Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 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.
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 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 | ★★★★★ | 7 | 0 |
| Ratliff Care Center | 2.4 mi | ★★★★★ | 0 | 0 |
| Heartland Care And Rehabilitation Center | 2.9 mi | ★★★★★ | 4 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.