Inspection Reports for
Sunterra Springs Dardenne Prairie
7275 STATE HIGHWAY N, DARDENNE PRAIRIE, MO, 63368-7128
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
8.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
60% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
24
18
12
6
0
Occupancy
Latest occupancy rate
76% occupied
Based on a November 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Routine
Census: 29
Deficiencies: 3
Date: Nov 5, 2025
Visit Reason
The inspection was conducted to assess compliance with professional standards of quality in nursing care, catheter care, and infection prevention and control at the nursing facility.
Findings
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.
Deficiencies (3)
Failure to follow physician orders for dressing changes to intravenous sites and wounds, and failure to secure indwelling catheter.
Failure to secure indwelling catheter drainage tubing and bags, increasing risk for urinary tract infections.
Failure to follow infection control standards including improper hand hygiene, failure to change gloves between tasks, and improper handling of soiled linens.
Report Facts
Residents affected: 2
Residents affected: 4
Facility census: 29
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Registered Nurse | Named in findings related to wound care and catheter care deficiencies |
| ADON | Assistant Director of Nursing | Involved in observations and interviews related to catheter and wound care deficiencies |
| Director of Nursing | Director of Nursing | Interviewed regarding expectations for staff compliance with physician orders and infection control |
| CNA D | Certified Nurse Aide | Observed failing to perform proper hand hygiene and glove changes during personal care |
| CNA E | Certified Nurse Aide | Observed failing to perform proper hand hygiene and glove changes during personal care |
Inspection Report
Complaint Investigation
Census: 66
Deficiencies: 1
Date: Jul 17, 2025
Visit Reason
The inspection was conducted following a complaint regarding an incident where a resident's foot was run over by a motorized wheelchair, resulting in injury.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failure to ensure a nursing home area is free from accident hazards and provide adequate supervision to prevent accidents, resulting in a resident's fractured toe from a motorized wheelchair.
Report Facts
Facility census: 66
Date of incident: Jun 25, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA B | Certified Nurse Aide | Reported the incident of the wheelchair running over the resident's foot and assisted in transferring the resident |
| CNA C | Certified Nurse Aide | Involved in transferring the resident and moving the electric wheelchair |
| NP A | Nurse Practitioner | Assessed the resident after the incident and ordered X-rays |
| ADON | Assistant Director of Nursing / Registered Nurse | Signed nurse's note reporting the incident and involved in assessment |
| LPN A | Licensed Practical Nurse | Aware of the incident but did not assess the resident |
| Director of Nursing | Director of Nursing | Reviewed hospital records and commented on expected nursing assessments and staff training |
| Administrator | Administrator | Commented on expectations for nursing assessments and staff training |
Inspection Report
Complaint Investigation
Census: 36
Deficiencies: 2
Date: Jun 13, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to notify a resident's physician when ordered medications were not available for administration.
Complaint Details
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.
Findings
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.
Deficiencies (2)
Failure to notify the resident's physician when ordered medications were not available for administration.
Failure to follow physician orders for medication administration and pain assessments as ordered.
Report Facts
Missed medication doses: 7
Census: 36
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Documented medications not available and did not notify physician; agency nurse without Pyxis access. |
| LPN C | Licensed Practical Nurse | Stated physician should be notified if medications not administered and described medication delivery process. |
| Director of Nursing | Director of Nursing | Stated expectation that medications be given as ordered and physician notified if not; described medication delivery and stock medication use. |
Inspection Report
Annual Inspection
Census: 33
Deficiencies: 2
Date: Mar 19, 2025
Visit Reason
Annual inspection survey conducted to assess compliance with health and safety regulations related to pressure ulcer prevention and treatment at Sunterra Springs Dardenne Prairie.
Findings
The facility failed to consistently perform weekly skin assessments and adequately address pressure ulcers for two residents, resulting in unstageable and Stage III pressure ulcers. Documentation and care planning deficiencies were noted, including incomplete skin assessments and lack of interventions for pressure relief.
Deficiencies (2)
F686: The facility failed to complete weekly skin assessments for two residents and did not address pressure ulcers in care plans, resulting in unstageable and Stage III pressure ulcers. Documentation of wound assessments and interventions was incomplete or missing.
A4083: Facilities did not keep residents free from avoidable pressure sores and failed to provide adequate treatment as required by regulation.
Report Facts
Facility census: 33
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN D | Registered Nurse | Conducted weekly wound rounds and documented findings |
| RN B | Registered Nurse | Wound nurse who measured wounds and reported findings |
| Director of Nurses | Director of Nursing | Provided information about resident skin issues and facility expectations |
| Nurse Practitioner | Nurse Practitioner | Contracted wound care provider who assessed resident wounds |
| Certified Nurse Aide | CNA | Reported resident complaints and observations about skin condition |
| Administrator | Administrator | Signed plan of correction and provided interview statements |
| Medical Director/Physician A | Medical Director/Physician | Provided interview statements regarding nursing policy adherence |
Inspection Report
Routine
Census: 33
Deficiencies: 1
Date: Mar 19, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with pressure ulcer care and prevention policies following concerns about failure to complete weekly skin assessments for two residents, resulting in pressure ulcers.
Findings
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.
Deficiencies (1)
Failure to complete weekly skin assessments per facility policy for two residents, resulting in pressure ulcers.
Report Facts
Facility census: 33
Pressure ulcer measurements: 2
Pressure ulcer measurements: 3.3
Pressure ulcer measurements: 3
Pressure ulcer measurements: 0.7
Pressure ulcer measurements: 1.5
Pressure ulcer measurements: 0.7
Pressure ulcer measurements: 1.3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN D | RN Supervisor | Assessed and documented Stage III pressure ulcer on Resident #1 on 1/19/25 |
| RN B | Wound Nurse | Measured wounds and conducted weekly wound rounds; involved in wound care for Resident #1 and Resident #2 |
| Director of Nurses | Director of Nurses (DON) | Provided information about Resident #1 and Resident #2's skin conditions and facility policies |
| Nurse Practitioner | Contracted Wound Care Nurse Practitioner | Assessed Resident #1's Stage III pressure ulcer on 1/22/25 |
| Certified Nurse Aide A | Certified Nurse Aide (CNA) | Reported on Resident #2's skin condition and refusal to wear protective boots |
| RN C | Registered Nurse | Conducted weekly wound rounds and documented wounds |
| Administrator | Facility Administrator | Provided expectations for nursing staff regarding skin and pressure ulcer policies |
| Medical Director/Physician A | Facility Medical Director/Physician | Provided expectations for nursing staff regarding skin assessments and pressure ulcer identification |
Inspection Report
Plan of Correction
Census: 34
Deficiencies: 2
Date: Dec 5, 2024
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction for Sunterra Springs Dardenne Prairie, addressing failures in notification of changes in resident condition and responsible party contact.
Findings
The facility failed to notify the physician and responsible parties when two residents had changes in condition and did not ensure contact information was properly documented and communicated. The facility's policy for Notification of Changes was reviewed and found not fully implemented.
Deficiencies (2)
F580 Notification of Changes: The facility failed to promptly notify the resident's physician and responsible parties of significant changes in condition for two residents. The facility also failed to maintain updated contact information and notify responsible parties when residents were sent to the hospital.
A4088 Notify Responsible Party-Change in Condition: The facility did not immediately notify the person designated in the resident's record as the designee or responsible party in the event of significant changes in condition. This regulation was not met as evidenced by Class III deficiency.
Report Facts
Facility census: 34
Residents discharged: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse B | Licensed Practical Nurse | Named in interview and nurse notes regarding Resident #1 hospital transfer |
| Social Services Director | Social Services Director | Interviewed regarding facility intake and notification processes |
| Administrator | Administrator | Signed the plan of correction and provided interview statements |
| Director of Nursing | Director of Nursing | Interviewed about notification procedures and staff communication |
Inspection Report
Complaint Investigation
Census: 34
Deficiencies: 1
Date: Dec 5, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to notify physicians and responsible parties when two residents had a change in condition.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failure to notify the resident's doctor and family member of changes in condition and hospital admission for two residents.
Report Facts
Residents affected: 2
Facility census: 34
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse B | Licensed Practical Nurse | Named in relation to sending Resident #1 to the hospital and lack of notification. |
| Family Member A | Responsible party for Resident #1, not notified of hospital admission. | |
| Family Member B | Emergency contact for Resident #2, not notified by facility. | |
| Director of Nursing | Director of Nursing | Interviewed regarding notification procedures and lack of contact documentation. |
| Administrator | Administrator | Interviewed regarding expectations for notification of responsible parties. |
| Social Services Director | Social Services Director | Provided information about resident contacts and facility procedures. |
Inspection Report
Complaint Investigation
Census: 36
Deficiencies: 1
Date: Sep 30, 2024
Visit Reason
The inspection was conducted due to a complaint regarding a staff member failing to follow facility policy during a sit to stand lift transfer of Resident #1, resulting in injury to the resident.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failure to ensure staff followed facility policy requiring two staff members for mechanical lift transfers, resulting in injury to Resident #1.
Report Facts
Facility census: 36
Pain level: 10
Date of injury: Sep 24, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nurse Aide | Transferred Resident #1 alone using sit to stand lift, causing injury |
| Director of Nursing | Director of Nursing | Signed nurse notes documenting injury and follow-up |
| Director of Therapy | Director of Therapy | Provided information on therapy assessment and staff training |
Inspection Report
Plan of Correction
Census: 32
Deficiencies: 1
Date: Dec 20, 2023
Visit Reason
The inspection was conducted to assess compliance with federal regulations regarding the management of residents' personal funds.
Findings
The facility failed to hold, manage, safeguard, or account for any personal funds for residents, which is a violation of federal requirements. The facility's census at the time was 32 residents.
Deficiencies (1)
F 567: The facility did not hold, manage, safeguard, or account for any personal funds for residents, failing to meet federal requirements for managing residents' personal funds.
Report Facts
Facility census: 32
Average length of stay: 14
Average length of stay: 16
Inspection Report
Routine
Census: 29
Deficiencies: 13
Date: Nov 30, 2023
Visit Reason
The inspection was conducted to assess compliance with resident rights, care standards, medication administration, infection control, and facility safety.
Findings
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.
Deficiencies (13)
Failure to promote resident self-determination through support of resident choice in bathing preferences for three residents.
Failure to maintain a clean environment for a resident in contact isolation with accumulation of soiled linen and overflowing trash.
Failure to provide timely notification in writing to residents and representatives before transfer or discharge for two residents.
Failure to develop and present baseline care plans within 48 hours of admission for 13 residents.
Failure to document administration of narcotic medications for two residents.
Failure to provide timely assistance for incontinent resident leading to prolonged soiling and discomfort.
Failure to properly secure foley catheters and position urinary drainage bags for two residents, increasing risk of urinary tract infections.
Medication error rate above 5% with missed administration of anticoagulant and other medications for one resident.
Medication carts and treatment carts left unlocked and unsecured on two resident halls.
Failure to ensure clean pans were air dried prior to storage and not stacked wet in dietary services.
Failure to properly dispose of garbage and maintain dumpster area clean and covered.
Quality Assurance and Performance Improvement committee failed to ensure required members attended quarterly meetings for two of four quarters reviewed.
Failure to ensure staff and visitors wore appropriate personal protective equipment for a resident on isolation precautions and failure to maintain water management program documentation.
Report Facts
Residents affected: 3
Residents affected: 1
Residents affected: 2
Residents affected: 13
Residents affected: 2
Residents affected: 1
Residents affected: 2
Medication error rate: 8
Residents affected: 2
Residents affected: 38
Residents affected: 38
Quarterly meetings reviewed: 4
Quarterly meetings with missing required members: 2
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Named in medication error finding and interview regarding bathing and call light deficiencies |
| Licensed Practical Nurse (LPN) 5 | Licensed Practical Nurse | Named in catheter care and infection control PPE findings |
| Certified Nurse Aide (CNA) 7 | Certified Nurse Aide | Named in bathing, medication administration, and infection control PPE findings |
| Assistant Director of Nursing (ADON) | Assistant Director of Nursing | Named in catheter care and infection control PPE findings |
| Dietary Manager | Dietary Manager | Named in dietary pan drying and infection control PPE findings |
| Certified Medicine Technician/Certified Nursing Assistant (CMT/CNA) 7 | Certified Medicine Technician/Certified Nursing Assistant | Named in medication administration and infection control PPE findings |
| Certified Nursing Assistant (CNA) 2 | Certified Nursing Assistant | Named in catheter care findings |
| Licensed Practical Nurse (LPN) 7 | Licensed Practical Nurse | Named in medication cart security findings |
| Certified Nursing Assistant (CNA) 8 | Certified Nursing Assistant | Named in catheter care findings |
| Administrator | Administrator | Named in QAPI findings and water management program findings |
| Maintenance Director | Maintenance Director | Named in water management program findings |
Inspection Report
Life Safety
Census: 37
Capacity: 38
Deficiencies: 6
Date: Nov 30, 2023
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements and the 2012 Edition of the National Fire Protection Association (NFPA) 101 Life Safety Code.
Findings
The facility was found to be in noncompliance with fire alarm system testing, sprinkler system maintenance, corridor door smoke resistance, smoke barrier construction, fire drills, and electrical system maintenance. Deficiencies had the potential to affect all 37 residents.
Deficiencies (6)
K345 Fire Alarm System testing and maintenance was not conducted bi-annually as required, and sensitivity calibration documentation was missing.
K353 Sprinkler system maintenance and testing were not maintained according to NFPA 25 standards, including failure to conduct weekly inspections of dry sprinkler gauges.
K363 Corridor doors failed to close and latch properly, allowing passage of smoke, affecting 20 residents.
K372 Smoke barriers had unsealed gaps and penetrations, including holes and unsealed pipe penetrations, compromising smoke resistance.
K712 Fire drills were not conducted at least quarterly per shift, and missing fire drill records were noted.
K918 Electrical systems maintenance and testing were not maintained as required, including missing documentation of weekly and monthly generator tests.
Report Facts
Facility census: 37
Facility capacity: 38
Missing generator inspection months: 6
Inspection Report
Complaint Investigation
Census: 29
Deficiencies: 4
Date: Jun 14, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding alleged abuse and neglect of a resident at Sunterra Springs Dardenne Prairie.
Complaint Details
The complaint investigation substantiated that CNA A abused Resident #1 by roughly handling and throwing the resident onto the toilet, causing injury and fear. The facility failed to report the abuse allegations immediately as required. The resident and family members reported fear of retaliation and multiple complaints about CNA A's rough care.
Findings
The facility failed to ensure one resident was free from abuse when a Certified Nurse Aide (CNA A) was found to have roughly handled the resident, causing physical harm and fear. The facility also failed to report the abuse allegations immediately as required by regulations.
Deficiencies (4)
F600: The facility failed to ensure a resident was free from abuse when a CNA aggressively transferred the resident causing injury and fear. The resident reported pain and fear of the CNA after the incident.
F609: The facility failed to report all allegations of abuse immediately as required, resulting in delayed notification to the administrator and other officials. The resident reported that CNA A threw him onto the toilet causing injury and fear.
A8023: The facility did not develop and implement written policies prohibiting mistreatment, neglect, and abuse of residents, requiring reports to the department for any suspected abuse or neglect.
A8025: The facility failed to report abuse allegations to the Department of Health and Senior Services and Department of Mental Health as required when a resident was abused by a staff member.
Report Facts
Facility census: 29
Date of incident: Jun 9, 2023
Date of survey: Jun 14, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nurse Aide | Named in abuse allegation for roughly handling resident |
| CNA B | Certified Nurse Aide | Reported resident's refusal of CNA A and described abuse |
| LPN A | Licensed Practical Nurse | Interviewed about abuse allegations and resident condition |
| Director of Nurses | Director of Nursing | Interviewed regarding abuse allegations and facility response |
| Administrator | Facility Administrator | Interviewed about abuse incident and reporting procedures |
Inspection Report
Complaint Investigation
Census: 20
Deficiencies: 5
Date: Sep 22, 2022
Visit Reason
The inspection was conducted due to a complaint investigation regarding failure to notify the resident's physician and responsible party following an unwitnessed fall of Resident #2.
Complaint Details
The complaint investigation was substantiated. The facility failed to notify the resident's physician and family following an unwitnessed fall of Resident #2 and failed to complete required neurological assessments.
Findings
The facility failed to notify the resident's physician and family after an unwitnessed fall, and failed to complete neurological assessments as required. The facility census was 20 at the time of inspection.
Deficiencies (5)
F580 Notification of Changes: The facility failed to notify the resident's physician and responsible party after an unwitnessed fall of Resident #2, violating notification requirements.
F658 Services Provided Meet Professional Standards: The facility failed to complete and document neurological assessments for Resident #2 after an unwitnessed fall, not meeting professional standards.
A4075 Nursing Care per Resident Condition: Each resident must receive personal attention and nursing care consistent with current acceptable nursing practice. This regulation was not met as evidenced by Class II deficiency.
A4087 Doctor Notification-Change in Condition: Facility staff failed to notify the resident's physician in accordance with emergency treatment policies after a significant change in condition.
A4088 Notify Responsible Party-Change in Condition: Facility staff failed to immediately notify the responsible party of a significant change in the resident's condition.
Report Facts
Facility census: 20
Deficiencies cited: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Registered Nurse | Named in failure to notify physician and family after resident fall |
| Director of Nursing | Executive Director | Named in education and auditing related to notification and neurological assessments |
Inspection Report
Plan of Correction
Census: 16
Deficiencies: 2
Date: Apr 12, 2022
Visit Reason
The inspection was conducted to investigate deficiencies related to professional standards of care and treatment/services to prevent and heal pressure ulcers at Sunterra Springs Dardenne Prairie.
Findings
The facility failed to meet professional standards in comprehensive care plans and wound treatment, including failure to follow physician orders for medication and wound care, and inadequate documentation and monitoring of wounds. The facility also failed to provide treatment and monitoring to promote healing of pressure ulcers for one resident.
Deficiencies (2)
F658 Services Provided Meet Professional Standards. The facility failed to follow physician's orders for medication and wound treatment for three residents and failed to document detailed wound assessments for one resident.
F686 Treatment/Services to Prevent/Heal Pressure Ulcer. The facility failed to provide treatment and monitoring to promote healing for one resident with pressure ulcers and wounds.
Report Facts
Facility census: 16
Deficiencies cited: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Named in plan of correction and responsible for education and audits related to deficiencies |
| Unit Manger | Unit Manager | Named in plan of correction and responsible for education and audits related to deficiencies |
Inspection Report
Deficiencies: 0
Date: Dec 18, 2020
Visit Reason
The document is a statement of deficiencies and plan of correction for Sunterra Springs Dardenne Prairie nursing home, summarizing the results of a regulatory survey completed on December 18, 2020.
Findings
No health deficiencies were found during the survey.
Inspection Report
Original Licensing
Deficiencies: 0
Date: Dec 18, 2020
Visit Reason
Initial certification survey to assess compliance for licensing of the facility.
Findings
No health deficiencies or state licensure deficiencies were cited as a result of this initial certification survey and licensure inspection.
Inspection Report
Life Safety
Deficiencies: 0
Date: Dec 18, 2020
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code and emergency preparedness regulations at Sunterra Springs Dardenne Prairie.
Findings
The facility met the applicable provisions of the 2012 Life Safety Code with no deficiencies cited. No deficiencies were found related to emergency preparedness or state licensure during this inspection.
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