident with transfer to the bed, removed pants and a brief soiled with fecal matter, and did not change gloves or perform hand hygiene. CMT D cleaned the catheter tubing and wiped toward the insertion site instead of away, and neither staff member changed gloves or performed hand hygiene during the care. The resident was then turned, buttocks were cleaned, gloves were changed, and hand hygiene was performed before staff exited the room. Resident #67 had diagnoses of UTI and pseudomonas and an order dated 04/08/26 to ensure EBP was being utilized with direct contact care. During observation of urinary catheter care, CNA F put on a gown, performed hand hygiene, and put on gloves before care. After catheter care, CNA F removed the gown, performed hand hygiene, changed gloves, dumped soiled water from the basin into the resident's toilet, and again performed hand hygiene and changed gloves. CNA F then threaded the urinary catheter bag through the resident's underwear and pant leg, pulled the resident's underwear and pants up to the thighs, removed gloves, and performed hand hygiene. CNA F assisted the resident to stand, placed the catheter bag into a privacy bag on the walker, adjusted the resident's clothing with bare hands without hand hygiene, assisted the resident to sit in the recliner with bare hands, gathered used sheets and towels into a laundry bag with bare hands, and picked up the dirty laundry bag with bare hands after hand hygiene. Facility staff interviews confirmed the expected use of gowns and gloves for residents on EBP during high-contact care and the need for hand hygiene before and after incontinent care and when moving from dirty to clean tasks. The facility policy stated that EBP applies to residents with MDRO colonization, indwelling medical devices, chronic wounds, and non-intact skin, and that staff must wear gown and gloves during high-contact care activities and perform hand hygiene after glove removal. The catheter care policy also required standard precautions and PPE as needed during urinary catheter care.
Failure to Cover Catheter Drainage Bag with Dignity Bag
Penalty
Summary
The facility failed to maintain the dignity of a resident by not covering the resident's urinary catheter drainage bag with a dignity bag. This deficiency was observed in one resident out of two sampled residents, with the facility census being 51. The resident, who was admitted with a diagnosis of acute cystitis with hematuria and had a urinary catheter present upon admission, was observed multiple times in both the dining and common rooms with the catheter drainage bag hanging from the bottom of the wheelchair, partially filled with yellow urine, and not covered with a dignity bag. Interviews with facility staff, including a CNA, an LPN, and the Director of Nursing, confirmed the expectation that a catheter drainage bag should be covered with a dignity bag to protect the resident's privacy and dignity. Despite this expectation, the observations indicated that the resident's dignity was not maintained as the catheter drainage bag was left uncovered in common areas.
Failure to Notify Residents of Hospital Transfers
Penalty
Summary
The facility failed to notify two residents and/or their representatives in writing about their transfers to a hospital, which is a requirement for proper communication and documentation. Resident #2 was transferred to the hospital on December 14, 2024, and readmitted to the facility later, but there was no documentation indicating that the resident or their representative was informed in writing about the transfer. Similarly, Resident #35 was transferred to the hospital on October 18, 2024, and readmitted to the facility, yet there was no written notification provided to the resident or their representative regarding the transfer. During interviews, an LPN stated that nurses were responsible for completing transfer paperwork and providing copies to the resident and for the resident's chart. The Administrator expected that the appropriate forms would be filled out and given to the resident or their representatives during such transfers.
Failure to Inform Residents of Bed Hold Policy
Penalty
Summary
The facility failed to inform two residents and/or their legal representatives of the bed hold policy at the time of their transfer to the hospital. Resident #2 was transferred to the hospital on December 14, 2024, and readmitted to the facility on an unspecified date, with no documentation indicating that the resident or their representative was informed in writing of the bed hold policy. Similarly, Resident #35 was transferred to the hospital on October 18, 2024, and readmitted on an unspecified date, also without documentation of being informed of the bed hold policy. During interviews, an LPN stated that nurses were responsible for completing the transfer/bed hold paperwork, making copies, and providing one to the resident and placing another in the resident's chart. The Administrator expressed an expectation that the appropriate forms would be filled out and given to the resident or their representative upon transfer to the hospital.
Failure to Provide RN Coverage for Required Hours
Penalty
Summary
The facility failed to provide a Registered Nurse (RN) for eight consecutive hours per day, seven days a week, which is a requirement for long-term care facilities. This deficiency was identified through interviews and record reviews, revealing that the facility did not have a policy for RN coverage. The facility's assessment indicated the need for at least one RN during both day and night shifts. However, the CMS Payroll Based Journal staffing data showed multiple days across July, August, and September 2024, where no RN hours were recorded. Additionally, nursing schedules and staffing sheets from October 2024 to January 2025 indicated that no RN worked on ten specific days out of 93 days reviewed. During an interview, the Administrator acknowledged the absence of an RN on duty for the required hours, explaining that an RN had been scheduled for each day shift, but the position was filled by a Licensed Practical Nurse (LPN) after an RN quit. Although an RN was on call every weekend, they were not always present in the building and were only available by phone. The Administrator was aware of the requirement for an RN to be on duty at least eight hours a day, seven days a week, but the facility failed to meet this standard.
Medication Error Rate Exceeds Acceptable Threshold Due to Insulin Administration Errors
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, resulting in a rate of 5.56% due to errors in insulin administration for two residents. The facility's policy on administering medications, including insulin pens, was not followed correctly. Specifically, the policy required that insulin pens be primed before each use to ensure accurate dosing, but this step was not performed by the nursing staff during medication administration. For Resident #2, an LPN administered 20 units of Humalog insulin without priming the KwikPen as per the manufacturer's instructions. Similarly, for Resident #26, another LPN administered 10 units of insulin aspart without priming the FlexPen. Interviews with the nursing staff revealed a misunderstanding of the priming procedure, as one LPN believed priming was only necessary when the pen was brand new. The Director of Nursing confirmed that all insulin pens should be primed before each dose to maintain a medication error rate below five percent.
Infection Control Deficiencies in Catheter and Gastrostomy Tube Care
Penalty
Summary
The facility failed to maintain proper infection control practices during catheter care for one resident and gastrostomy tube care for another resident, as well as during meal tray delivery. Observations revealed that staff did not perform hand hygiene after touching potentially contaminated surfaces, such as trash can lids, before delivering meal trays to residents. This was observed multiple times over two days, with staff failing to wash or sanitize their hands between tasks, despite the facility's policy requiring hand hygiene in such situations. During catheter care for a resident, staff did not adhere to proper hand hygiene protocols. A CNA was observed not performing hand hygiene between glove changes while providing catheter care, and exited the resident's room without removing the gown, contrary to the facility's Enhanced Barrier Precautions (EBP) policy. The CNA acknowledged receiving training on infection control and EBP but did not follow the procedures during the observed care. In another instance, a Licensed Practical Nurse (LPN) did not wear a gown while providing gastrostomy tube care to a resident, despite the EBP signage indicating the need for such precautions. The LPN's actions were inconsistent with the facility's policy that requires staff to wear EBP when caring for residents with indwelling devices. Interviews with staff, including the Director of Nursing, confirmed the expectation for adherence to infection control practices, which were not followed in these cases.
Inadequate In-Service Training for CNA
Penalty
Summary
The facility failed to ensure that Certified Nurse Assistants (CNAs) received the required twelve hours of in-service education per year, as mandated by their policy. This deficiency was identified through the review of CNA F's in-service record, which showed that CNA F, hired on 07/05/23, had only completed seven hours of in-service training for the period from July 2023 through July 2024. The facility's policy, revised in August 2022, requires all personnel to participate in regular in-service education, with annual in-services totaling no less than twelve hours per employment year. The Administrator acknowledged during an interview that although the Director of Nursing provided education more frequently than monthly, not all of the education sessions were documented, leading to the shortfall in recorded training hours for CNA F.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Cape Girardeau
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Life Care Center Of Cape Girardeau | 0.9 mi | ★★★★★ | 1 | 0 |
| Lutheran Home, The | 1 mi | ★★★★★ | 0 | 0 |
| Fountainbleau Lodge | 2.1 mi | ★★★★★ | 0 | 0 |
| Ratliff Care Center | 2.4 mi | ★★★★★ | 0 | 0 |
| Heartland Care And Rehabilitation Center | 2.9 mi | ★★★★★ | 4 | 0 |
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