Inspection Reports for
Fountainbleau Lodge
2001 NORTH KINGSHIGHWAY, CAPE GIRARDEAU, MO, 63701-2193
Back to Facility ProfileDeficiencies (last 7 years)
Deficiencies (over 7 years)
11.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
111% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
32
24
16
8
0
Occupancy
Latest occupancy rate
34% occupied
Based on a September 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate 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: 7
Date: Aug 8, 2024
Visit Reason
The inspection was a routine survey conducted to assess compliance with federal and state regulations for the Fountainbleau Lodge nursing facility.
Findings
The facility was found deficient in multiple areas including failure to complete required background checks prior to employment, inadequate notification procedures before resident transfers and discharges, incomplete care plans, food safety violations, infection control deficiencies, and pest control issues. The facility submitted a plan of correction addressing these deficiencies.
Deficiencies (7)
F607 The facility failed to ensure Nurse Aide Registry checks and other background checks were completed prior to employment for multiple employees. The facility's census was 29.
F623 The facility failed to notify residents, their representatives, and the State Long-Term Care Ombudsman in writing of transfers or discharges for multiple residents. The facility's census was 29.
F625 The facility failed to provide written notice of the bed-hold policy to residents or their representatives at the time of transfer to the hospital for multiple residents. The facility's census was 29.
F656 The facility failed to develop and implement comprehensive, person-centered care plans with measurable objectives and specific interventions for residents, including those on dialysis. The facility's census was 29.
F812 The facility failed to store and distribute food under sanitary conditions, increasing the risk of cross contamination and foodborne illnesses. The facility's census was 29.
F880 The facility failed to maintain infection control practices to prevent infection transmission during incontinent care for two sampled residents. The facility's census was 29.
F925 The facility failed to maintain an effective pest control program, resulting in the presence of flies and gnats affecting residents. The facility's census was 29.
Report Facts
Facility census: 29
Number of sampled residents: 12
Number of residents affected by pest control deficiency: 3
Inspection Report
Life Safety
Census: 29
Deficiencies: 4
Date: Aug 8, 2024
Visit Reason
The inspection was conducted as a Life Safety Code survey to assess compliance with fire safety and hazardous area regulations at Fountainbleau Lodge.
Findings
The facility failed to meet applicable provisions of the 2012 Life Safety Code related to hazardous areas and oxygen storage. Deficiencies included a kitchen door that did not automatically latch and unsecured oxygen cylinders, potentially affecting all residents and staff.
Deficiencies (4)
K321 Hazardous Areas - The kitchen door leading to the dining area did not automatically latch and had gaps allowing smoke passage, failing to maintain the kitchen free of hazards.
K923 Gas Equipment - The facility failed to adequately secure oxygen cylinders, including an unsecured tank in the oxygen storage room and an unsupported tank in the beauty shop.
A2008 Hazardous Areas - Hazardous areas were not separated by at least a one-hour fire-resistant barrier or automatic sprinkler system as required by regulation.
A2010 Oxygen Storage - Oxygen storage was not in accordance with NFPA 99, including failure to secure cylinders properly.
Report Facts
Facility census: 29
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 related to medication safety and supervision concerns at Fountainbleau Lodge.
Complaint Details
Complaint #MO237379 was investigated. The complaint was substantiated based on observations, record reviews, interviews, and video footage showing the resident accessed medication cards from an unlocked overflow medication cart.
Findings
The facility failed to provide adequate supervision and secure medication carts, resulting in a resident accessing and removing medication cards and pills, posing a risk of overdose. The facility had a small medication room and an overflow medication cart that was not consistently locked or monitored.
Deficiencies (1)
F 689 Free of Accident Hazards/Supervision/Devices CFR(s): 483.25(d)(1)(2) The facility failed to ensure the resident environment was free of accident hazards and did not provide adequate supervision to prevent unauthorized access to medication carts. A resident accessed medication cards and pills, risking overdose.
Report Facts
Facility census: 27
Medication quantities missing: 6
Medication quantities ingested: 6
Medication cards removed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Notified to check resident's room and retrieved medication cards after resident accessed medication cart. |
| CMT C | Certified Medication Technician | Reported medication cart should always be locked and was responsible for keys on day of incident. |
| RN B | Registered Nurse | Stated overflow medication cart should always be locked unless in use. |
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
Plan of Correction
Census: 41
Deficiencies: 3
Date: Oct 31, 2023
Visit Reason
The visit was conducted to identify deficiencies and to review the facility's compliance with fire extinguisher maintenance, resident rights admission/annual review, and advance directive requirements.
Findings
The facility failed to properly maintain fire extinguisher documentation and monthly pressure checks. The facility also failed to ensure annual resident rights and advance directive documentation were completed for sampled residents.
Deficiencies (3)
19 CSR 30-86.022(3)(D) Fire Extinguishers U/L/FM, Maintain/Check: The facility failed to properly maintain fire extinguisher documentation and monthly pressure checks for extinguishers located between rooms 101-116 and 117-128.
19 CSR 30-88.010(4) Resident Rights-Admission/Annual Review: The facility failed to ensure annual resident rights documentation was completed for four sampled residents.
19 CSR 30-88.010(10) Advance Directive Requirements: The facility failed to complete annual updated advance directive documentation for four sampled residents.
Report Facts
Facility census: 41
Inspection Report
Annual Inspection
Census: 30
Deficiencies: 14
Date: Mar 10, 2023
Visit Reason
The inspection was the annual survey of Fountainbleau Lodge to assess compliance with federal regulations and state licensing requirements.
Findings
The facility was found deficient in multiple areas including failure to conduct timely criminal background checks, inadequate notification of resident transfers and discharges, incomplete comprehensive care plans, deficiencies in drug regimen review, and failure to maintain quality assurance meetings. Several residents' medical records lacked required documentation and the facility failed to implement certain policies and procedures as required.
Deficiencies (14)
F607: The facility failed to complete criminal background checks and Employee Disqualification List verifications within two days of hire for multiple employees.
F623: The facility failed to notify residents or their representatives in writing of transfers or discharges within 30 days for sampled residents.
F625: The facility failed to provide written notice of bed-hold policy and return rights to residents and their representatives upon transfer or discharge.
F656: The facility failed to develop and implement comprehensive, person-centered care plans with measurable goals for sampled residents.
F756: The facility failed to ensure monthly drug regimen reviews by a licensed pharmacist for sampled residents and did not act on pharmacist recommendations.
F758: The facility failed to ensure psychotropic drugs were used appropriately, including failure to provide gradual dose reductions and behavioral interventions.
F867: The facility failed to maintain effective quality assurance and performance improvement systems, including failure to hold required quarterly QAA/QAPI meetings.
F868: The facility failed to maintain quarterly quality assurance assessment and assurance committee meetings with required members.
F883: The facility failed to ensure residents received pneumococcal and influenza immunizations and education according to policy.
A4017: The facility failed to ensure criminal background checks were requested and maintained for employees prior to hire.
A4031: The facility failed to follow appropriate infection prevention practices including tuberculosis screening for employees.
A4061: The facility failed to conduct monthly drug regimen reviews by a pharmacist and report irregularities in writing.
A8008: The facility failed to inform residents or representatives in writing of changes in services, discharges, or transfers.
A8018: The facility failed to provide timely written notice of emergency discharges to residents or their representatives.
Report Facts
Facility census: 30
Number of sampled residents: 12
Number of employees with CBC/EDL deficiencies: 9
Number of residents with medication review deficiencies: 3
Number of residents with transfer notification deficiencies: 1
Number of residents with bed hold policy deficiencies: 2
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
Inspection Report
Life Safety
Census: 30
Deficiencies: 4
Date: Mar 8, 2023
Visit Reason
The visit was conducted as an Emergency Preparedness Life Safety Code survey to assess compliance with fire safety regulations.
Findings
The facility failed to meet several Life Safety Code requirements including maintenance of self-closing doors, hazardous area enclosures, fire alarm system installation, and electrical equipment safety. Deficiencies potentially affected all residents and staff.
Deficiencies (4)
K223 Doors with Self-Closing Devices: Doors in exit passages and hazardous areas were held open with doorstops, violating NFPA 101 standards. The facility census was 30.
K321 Hazardous Areas - Enclosure: Hazardous areas were not properly separated by fire barriers or automatic extinguishing systems, with holes in the water heater room ceiling and broken fire door glass. The facility census was 30.
K341 Fire Alarm System - Installation: The fire alarm system was incomplete and failed to maintain a complete system as required by NFPA standards. The facility census was 30.
K920 Electrical Equipment - Power Cords and Extension Cords: Temporary wiring was used improperly and power strips were used inappropriately, violating NFPA 101 standards. The facility census was 30.
Report Facts
Facility census: 30
Inspection Report
Plan of Correction
Census: 40
Deficiencies: 2
Date: Feb 23, 2023
Visit Reason
The document is a plan of correction submitted by Fountainbleau Lodge following a state inspection conducted on 02/23/2023. The purpose is to address deficiencies identified during the inspection related to hot water temperature and medication system safety.
Findings
The facility failed to maintain hot water temperatures within the required range of 105°F to 120°F, with observed temperatures exceeding this limit. Additionally, the facility did not ensure medications were kept in a safe and effective manner for seven residents on insulin.
Deficiencies (2)
19 CSR 30-86.032(34) Hot Water 105-120 Degrees F: The facility failed to maintain hot water temperatures between 105°F and 120°F, with observed temperatures up to 125.2°F in resident rooms.
19 CSR 30-86.047(46) Safe & Effective Medication System: The facility failed to ensure medications were kept safely and effectively for seven residents on insulin, including undated opened insulin vials.
Report Facts
Facility census: 40
Number of residents with medication deficiencies: 7
Inspection Report
Routine
Deficiencies: 0
Date: Dec 20, 2022
Visit Reason
A COVID-19 Focused Emergency Preparedness survey and a COVID-19 Focused Infection Control Survey were conducted to assess compliance with relevant CMS and CDC requirements.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Plan of Correction
Census: 35
Deficiencies: 1
Date: Jul 7, 2022
Visit Reason
The inspection was conducted to evaluate compliance with admission physical examination requirements for residents at Fountainbleau Lodge.
Findings
The facility failed to ensure that one out of four sampled residents had an admission physical examination completed by a licensed physician. Documentation was missing and staff were unaware that the examination had not been completed.
Deficiencies (1)
19 CSR 30-86.047(26) Admission Physical: The facility failed to ensure one resident had an admission physical examination completed by a licensed physician. Documentation of the physical examination was missing and staff were unaware it had not been completed.
Report Facts
Facility census: 35
Sampled residents: 4
Inspection Report
Complaint Investigation
Census: 29
Deficiencies: 1
Date: Jun 30, 2022
Visit Reason
The investigation was triggered by a complaint regarding failure to initiate cardiopulmonary resuscitation (CPR) for a resident who required emergency care and subsequently died in the facility.
Complaint Details
The complaint investigation was substantiated based on failure to initiate CPR and inadequate documentation related to the resident's code status and death notifications.
Findings
The facility failed to initiate CPR for a resident with a full code status who was found unresponsive, resulting in the resident's death. Documentation and adherence to CPR and Do Not Resuscitate (DNR) policies were inadequate, and staff failed to follow facility protocols.
Deficiencies (1)
F678 Cardio-Pulmonary Resuscitation (CPR): The facility failed to initiate CPR for a resident with a full code status who was found unresponsive and died. Documentation and staff adherence to CPR and resident code status policies were deficient.
Report Facts
Facility census: 29
Residents identified with full code status: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Registered Nurse | Named in failure to initiate CPR and documentation issues. |
| CMT B | Certified Medication Technician | Provided observations related to resident condition and CPR initiation. |
| CNA D | Certified Nursing Aide | Involved in resident care and CPR initiation discussion. |
| LPN I | Licensed Practical Nurse | Provided information on code status training and documentation. |
| LPN H | Licensed Practical Nurse | Provided information on resident transfer and code status orders. |
| Administrator | Administrator | Notified of incident and involved in policy oversight. |
| Director of Nursing | Director of Nursing | Notified of incident and involved in investigation. |
Inspection Report
Plan of Correction
Census: 33
Deficiencies: 1
Date: Apr 19, 2022
Visit Reason
The inspection was conducted to assess compliance with COVID-19 vaccination requirements for facility staff.
Findings
The facility failed to ensure 100% of staff received at least one dose of a COVID-19 vaccine or had an approved exemption. The facility had 76.5% of staff completely vaccinated or exempted and no resident COVID-19 infections in the previous four weeks.
Deficiencies (1)
F 888 COVID-19 Vaccination of facility staff. The facility must develop and implement policies and procedures to ensure all staff are fully vaccinated for COVID-19 or have approved exemptions. The facility failed to ensure 100% of staff received at least one dose of a COVID-19 vaccine or had an approved exemption.
Report Facts
Facility census: 33
Staff total: 47
Staff partially vaccinated: 4
Staff not vaccinated without exemption: 7
Staff vaccinated or exempted: 76.5
New staff without vaccination or exemption: 7
Inspection Report
Complaint Investigation
Census: 27
Deficiencies: 3
Date: Nov 4, 2021
Visit Reason
The inspection was conducted in response to complaints #MO192755 and #MO192724 regarding the facility's handling and storage of controlled medications.
Complaint Details
Complaints #MO192755 and #MO192724 triggered the investigation. The findings confirmed deficiencies in medication storage and destruction practices.
Findings
The facility failed to properly store controlled medications behind two locked compartments with limited access to authorized personnel. The facility also failed to destroy discontinued controlled medications for ten residents as required by policy and regulations.
Deficiencies (3)
F761: The facility failed to properly store controlled medications behind two locked compartments with limited access to authorized personnel. The facility also failed to destroy discontinued controlled medications for ten residents.
A4064: Facilities shall store Schedule II medications under double lock separately from noncontrolled medications. This regulation was not met as evidenced by Class II deficiency.
A4066: All non-unit doses and controlled substances discontinued must be destroyed within 30 days. This regulation was not met as evidenced by Class III deficiency.
Report Facts
Facility census: 27
Residents affected: 10
Tablets of Lorazepam: 31
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding medication storage and destruction practices |
| Registered Nurse | Registered Nurse (RN) A | Interviewed about medication handling |
| Certified Medication Technician | Certified Medication Technician (CMT) B | Interviewed about medication storage |
| Pharmacist Consultant | Pharmacist Consultant | Interviewed about medication storage best practices |
| Administrator | Administrator | Interviewed about medication destruction policy and expectations |
Inspection Report
Routine
Deficiencies: 0
Date: Sep 21, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness survey and a COVID-19 Focused Infection Control Survey were conducted to assess compliance with relevant federal regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Life Safety
Census: 25
Deficiencies: 4
Date: Dec 3, 2020
Visit Reason
The inspection was a life safety code survey to assess compliance with the 2012 Existing Edition of the Life Safety Code of the National Fire Protection Association (NFPA) and related regulations.
Findings
The facility failed to maintain adequate exit signage, clean kitchen exhaust hoods, proper use of power strips, and oxygen tank separation. These deficiencies potentially affected all residents and staff.
Deficiencies (4)
K293 Exit Signage: The facility failed to maintain adequate exit signage in the central courtyard, with no exit sign indicating how to leave the courtyard in case of an emergency.
K324 Cooking Facilities: The facility failed to maintain clean exhaust hoods in the kitchen, with a heavy buildup of brown, tacky grease observed.
K920 Electrical Equipment - Power Cords and Extension Cords: The facility failed to maintain the facility free of temporary wiring devices, with multiple basic power strips in use that were not approved.
K923 Gas Equipment - Cylinder and Container Storage: The facility failed to maintain adequate oxygen tank separation, with empty tanks mixed with full tanks in the oxygen storage closet.
Report Facts
Facility census: 25
Inspection Report
Annual Inspection
Census: 26
Deficiencies: 5
Date: Dec 3, 2020
Visit Reason
Annual inspection survey conducted to assess compliance with federal regulations and quality of care standards at Fountainbleau Lodge.
Findings
The facility was found deficient in multiple areas including accuracy of advance directives, assessment coding, quality of care, food safety, and immunization documentation. Deficiencies affected several residents and had potential or actual impact on resident care.
Deficiencies (5)
F578: The facility failed to ensure the accuracy of the advance directive regarding the resuscitation status for one resident.
F641: The facility failed to accurately code the Minimum Data Set (MDS) assessments for three residents to reflect their status.
F684: The facility failed to ensure that all residents receive treatment and care in accordance with professional standards, including obtaining an order for hospice admission and a coordinated plan of care for one hospice resident.
F812: The facility failed to store, prepare, distribute, and serve food under sanitary conditions potentially affecting all residents.
F883: The facility failed to provide documentation of pneumococcal vaccine history or evidence that four residents received or refused the vaccine on admission.
Report Facts
Facility census: 26
Number of residents affected: 1
Number of residents affected: 3
Number of residents affected: 1
Number of residents affected: 4
Inspection Report
Routine
Deficiencies: 0
Date: Oct 13, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with related federal regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 and CMS and CDC recommended practices for COVID-19 preparedness and infection control.
Inspection Report
Routine
Census: 23
Deficiencies: 3
Date: Oct 1, 2020
Visit Reason
The inspection was a COVID-19 focused emergency preparedness survey conducted to assess compliance with infection prevention and control requirements during the pandemic.
Findings
The facility was found noncompliant with infection prevention and control policies, including improper use of personal protective equipment (PPE), failure to follow screening and hand hygiene protocols, and inadequate notification of COVID-19 cases to residents' families.
Deficiencies (3)
F880 Infection prevention and control program was not properly maintained, including failure to follow PPE use, screening, hand hygiene, and isolation procedures.
F885 COVID-19 reporting requirements were not met as the facility failed to notify responsible parties for two residents within required timeframes.
A4085 Infection control/communicable disease regulation was not met as residents were not isolated properly to prevent exposure.
Report Facts
Facility census: 23
Positive COVID-19 cases: 3
Positive COVID-19 cases: 3
Positive COVID-19 cases: 3
Positive COVID-19 cases: 10
Positive COVID-19 cases: 1
Positive COVID-19 cases: 2
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: May 21, 2020
Visit Reason
A COVID-19 focused infection control and emergency preparedness survey was conducted to assess compliance with CMS and CDC recommended practices and relevant federal regulations.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices for COVID-19 infection control and with 42 CFR 483.73 related to emergency preparedness.
Inspection Report
Annual Inspection
Census: 27
Deficiencies: 6
Date: Jan 11, 2019
Visit Reason
The inspection was conducted as an annual survey to assess compliance with federal regulations for nursing facilities, including review of transfer/discharge notices, bed hold policies, PASARR screening, baseline care plans, restorative care, and food safety.
Findings
The facility was found noncompliant with several requirements including failure to notify residents and representatives of transfers to hospital, failure to inform residents of bed hold policies, incomplete PASARR screening for one resident, incomplete baseline care plans, inadequate restorative care services, and unsanitary food storage and preparation conditions.
Deficiencies (6)
F623 The facility failed to notify the resident or the resident's representative in writing of the reason for transfer to the hospital and did not notify the state Long-Term Care Ombudsman of transfers for three residents.
F625 The facility failed to inform two residents and their representatives of the bed hold policy at the time of transfer to the hospital.
F645 The facility failed to ensure a Level 1 PASARR screening and resident review was completed upon admission for one resident with a chronic mental health condition.
F655 The facility failed to provide a written summary of the baseline care plan within 48 hours of admission for one resident and failed to complete a baseline care plan within 48 hours for another resident.
F688 The facility failed to provide restorative care services to six of eight sampled residents, missing numerous therapy opportunities and documentation.
F812 The facility failed to store, prepare, distribute, and serve food and ice under sanitary conditions, including dirty equipment, unclean surfaces, and improper food labeling.
Report Facts
Facility census: 27
Residents affected by F623: 3
Residents affected by F625: 2
Residents affected by F645: 1
Residents affected by F655: 2
Residents affected by F688: 6
Inspection Report
Life Safety
Census: 28
Deficiencies: 3
Date: Jan 11, 2019
Visit Reason
The inspection was a life safety code survey to assess compliance with the 2012 Existing Edition of the Life Safety Code of the National Fire Protection Association (NFPA) and related regulations.
Findings
The facility failed to maintain ashtrays free of combustibles, failed to prohibit the use of flammable decorations including candles with wicks, and failed to maintain oxygen tank separation. These deficiencies potentially affected all residents and staff.
Deficiencies (3)
K741 Smoking Regulations: The facility failed to maintain ashtrays free of combustibles, evidenced by multiple cigarette butts on the ground by laundry vents and a trashcan with leaves and used cigarette butts.
K753 Combustible Decorations: The facility failed to prohibit the use of flammable decorations, including candles with wicks, creating a fire hazard by providing a source of ignition and fuel.
K923 Gas Equipment - Cylinder and Container Storage: The facility failed to maintain oxygen tank separation, with three empty tanks mixed with full tanks in the oxygen storage room.
Report Facts
Facility census: 28
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