Above average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
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 Fountainbleau Lodge during CMS and state inspections, most recent first.
Food was not consistently served at safe, appetizing temperatures. Multiple residents said meals were often cold, especially when eaten in their rooms, and one resident reported cold hot dogs and a cold grilled cheese sandwich with unmelted cheese. An observed test tray showed a grilled pork chop at 112°F and stuffing at 116°F, while the Dietary Manager, DON, and Administrator stated hot food should be served hot.
Incorrect MDS Medication Coding: The facility inaccurately coded the MDS for three residents by recording antipsychotic use based on diagnoses linked to medications rather than the actual drug class. Records showed one resident had alprazolam ordered with no antipsychotic, another had buspirone, sertraline, and a discontinued quetiapine order, and a third had venlafaxine with no antipsychotic order, yet each MDS reflected antipsychotic use.
Failure to follow EBP occurred for two residents during G-tube and wound care. An RN did not wear a gown or avoid leaning on the bed while providing G-tube care for a resident with an indwelling device, and during wound care for another resident, the RN did not change gloves or perform hand hygiene after removing a soiled dressing and continued handling clean supplies, cleaning the wound, applying treatment, and dressing the wound without changing gloves or hand hygiene.
The facility failed to maintain sanitary conditions in food handling, with staff not changing gloves or washing hands between tasks, and food items left uncovered and unlabeled. Observations showed staff touching various surfaces and food items without proper hygiene, increasing the risk of cross-contamination and food-borne illnesses. Interviews confirmed the lack of hand sanitizer in the dining room and improper food covering practices.
The facility failed to conduct required NA Registry checks for seven employees and did not complete CBC and EDL checks for one employee before their hire dates. This non-compliance was identified through interviews and record reviews, revealing a lapse in adherence to the facility's policies.
The facility failed to provide timely written notification to residents and their representatives regarding hospital transfers, affecting two residents within the sample and one outside. Despite verbal notifications being made, there was no documentation of written notices as required by the facility's policy. Interviews with staff revealed inconsistencies in following the notification process, with the Administrator acknowledging the expectation for compliance with regulations.
The facility failed to provide written notification of the bed hold policy to residents or their representatives during hospital transfers, as required by their policy. This deficiency was identified for two residents, with no documentation in their medical records indicating they were informed in writing. Interviews with staff revealed inconsistencies in implementing the policy, despite expectations for compliance.
A facility failed to include dialysis treatment in a resident's care plan, despite a physician's order for dialysis on specific days. The resident, with conditions such as hemiplegia and chronic kidney disease, required dialysis, but the care plan lacked this critical intervention. The facility's policy mandates comprehensive care plans, yet this was not followed, as acknowledged by the Administrator and DON.
The facility failed to maintain infection control practices during incontinent care for two residents, with CNAs not adhering to hand hygiene protocols and glove changes. Additionally, the facility did not implement a risk management process for Legionnaires' disease, with water temperature logs showing non-compliance with acceptable ranges and no interventions documented. Staff interviews revealed a lack of adherence to infection control policies, highlighting significant gaps in practice.
The facility failed to maintain an effective pest control program, as flies were observed in resident rooms, the dining room, and common areas, affecting three residents and potentially impacting all 29 residents. Interviews with residents and staff confirmed the persistent issue, despite the facility's policy requiring an ongoing pest control program.
A resident accessed an unlocked medication overflow cart, taking Gabapentin and Metoprolol, due to the facility's failure to secure the cart as per policy. The resident, experiencing pain, ingested six Gabapentin capsules. Staff interviews revealed the cart was expected to be locked, but it was not regularly checked, leading to the security breach.
Food Served at Improper Temperatures
Penalty
Summary
The facility failed to provide palatable, attractive food at safe and appetizing temperatures. The facility policy titled Food Preparation and Service, revised November 2022, addressed safe food handling practices and defined the danger zone as temperatures above 41°F and below 135°F, but it did not address holding or serving temperatures of food. During interviews, multiple residents said food was often served cold, especially when eaten in their rooms. One resident reported that hot dogs ordered on 09/01/25 were cold and that a grilled cheese sandwich ordered on 09/02/25 was cold with unmelted cheese. During an observation on 09/04/25, a test tray with a lid covering the food showed a grilled pork chop at 112°F and stuffing at 116°F. The Dietary Manager stated hot food should be at least 135°F when served, and the DON and Administrator stated they would expect hot food to be served hot.
Incorrect MDS Medication Coding
Penalty
Summary
The facility failed to accurately code the MDS for three residents out of a sample of 12. The facility policy stated that MDS assessments should be completed by qualified staff and should consistently reflect progress notes, plans of care, and resident observations and interviews. The RAI 3.0 User’s Manual stated that high-risk drug class medications must be coded according to pharmacological classification, not how they are being used. For Resident #3, the record showed diagnoses of dementia with anxiety and an order for alprazolam as needed for anxiety, with no antipsychotic medication ordered, yet the admission MDS coded the resident as receiving antipsychotic medications on a routine basis. For Resident #14, the record showed diagnoses including dementia, anxiety disorder, dysphagia, major depressive disorder, and unspecified psychosis, with orders for buspirone and sertraline and a discontinued order for quetiapine, yet the quarterly MDS coded the resident as receiving an antipsychotic medication seven out of seven days. For Resident #23, the record showed diagnoses of heart failure, anxiety disorder, depression, and dysphagia, with an order for venlafaxine and no antipsychotic medication ordered, yet the annual MDS coded the resident as receiving an antipsychotic medication seven out of seven days. During interview, the MDS Coordinator stated the MDS was incorrectly coded based on the residents’ diagnoses linked to the medications rather than the medication drug class, and the Administrator stated medications should be coded accurately on the MDS.
Failure to Follow Enhanced Barrier Precautions During G-tube and Wound Care
Penalty
Summary
The facility failed to maintain appropriate infection control practices for two residents who were on enhanced barrier precautions (EBP). Resident #6 had a G-tube, with orders to cleanse the site with soap and water, place a drain sponge at the insertion site daily and as needed, and use EBP related to the G-tube. The resident’s care plan also directed staff to follow the facility’s EBP policy for the duration of the stay or until the G-tube was discontinued. During observation of the G-tube dressing change and water flush, RN A did not put on a gown, leaned on the resident’s bed while removing the soiled dressing, cleaning around the G-tube, placing the new dressing, and putting a roll of tape into the resident’s drawer. Resident #35 had orders for daily care of both lower extremities and for wound care to the right calf, right foot, and left foot, with EBP signage posted on the door. During observation of wound care, RN A removed the soiled dressing from the left foot, did not change gloves or perform hand hygiene, and reached into the clean bag of dressing supplies. RN A then continued the wound care without changing gloves or performing hand hygiene, including cleaning the wound, applying the compounded antibiotic treatment, and applying the clean dressing. During interview, RN A stated that staff should wear gloves and a gown for EBP, and the Administrator and DON stated they would expect staff to wear gowns during high-contact care for a resident with a G-tube and to change gloves and perform hand hygiene after touching anything dirty.
Deficient Sanitary Practices in Food Handling
Penalty
Summary
The facility failed to maintain sanitary conditions in food storage and distribution, which increased the risk of cross-contamination and food-borne illnesses for all residents. Observations revealed that staff members wore gloves but did not change them or wash their hands between tasks, such as touching door handles, residents' plates, and utensils. There was a lack of hand sanitizer in the dining room, and staff did not sanitize or wash their hands between glove changes. Additionally, staff members handled food and utensils with bare hands, further contributing to unsanitary conditions. In the kitchen and dining areas, food items were found uncovered and unlabeled, including sliced tomatoes, onions, and a squeeze bottle of an unidentified red substance. Cooked bratwurst patties were left uncovered with a fly buzzing over them, and fruit cups were covered but not labeled. Interviews with staff, including the Maintenance Director, CNAs, and the Director of Nursing, confirmed the absence of hand sanitizer in the dining room and acknowledged the expectation for proper hand hygiene and food covering practices.
Failure to Conduct Pre-Employment Background Checks
Penalty
Summary
The facility failed to ensure that Nurse Aide (NA) Registry checks were completed prior to the employment start date for seven employees out of a sample of ten. Additionally, the facility's policy did not address checking the NA Registry for all employees prior to employment. The facility also failed to follow their policy to ensure the Criminal Background Check (CBC), Employee Disqualification List (EDL), or Family Care Safety Registry (FCSR) were completed prior to the employment date for one employee. This oversight was identified through interviews and record reviews. Specific instances of non-compliance included the failure to check the NA Registry for a Certified Medication Technician/Certified Nurse Aide, a housekeeper, two Licensed Practical Nurses, a Registered Nurse, and two dietary aides before their hire dates. Furthermore, the facility did not conduct the required CBC and EDL checks for a dietary aide. Interviews with the Director of Nursing and the Administrator revealed an expectation that these checks should be completed before employment, indicating a lapse in adherence to the facility's policies.
Failure to Notify Residents and Representatives of Hospital Transfers
Penalty
Summary
The facility failed to provide timely written notification to residents and their representatives regarding transfers to the hospital, as well as failing to notify the Office of the State Long-Term Care Ombudsman. This deficiency was identified for two residents within the sample and one resident outside the sample. The facility's policy requires that transfer/discharge notices be given as soon as practicable, especially in cases of emergency transfers due to urgent medical needs. However, there was no documentation in the medical records of the involved residents indicating that they or their representatives were notified in writing about the transfers. Interviews with facility staff revealed that while verbal notifications were made to families, the required written notifications were not consistently documented. A Licensed Practical Nurse (LPN) mentioned that a bed hold form is completed and families are called when a resident is hospitalized. The Social Services Designee stated that a letter is sent to the family within seven days, but there was no evidence of this process being followed in the cases reviewed. The Administrator acknowledged the expectation for notifications to be sent per regulation, indicating a lapse in adherence to the facility's policies and procedures.
Failure to Provide Written Bed Hold Policy Notification
Penalty
Summary
The facility failed to inform residents and/or their representatives in writing about the bed hold policy at the time of transfer to the hospital, as required by their own policy. This deficiency was identified for one resident within the sample and one resident outside the sample. The facility's policy, dated October 2022, mandates that residents or their representatives receive written information about the bed hold policy in advance of any transfer and at the time of transfer, or within 24 hours in case of an emergency. However, there was no documentation in the medical records of the two residents indicating that they or their representatives were informed in writing about the bed hold policy during their transfers to the hospital. Interviews with facility staff revealed inconsistencies in the implementation of the bed hold policy. An LPN stated that nursing staff complete a bed hold form for the family to sign and inform them verbally when a resident is hospitalized. The Social Services Designee mentioned that the nurse should fill out the Skilled Nursing Facility Holding Room policy and ensure the family is notified, followed by sending a letter within seven days. The Administrator expected the bed hold papers to be sent per regulations. Despite these procedures, the lack of documentation for the two residents indicates a failure to adhere to the facility's policy, resulting in the deficiency.
Failure to Implement Comprehensive Care Plan for Dialysis
Penalty
Summary
The facility failed to implement a comprehensive care plan with specific interventions to meet the needs of a resident, identified as Resident #26, who was part of a sample of 12 residents. The facility's policy on Comprehensive Person-Centered Care Plans, revised in March 2022, requires the interdisciplinary team to develop and implement a care plan that includes measurable objectives and timeframes, addressing the resident's highest practicable physical, mental, and psychosocial well-being. However, the care plan for Resident #26, last revised on 07/10/24, did not include interventions related to the resident's dialysis treatment, despite a physician's order dated 07/02/24 for dialysis on specific days. Resident #26 was admitted with diagnoses including hemiplegia and hemiparesis following a nontraumatic intracerebral hemorrhage, acute kidney disease, and chronic kidney disease. The resident required dialysis, as indicated by the physician's order, but this critical treatment was not addressed in the care plan. During an interview, the Administrator and Director of Nursing acknowledged that they would expect care plans to include treatments and any changes in orders or the plan of care, indicating a lapse in the facility's adherence to its own care planning policy.
Infection Control and Legionella Management Deficiencies
Penalty
Summary
The facility failed to maintain proper infection control practices during incontinent care for two residents, Resident #22 and Resident #24. Observations revealed that Certified Nurse Aides (CNAs) did not adhere to hand hygiene protocols, such as washing hands before and after resident contact, and changing gloves between soiled and clean tasks. For Resident #22, CNA I and CNA J were observed using the same gloves throughout the care process, including cleaning the resident's perineal area, handling soiled items, and applying cream, without washing hands or changing gloves. Similarly, for Resident #24, CNA K did not wash or sanitize hands before donning gloves, and continued to use the same gloves for multiple tasks, including moving a trash can, cleaning the resident, and handling clean items. The facility also failed to implement a risk management process specific to Legionnaires' disease, which could potentially affect all residents, staff, and visitors. The facility's water management program, part of the infection prevention and control program, was not effectively monitored or managed. The water temperature logs from April 2023 to July 2024 showed multiple instances where water temperatures were outside the acceptable range of 105-115 degrees Fahrenheit, with no documented interventions. The Maintenance Director was unaware of the need to check for Legionella, assuming that being on city water was sufficient, and was not informed of the correct temperature range until later. Interviews with the facility's staff, including the CNAs, Administrator, and Maintenance Director, indicated a lack of adherence to established infection control policies and procedures. The CNAs expressed an understanding of the need to change gloves and wash hands between tasks, yet their actions during care did not reflect this knowledge. The Administrator and Director of Nursing expected staff to follow proper procedures, but the observations and interviews highlighted significant gaps in practice. The Maintenance Director's lack of awareness regarding the water management program and appropriate temperature ranges further underscored the facility's deficiencies in infection prevention and control.
Deficiency in Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by multiple observations of flies in various areas of the facility. The facility's policy, revised in May 2008, mandates an ongoing pest control program to keep the building free of insects and rodents. However, observations over several days revealed flies landing on residents, their belongings, and in common areas such as the dining room and hallways. These observations affected three residents directly and had the potential to impact all residents in the facility, which had a census of 29. Interviews with residents and staff corroborated the presence of pests. A resident expressed frustration with the persistent fly problem, and another resident mentioned keeping a fly swatter in their room. An LPN acknowledged issues with flies and spiders, and the Administrator stated an expectation for the facility to be free of pests. Despite the facility's policy, the presence of flies in resident areas and common spaces indicates a deficiency in the pest control program.
Medication Cart Security Breach
Penalty
Summary
The facility failed to provide protective oversight when a medication overflow cart was left unlocked and unattended, allowing a resident to access and take medications. The incident involved a resident with a history of brain cancer, depression, anxiety, repeated falls, and other conditions, who was alert and oriented with no cognitive concerns. The resident accessed the cart, which was parked at the intersection of two hallways, and took two medication cards of Gabapentin and one card of Metoprolol to their room. The facility's policy required medication carts to be locked when not in use or out of the nurse's view, but it did not address the specific use and monitoring of the overflow medication cart. On the day of the incident, the cart was left unlocked, and the resident, experiencing pain and unable to take their as-needed medication, decided to check the cart. Finding it unlocked, the resident took the medications and ingested six Gabapentin capsules. Interviews with staff revealed that the overflow cart was expected to be locked at all times unless being accessed by a nurse. However, the cart was not checked regularly for being locked, and the responsibility for the keys was with a specific LPN. The incident highlighted a lapse in the facility's adherence to its medication security policy, leading to the resident's unauthorized access to medications.
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What surveyors actually found near you
We read the 116 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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) |
|---|---|---|---|---|
| Heartland Care And Rehabilitation Center | 1.1 mi | ★★★★★ | 4 | 0 |
| Chateau Girardeau | 2.1 mi | ★★★★★ | 0 | 0 |
| Life Care Center Of Cape Girardeau | 2.9 mi | ★★★★★ | 1 | 0 |
| Lutheran Home, The | 3.1 mi | ★★★★★ | 0 | 0 |
| Ratliff Care Center | 3.3 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.