Inspection Reports for
Sunterra Springs Dardenne Prairie

The facility failed to ensure staff followed physician orders for wound and catheter care for two residents, failed to secure indwelling catheter tubing increasing risk of urinary tract infections, and failed to follow infection control standards including proper hand hygiene and glove use during personal care for four residents. These deficiencies posed minimal harm or potential for actual harm.

The complaint investigation found that the resident's left foot was run over by a motorized wheelchair during transfer, resulting in a fractured toe. The resident was initially assessed with no visible injury but later required hospitalization and a walking boot. Staff lacked training on the wheelchair and failed to properly assess the resident after the incident.

The facility failed to ensure the safety of one resident when staff ran a motorized wheelchair over the resident's left foot, causing a fractured toe. The investigation revealed inadequate supervision and lack of staff training on the use of the electric wheelchair.

The complaint investigation found that the facility failed to notify the physician when medications were not administered as ordered. The resident missed seven total doses of medications. The investigation included interviews with nursing staff and the Director of Nursing, confirming lack of notification and failure to use available medication supplies.

The facility failed to notify the physician of missed medication doses for Resident #1, who missed seven total doses of various medications despite some being available in the Pyxis and stock supply. Nursing staff did not follow physician orders or document notifications properly.

The facility failed to complete weekly skin assessments per policy for two residents, leading to the development of a Stage III pressure ulcer and multiple unstageable pressure ulcers. Documentation and care plans lacked interventions for pressure relief, and staff failed to identify skin issues timely. The facility census was 33 at the time of inspection.

The complaint investigation found that the facility did not notify responsible parties or physicians when Residents #1 and #2 were sent to the hospital. Resident #1 had no emergency or family contacts listed on the face sheet, and Resident #2's family was not notified by the facility despite being listed as emergency contact. Interviews with family members and staff confirmed lack of notification.

The facility failed to notify the physician and/or responsible parties for two residents when they experienced a change in condition and were sent to the hospital. The facility's policy requires notification of significant changes, but documentation and interviews confirmed notifications were not made. The facility also lacked proper contact information on the face sheets for residents.

The complaint was substantiated. Resident #1 was injured due to improper transfer by a single staff member using a sit to stand lift without the required assistance of a second staff member. The resident sustained significant pain and bruising. The facility took corrective actions including staff training and removal of the responsible CNA.

The facility failed to ensure the safety of Resident #1 during a sit to stand lift transfer when a Certified Nurse Aide transferred the resident without the assistance of an additional staff member, causing significant pain and bruising. The facility initiated an investigation, provided staff in-service training, and corrected the deficiency promptly.

The facility was found deficient in multiple areas including failure to support resident self-determination in bathing preferences, inadequate incontinence care, medication administration errors, improper catheter care, unlocked medication and treatment carts, improper food pan drying, improper garbage disposal, incomplete water management program, and inconsistent infection control practices.