Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Nursing Center during CMS and state inspections, most recent first.
Unsafe and Unclean Resident Environment: Surveyors observed a strong urine odor on the hall, holes and missing sheetrock in a resident room, and a shower room with dirty rags, scattered personal items, open toiletries, and dirt and grime on the tile and walls. Multiple resident rooms also had stained carpets with a musty odor, and a resident reported the wall and door damage had been present since moving in.
Inappropriate sexual contact and messaging with resident: A dietary aide exchanged sexual texts with a resident, sent an explicit genital photo, and made sexual comments and advances toward the resident. The resident had ESRD, hemiplegia, anxiety, depression, COPD, and DM2, used an electric wheelchair, and had no cognitive impairment on MDS. The resident also reported unwanted physical contact, while video review showed the resident and aide talking, a piece of paper placed on the resident’s chest area, and a hug.
Failure to Individualize Care Plans for PTSD and Dementia: The facility did not develop complete, person-centered care plans for residents with PTSD and dementia. Care plans for several residents failed to address diagnoses, resident-specific triggers, or individualized interventions, and one resident with PTSD stated that anger was a trigger. The MDS Coordinator said care plans should reflect individualized needs, while the DON, Administrator, and Social Worker stated the trauma assessments were broad and did not provide enough detail about residents’ trauma or triggers.
Failure to Provide Trauma-Informed Care for Residents with PTSD: The facility did not identify, assess, or document individualized trauma triggers and supportive interventions for three residents with PTSD. One resident’s assessment noted nightmares, avoidance, and hypervigilance but no trigger-based interventions, while two other residents had trauma assessments with no trauma details and care plans that focused mainly on psychotropic meds or general support rather than PTSD-related triggers. Staff, including the DON, MDS Coordinator, and social worker, stated they did not know the residents’ triggers and that the trauma assessments were too broad to guide individualized care.
Controlled medication count records were incomplete and inaccurate on multiple med carts. Nursing staff and CMTs failed to sign required narcotic count sheets for numerous shift-change opportunities, and one cart had a mismatch between the total card count sheet and the physical count. An CMT also forgot to add a resident's clonazepam to the count sheet when it arrived, and staff stated signatures should be completed on all lines at each shift change and the total count sheet updated when meds were added.
Infection control practices were not followed during medication pass, wound care, and suprapubic catheter care. A CMT did not perform hand hygiene before or after giving meds to three residents and handled tablets with a bare hand. An LPN providing wound care and a CNA providing catheter care both failed to wear the required gown under EBP, and the LPN also placed scissors and a marker into a pocket during wound care instead of keeping them clean.
Items were found stored on top of overbed light fixtures in three resident rooms, including a framed photo collage, a poster, a license plate, a framed picture, and stuffed animals. A CNA said some residents place items there, and the Administrator acknowledged that a couple of residents did this. The Administrator and DON stated items should not be placed on the light fixtures due to possible hazards.
CNA in-service training records did not show the required annual competencies for dementia care or abuse/neglect prevention, and did not document at least 12 hours of annual in-service education for three sampled CNAs. The DON said the facility tracked training on a spreadsheet and was unsure of the required annual hours and topics, while the Administrator said staff should receive at least 12 hours of in-service training that is dated and includes the length of each session.
The facility failed to provide a safe, clean, and homelike environment, affecting two residents and potentially impacting all residents. Observations revealed strong urine odors, unsanitary shower rooms, and dirty carpets in multiple rooms. Residents expressed dissatisfaction with the conditions, and the Housekeeping Manager admitted that carpet cleaning was not part of the regular cleaning rotation. The Administrator acknowledged the expectation for cleanliness and odor-free rooms.
The facility's pest control program failed to control a fly infestation, affecting residents' comfort and sleep. Observations showed flies in rooms, hallways, and common areas, with residents expressing frustration over the persistent issue. The facility's policy requires an ongoing pest control program, but the problem remained unresolved.
The facility did not follow its background screening policy for three employees, failing to conduct timely Criminal Background Checks (CBC) and Nurse Aide Registry verifications before their employment start dates. This lapse was confirmed by interviews with the Director of Nurses and the Administrator, who expected these checks to be completed upon hire.
Unsafe and Unclean Resident Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment. Observation and record review showed a strong urine odor on the 300 Hall on 02/09/26 and 02/10/26. In room [ROOM NUMBER], surveyors observed a three inch by three inch circular hole in the bathroom door, a three inch by four inch area of missing sheetrock with visible screws, and multiple areas of missing sheetrock on the wall beside the first bed. Resident #22 stated the holes had been there since moving in about a month earlier and that no one had come to fix them. Surveyors also observed the 300/400 Hall shower room with dirty rags, gloves, a razor, bottles of lotion, a stick of deodorant, and a watch scattered on and around a shower chair; opened bottles of shampoo and soap on the floor; an open cabinet with items scattered on the floor; an opened backpack and shoes on the floor; and dirt, grime, and a brown substance on the shower tile on the floor and walls. In addition, carpets in multiple resident rooms, including rooms 102, 103, 104, 105, 108, 110, 112, 116, 205, 208, 209, 210, 213, 214, 215, 301, 302, 304, 307, 310, 312, 401, 410, and 411, were observed to have dirt and stains with a musty odor. The Administrator stated she would expect the facility to be free from odors, the carpet to be free from stains and odors, the walls to be free from holes and scratches, and the shower rooms to be clean, organized, and free from dirt and grime.
Inappropriate sexual contact and messaging with resident
Penalty
Summary
The facility failed to ensure a resident was free from abuse when a dietary aide knowingly engaged in inappropriate sexual communication with the resident and sent an explicit sexual image. The resident had diagnoses including ESRD, morbid obesity, hemiplegia, intracranial injury with loss of consciousness, generalized anxiety, major depressive disorder, COPD, and type 2 diabetes, and the quarterly MDS showed no cognitive impairment. The resident also required assistance with personal care, used an electric wheelchair, and received hemodialysis. The resident reported that the dietary aide asked for the resident’s phone number, exchanged sexual text messages, asked for sexual acts, and sent a picture of his/her genitals. The resident also stated that the dietary aide told the resident not to tell anyone because he/she would lose his/her job. The resident said the texting and sexual comments upset him/her at times and that he/she later told staff about the situation. The resident also described two episodes of physical contact, including one where the dietary aide placed a piece of paper down the front of the resident’s outfit and another where the dietary aide put a hand under the resident’s clothing and tried to get between the resident’s legs. The facility’s investigation confirmed that the dietary aide and the resident exchanged sexual texts and that the dietary aide sent an explicit photo. The dietary aide stated that he/she continued texting after realizing the number belonged to the resident and said the photo was sent by mistake while using a dating app. The facility reviewed video footage from the area where the resident reported physical contact; the footage showed the resident and dietary aide talking, a piece of paper being placed on the resident’s chest area, and a hug, but did not show the specific touching described by the resident. The administrator, DON, and ADON reviewed the resident’s phone and recovered multiple sexual texts and the explicit image.
Failure to Individualize Care Plans for PTSD and Dementia
Penalty
Summary
The facility failed to implement complete, individualized care plans for residents with PTSD and dementia. Review of the records for Residents #3, #36, and #67 showed diagnoses of PTSD, but their care plans did not address PTSD, resident-specific triggers, or individualized interventions. Resident #3 also had diagnoses of major depressive disorder and schizoaffective disorder, yet the revised care plan only mentioned PTSD in relation to psychotropic medication use and did not include triggers or care interventions. Resident #36’s revised care plan likewise did not address PTSD or personalized triggers or interventions, and Resident #67’s care plan did not address PTSD, triggers, or interventions. Resident #8’s record showed a diagnosis of dementia, but the revised care plan did not address dementia or include personalized dementia care or interventions associated with the resident or diagnosis. During interview, the resident with PTSD stated that anger was a trigger. The MDS Coordinator stated that care plans should be person-centered and reflect diagnoses such as PTSD or dementia with individualized triggers and interventions. The Administrator, DON, and Social Worker stated that trauma assessments were completed and discussed with residents, but the Social Worker said the assessment was broad and did not provide enough information about the residents’ trauma or triggers, and she had not known she should be updating the care plan until recently.
Failure to Provide Trauma-Informed Care for Residents with PTSD
Penalty
Summary
The facility failed to identify, assess, and provide supportive interventions for three residents with PTSD. The report states the facility did not provide a policy on trauma informed care. For Resident #3, the record showed diagnoses including PTSD, major depressive disorder, bipolar disorder, social phobia, and schizoaffective disorder, and the PASARR also listed PTSD. Although a trauma informed care assessment noted the resident had experienced something unusually or especially frightening or traumatic and had nightmares, intrusive thoughts, avoidance, and hypervigilance, it did not address triggers or interventions if the resident was triggered. The care plan only mentioned PTSD as a diagnosis related to psychotropic medication use and did not list triggers or trauma-related interventions. A behavioral note also documented the resident continued to see mice in the room, and the social worker stated staff talking about similar situations could trigger the resident. For Resident #67, the record showed diagnoses of PTSD, schizophrenia, major depressive disorder, and anxiety disorder, and the PASARR also listed PTSD, anxiety disorder, panic disorder, and MDD. The trauma informed care assessment contained no information regarding trauma. The care plan addressed MDD and anxiety and focused on medication administration, monitoring for side effects, and safety, but did not address PTSD, the resident’s past trauma, or any triggers that could cause behaviors. For Resident #96, the record showed diagnoses of PTSD, schizophrenia, MDD, anxiety disorder, mood disturbance, and bipolar disorder, and the PASARR also listed PTSD. The trauma informed care assessment contained no information regarding trauma. The undated care plan noted the resident had experienced an event or series of events with a long-lasting negative impact and included general interventions such as offering choices, giving medications as ordered, and validating feelings, but it did not identify triggers voiced by the resident. During interviews, LPN B, the DON, the MDS Coordinator, the Administrator, and the social worker stated they did not know the resident’s triggers or that the trauma assessments were broad and did not provide enough information to know what the residents’ trauma involved.
Controlled medication count records were incomplete and inaccurate
Penalty
Summary
The facility failed to establish a system of records for the receipt and disposition of controlled medications in sufficient detail to allow an accurate reconciliation of controlled medications. Review of the facility policy titled, Controlled Substances, showed that nursing staff were to count controlled medication inventory at the end of each shift and that the nurse coming on duty and the nurse going off duty were to make the count together and document and report any discrepancies to the DON. However, review of the North Nurses' Cart Nurse Count Log from February 1 through February 12, 2026 showed no signature and/or initials by the nurse for 14 of 46 opportunities. Similar documentation problems were found on multiple medication carts. The 200 Hall CMT Cart Narcotic Count Sheet showed no signature and/or initials by the nurse or CMT for 8 of 68 opportunities, and on February 12, 2026 at 9:30 A.M., staff had already signed as oncoming day shift, off-going day shift, oncoming evening shift, and off-going evening shift for that date. The 300 Hall Medication Cart Narcotic Count Sheet showed no signature and/or initials for 9 of 68 opportunities, and CMT A had already signed as the off-going day shift for that date; the Total Card Count Sheet for 300 Hall showed 18 cards total, but the physical card count was 19. The 400 Hall CMT Cart Narcotic Count Sheet showed no signature and/or initials for 20 of 68 opportunities, and CMT A had already signed as the off-going day shift for that date. During interviews, CMT A said he/she had been on the cart the prior night and forgot to add Resident #43's clonazepam to the count sheet when it arrived about 6:00 P.M. the previous day. The Infection Preventionist and CMT A stated signatures should be on all lines for each count at shift change, and the Administrator, DON, and ADON stated they expected off-going and oncoming staff to count and sign the narcotic sheet and for the total count sheet to be updated when medications were added to the cart.
Infection Control Failures During Medication Pass, Wound Care, and Catheter Care
Penalty
Summary
The facility failed to maintain infection prevention and control practices during medication administration, wound care, and suprapubic catheter care. During medication pass, a CMT did not wash or sanitize hands before or after giving medications to three residents and used an ungloved hand to pick two Tums tablets from the bottle before administering them to one resident. The CMT stated he/she should sanitize hands before giving medications and between residents and should not pick up tablets with a bare hand. During wound care for one resident with multiple wounds, an LPN sanitized hands and donned gloves but did not don a gown despite Enhanced Barrier Precautions signage being present. The LPN changed gloves and sanitized hands multiple times while cleaning and dressing wounds on the left ankle, left foot, right foot, right ankle, and left buttock, but also placed a marker and scissors into a pocket and later removed them from the pocket during the procedure. The LPN stated the PPE was forgotten and that the scissors and marker should not have been placed back into the pocket before being cleaned. During suprapubic catheter care for one resident, a CNA washed hands and donned gloves but did not don a gown despite EBP signage being present. The CNA cleaned and drained the catheter bag, then touched the resident's pants, bedspread, and bedside items before cleaning the catheter site, and used the same gloves while cleaning around the catheter insertion site and tubing. The CNA stated he/she should have worn PPE and should have changed to clean gloves after touching the resident's clothing and bedspread and before cleaning the catheter site.
Items Stored on Overbed Light Fixtures
Penalty
Summary
The facility failed to provide a safe and functional environment for residents by allowing items to be stored on top of overbed light fixtures in three resident rooms. On observation, a framed photo collage was seen on top of the light fixture above the bed by the window in one room, a poster, a license plate, and a framed picture were seen on top of the light fixture above the bed by the window in another room, and three stuffed animals were seen on top of the light fixture above the bed by the window in a third room. During interviews, a CNA stated he/she tries not to put things on top of the lights and tries to keep them clear, but knows some residents place items there because they want them on the lights. The Administrator stated she knew there were a couple of residents who did this and that housekeeping was checking it, and later the Administrator and DON stated items should not be placed on the light fixtures due to possible hazards.
CNA In-Service Training Lacked Required Dementia and Abuse Prevention Content
Penalty
Summary
The facility failed to provide annual competencies for dementia care and abuse/neglect training, and failed to provide at least 12 hours of nurse aide in-service education per year. This affected three of three sampled CNAs in a facility with a census of 105. The facility policy required annual in-services to ensure continuing CNA competence, include training in dementia management and resident abuse prevention, and document the date, time, topic, method, competency assessment, and hours completed for each training. Review of the in-service records showed CNA E had seven in-services after a 10/03/24 hire date, with no length of time documented for each in-service and no documented abuse/neglect or dementia care training. CNA D had 21 in-services after a 12/16/24 hire date, with no length of time provided for each in-service. CNA F had 20 in-services after a 12/27/24 hire date, with no length of time provided for each in-service and no documented abuse/neglect or dementia care training. During interview, the DON said the facility tracked CNA in-services on a spreadsheet and was not sure of the specific annual hour requirement or required trainings, and said it would be helpful if in-services were dated and included the length of time for each in-service. The Administrator said she expected all staff to have at least 12 hours of in-service training including abuse, neglect, and dementia care, and expected trainings to be dated and include the length of time for each in-service.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment, affecting two residents and potentially impacting all residents. Observations revealed a strong urine odor in the 300 and 400 halls, indicating inadequate sanitation. The south shower room was found with a used razor on the floor, a brown slimy substance around the shower drain, rotten flooring, dirty grout, and a scratched door with chipped paint. Similarly, the north shower room had brown spots on the ceiling, a dirty shower chair with a red substance and flies, used wet linens on the floor, a stained and peeling shower floor, and a detached sink basin. Further observations showed dirt and stains with a musty odor on carpets in multiple resident rooms, and a cracked light fixture with a hole in one room. Interviews with residents revealed dissatisfaction with the carpet conditions, with one resident expressing discomfort walking barefoot and another always wearing shoes to avoid contact with the floor. The Housekeeping Manager admitted that carpet cleaning was not part of the regular cleaning rotation, only addressing it upon complaints or reports. The Administrator acknowledged the expectation for resident rooms to be free from dirt, debris, stains, and odors.
Ineffective Pest Control Program Leads to Fly Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in a significant fly population affecting both sampled and non-sampled residents. Observations over several days revealed flies buzzing around residents in their rooms, hallways, and common areas, causing discomfort and disturbance. Residents reported that the flies were particularly bothersome, with some resorting to covering their heads with blankets to avoid them. The issue was noted to be more pronounced during warmer months when doors were frequently opened. Interviews with residents and staff highlighted ongoing complaints about the fly problem, with residents expressing frustration over the nuisance and its impact on their comfort and sleep. The facility's pest control policy, revised in July 2023, mandates an ongoing program to keep the building free of insects and rodents, yet the presence of flies persisted. The Housekeeping Supervisor mentioned that the pest control company visits monthly and can come more frequently if needed, but the problem remained unresolved at the time of the survey.
Failure to Conduct Timely Background Checks for New Hires
Penalty
Summary
The facility failed to adhere to its background screening policy for three out of ten employees reviewed, which is a deficiency in ensuring the safety and well-being of residents. The policy requires that Certified Nurse Aide (CNA) licenses be verified through the state registry before individuals can serve as nurse aides or nursing assistants. Additionally, the facility's policy mandates that employment background checks, including Criminal Background Checks (CBC), Family Care Safety Registry (FCSR), and Employee Disqualification List (EDL) checks, be completed prior to the employment start date. However, the facility did not conduct these checks in a timely manner for three employees. Specifically, the personnel file of NA A showed a hire date of December 28, 2023, but the CBC was not conducted until February 23, 2024. Similarly, CNA B was hired on January 2, 2024, but the CBC was delayed until January 5, 2024. Furthermore, the Assistant Director of Nursing (ADON) C was hired on December 26, 2023, but the facility failed to conduct the Nurse Aide Registry check. Interviews with the Director of Nurses and the Administrator confirmed that the facility's expectation was for these checks to be completed upon hire, indicating a lapse in following established procedures.
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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 Festus
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Crystal Oaks | 0.3 mi | ★★★★★ | 4 | 0 |
| Superior Manor Of Festus, Llc | 1.4 mi | ★★★★★ | 0 | 0 |
| Festus Manor | 1.4 mi | — | 0 | 0 |
| Scenic Wellness And Rehabilitation Center | 4 mi | ★★★★★ | 0 | 0 |
| Hillcrest Care Center Inc | 9.7 mi | ★★★★★ | 10 | 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.