Inspection Reports for
Fountainbleau Lodge
2001 NORTH KINGSHIGHWAY, CAPE GIRARDEAU, MO, 63701-2193
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
6.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
15% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
30 residents
Based on a September 2025 inspection.
Occupancy over time
Inspection Report
Routine
Census: 30
Deficiencies: 3
Date: Sep 4, 2025
Visit Reason
The inspection was conducted to assess compliance with federal regulations related to resident assessments, food service, and infection control practices at Fountainbleau Lodge nursing home.
Findings
The facility failed to accurately code the Minimum Data Set (MDS) for three residents, served food at unsafe temperatures affecting many residents, and did not maintain appropriate infection control practices for two residents, all with minimal harm or potential for actual harm.
Deficiencies (3)
Failed to accurately code the Minimum Data Set (MDS) for three residents.
Failed to provide palatable, attractive food at safe and appetizing temperatures.
Failed to maintain appropriate infection control practices for two residents.
Report Facts
Residents affected: 3
Facility census: 30
Food temperature: 112
Food temperature: 116
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MDS Coordinator | Interviewed regarding inaccurate MDS coding | |
| Administrator | Interviewed regarding expectations for MDS coding and food temperature | |
| RN A | Registered Nurse | Observed failing to wear gown and gloves during wound care and infection control procedures |
| Dietary Manager | Interviewed regarding expectations for hot food temperatures | |
| Director of Nursing (DON) | Interviewed regarding expectations for food temperature and infection control |
Inspection Report
Routine
Census: 29
Deficiencies: 6
Date: Aug 8, 2024
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements including employee screening, resident transfer notifications, care planning, food safety, infection control, and pest control.
Findings
The facility was found deficient in multiple areas including failure to complete Nurse Aide Registry and background checks prior to employment for several staff, failure to notify residents and representatives in writing about hospital transfers and bed hold policies, incomplete care plans for residents, improper food handling and sanitation practices, inadequate infection control during incontinent care, lack of a Legionella water management program, and ineffective pest control resulting in presence of flies.
Deficiencies (6)
Failed to ensure Nurse Aide Registry checks and background checks were completed prior to employment for seven employees out of ten sampled.
Failed to notify residents and/or representatives in writing of hospital transfers and bed hold policies for multiple residents.
Failed to implement a care plan with specific interventions to meet individual needs for one resident.
Failed to store and distribute food under sanitary conditions, increasing risk of cross contamination and food-borne illnesses.
Failed to maintain infection control practices during incontinent care and failed to implement a Legionella water management program.
Failed to maintain an effective pest control program, resulting in presence of flies in resident areas.
Report Facts
Employees with incomplete NA Registry checks: 7
Residents sampled: 12
Facility census: 29
Dates of hire for employees with incomplete checks: Specific hire dates listed for seven employees between 09/22/23 and 02/23/24
Water temperature readings: Multiple readings between 97.2°F and 104°F with no documented interventions
Number of residents affected by pest control issues: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Medication Technician/Certified Nurse Aide B | Failed to have NA Registry check prior to hire date of 09/22/23 | |
| Housekeeper C | Failed to have NA Registry check prior to hire date of 11/15/23 | |
| Licensed Practical Nurse D | Failed to have NA Registry check prior to hire date of 11/28/23 | |
| Dietary Aide E | Failed to have CBC, EDL, and NA Registry checks prior to hire date of 12/01/23 | |
| Registered Nurse F | Failed to have NA Registry check prior to hire date of 12/28/23 | |
| Licensed Practical Nurse G | Failed to have NA Registry check prior to hire date of 01/03/24 | |
| Dietary Aide H | Failed to have NA Registry check prior to hire date of 02/23/24 | |
| Certified Nurse Aide I | Observed failing to perform proper hand hygiene during food service and incontinent care | |
| Certified Nurse Aide J | Observed failing to perform proper hand hygiene during incontinent care | |
| Certified Nurse Aide K | Observed failing to perform proper hand hygiene during incontinent care | |
| Certified Nurse Aide M | Observed failing to perform proper hand hygiene and improper food handling | |
| Certified Nurse Aide N | Observed failing to perform proper hand hygiene and improper food handling | |
| Dietary Aide P | Observed failing to perform proper hand hygiene during food service | |
| Director of Nursing | Director of Nursing | Interviewed regarding employee screening and infection control expectations |
| Administrator | Administrator | Interviewed regarding employee screening, transfer notifications, infection control, and pest control expectations |
| Maintenance Director | Maintenance Director | Interviewed regarding Legionella water management and food safety |
| Licensed Practical Nurse A | Licensed Practical Nurse | Interviewed regarding transfer notifications and pest control |
| Social Services Designee | Interviewed regarding transfer notification procedures | |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding infection control and food safety expectations |
Inspection Report
Complaint Investigation
Census: 27
Deficiencies: 1
Date: Jun 18, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to provide protective oversight when a resident accessed an unlocked medication overflow cart and took medications unsupervised.
Complaint Details
Complaint #MO237379. The complaint involved a resident accessing an unlocked medication overflow cart and taking medications without supervision. The complaint was substantiated with findings of immediate jeopardy.
Findings
The facility failed to keep the medication overflow cart locked and unattended, allowing Resident #1 to access and take multiple medication cards, resulting in a potential overdose risk. The facility corrected the immediate jeopardy by educating staff and securing the cart.
Deficiencies (1)
Failure to provide protective oversight by leaving the medication overflow cart unlocked and unattended, allowing a resident to access and take medications unsupervised.
Report Facts
Residents affected: 4
Medication doses taken: 6
Medication doses missing: 6
Medication cards taken: 3
Facility census: 27
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | In charge of the overflow medication cart and notified to check resident's possession |
| Certified Medication Technician C | Certified Medication Technician | Commented on medication cart security and responsibility |
| Registered Nurse B | Registered Nurse | Stated medication cart should always be locked unless in use |
| Director of Operations | Director of Operations | Reported incident and described medication cart policies and expectations |
| Assisted Living Supervisor | Assisted Living Supervisor | Observed resident on camera removing medication cards from overflow cart |
Inspection Report
Census: 30
Deficiencies: 9
Date: Mar 10, 2023
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to background checks, resident transfer notifications, care planning, medication management, quality assurance, and vaccination policies at Fountainbleau Lodge.
Findings
The facility was found deficient in multiple areas including failure to complete timely criminal background checks for new hires, failure to notify residents or their representatives in writing about hospital transfers and bed hold policies, incomplete care plans for residents, lack of physician response to pharmacist medication recommendations, failure to implement gradual dose reductions for psychotropic medications, lack of ongoing quality assurance meetings, and failure to provide or document pneumococcal vaccinations or refusals.
Deficiencies (9)
Failed to complete Criminal Background Check (CBC) and Employee Disqualification List (EDL) checks for nine out of ten sampled staff prior to hire.
Failed to notify resident and/or resident's representative in writing of hospital transfer or discharge for one resident.
Failed to inform residents and families in writing of bed hold policy at time of hospital transfer for two residents.
Failed to implement complete care plans with specific interventions for four residents.
Failed to ensure physician responded to pharmacist recommendations regarding medications for three residents.
Failed to attempt Gradual Dose Reduction (GDR) for psychotropic medications for three residents.
Failed to ensure Quality Assurance/Performance Improvement committee met quarterly and developed corrective plans.
Failed to maintain quarterly Quality Assessment and Assurance meetings with required members.
Failed to provide and document influenza and pneumococcal vaccinations or refusals for two residents.
Report Facts
Residents affected: 9
Residents affected: 1
Residents affected: 2
Residents affected: 4
Residents affected: 3
Residents affected: 3
Facility census: 30
Residents affected: 2
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