Inspection Reports for
Sunterra Springs Dardenne Prairie
7275 STATE HIGHWAY N, DARDENNE PRAIRIE, MO, 63368-7128
Back to Facility Profile5 Reports
Inspection Report — Mar 19, 2025
Routine
Date: Mar 19, 2025
Visit Reason
Federal health survey (CMS-2567) and Missouri state licensure survey (State Form); the survey type is not stated.
Findings
2 deficiencies: one federal health deficiency for failure to perform required skin assessments and prevent/treat pressure ulcers, and one Missouri state licensure deficiency for pressure sore prevention/treatment.
Deficiencies (1)
19 CSR 30-85.042(74) Pressure Sore Prevention/Treatment: Refer to F686.
Report Facts
residents sampled: 5
Inspection Report — Dec 5, 2024
Routine
Date: Dec 5, 2024
Visit Reason
Federal health survey (CMS-2567) and Missouri Department of Health and Senior Services State Form; the survey type is not stated.
Findings
2 deficiencies: one federal deficiency for failure to notify the physician and/or responsible parties when residents had a change in condition or were sent to/admitted to the hospital, and one Missouri state licensure citation for failure to notify the responsible party referencing the federal finding.
Deficiencies (1)
19 CSR 30-85.042(79) Notify Responsible Party-Change in Condition: See the deficiency cited at F580.
Report Facts
residents sampled: 6
residents affected: 2
Inspection Report — Jun 14, 2023
Complaint Investigation
Date: Jun 14, 2023
Visit Reason
Federal health survey (CMS-2567) with accompanying Missouri State Form; complaint investigation citing MO219823.
Complaint Details
MO219823; substantiation not stated.
Findings
Four deficiencies were cited: two federal health survey deficiencies involving abuse/neglect and failure to report alleged violations, and two Missouri licensure deficiencies related to developing/implementing abuse/neglect policies and reporting to DHSS/DMH.
Deficiencies (2)
19 CSR 30-88.010(23) Develop/Implement A/N Policies: Refer to F600.
19 CSR 30-88.010(25) Report A/N to DHSS/DMH When Needed: Refer to F609.
Report Facts
residents sampled: 3
Inspection Report — Sep 22, 2022
Routine
Date: Sep 22, 2022
Visit Reason
Federal health survey (CMS-2567) and Missouri state licensure survey (State Form); the survey type is not stated.
Findings
Five deficiencies were cited: two federal health deficiencies for failure to notify the physician/responsible party after a resident fall and failure to complete neurological assessments after an unwitnessed fall, and three Missouri state licensure deficiencies referencing nursing care and notification requirements.
Deficiencies (3)
19 CSR 30-85.042(66) Nursing Care per Res Condition: Refer to F658.
19 CSR 30-85.042(78) Dr Notification-Change in Condition: Refer to F580.
19 CSR 30-85.042(79) Notify Responsible Party-Change in Condition: Refer to F580.
Report Facts
residents sampled: 5
residents affected: 1
Inspection Report — Apr 12, 2022
Routine
Date: Apr 12, 2022
Visit Reason
Federal health survey (CMS-2567) and Missouri state licensure survey (State Form); the survey type is not stated.
Findings
Four deficiencies were cited: two federal deficiencies involving failures in medication availability, wound assessment, documentation and treatment, and two Missouri state deficiencies for nursing care per resident condition and pressure sore prevention/treatment referring to the federal findings.
Deficiencies (2)
19 CSR 30-85.042(66) Nursing Care per Res Condition: Refer to F658.
19 CSR 30-85.042(74) Pressure Sore Prevention/Treatment: Refer to F686.
Report Facts
residents sampled: 5
closed records selected: 6
14 CMS Surveys
Inspection Report — Nov 5, 2025
Routine
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
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 — Jul 17, 2025
Complaint Investigation
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
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 — Jun 13, 2025
Complaint Investigation
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
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 — Mar 19, 2025
Routine
Date: Mar 19, 2025
Visit Reason
Federal health survey (CMS-2567) and Missouri state licensure survey (State Form); the survey type is not stated.
Findings
2 deficiencies: one federal health deficiency for failure to perform required skin assessments and prevent/treat pressure ulcers, and one Missouri state licensure deficiency for pressure sore prevention/treatment.
Deficiencies (1)
F686 Treatment/Svcs to Prevent/Heal Pressure Ulcer: Staff failed to complete required skin assessments and identify or address pressure injuries, resulting in residents developing unstageable and Stage III pressure ulcers.
Report Facts
residents sampled: 5
Inspection Report — Dec 5, 2024
Routine
Date: Dec 5, 2024
Visit Reason
Federal health survey (CMS-2567) and Missouri Department of Health and Senior Services State Form; the survey type is not stated.
Findings
2 deficiencies: one federal deficiency for failure to notify the physician and/or responsible parties when residents had a change in condition or were sent to/admitted to the hospital, and one Missouri state licensure citation for failure to notify the responsible party referencing the federal finding.
Deficiencies (1)
F580 Notify of Changes (Injury/Decline/Room, etc.): Based on interview and record review, the facility failed to notify the physician and/or responsible parties when two residents had a change in condition and documentation did not show notification when residents were sent to or admitted to the hospital.
Report Facts
residents sampled: 6
residents affected: 2
Inspection Report — Sep 30, 2024
Complaint Investigation
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
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 — Dec 20, 2023
Routine
Date: Dec 20, 2023
Visit Reason
Federal health (CMS-2567) survey; the survey type is not stated.
Findings
One federal health deficiency concerning management of residents' personal funds; scope and severity letter SS=D.
Deficiencies (1)
F 567 Protection/Management of Personal Funds (CFR(s): 483.10(f)(10)(ii)): Based on interview and record review, the facility failed to offer to hold, manage, safeguard, or account for residents' personal funds. The facility's memo and admission agreement indicated it did not manage resident funds and residents were short-term, so requests for holding funds were unlikely.
Inspection Report — Nov 30, 2023
Life Safety
Date: Nov 30, 2023
Visit Reason
CMS-2567 Life Safety Code survey (K-tag life safety). An Emergency Preparedness initial comments page (E000) is included.
Findings
Six life safety deficiencies were cited addressing fire alarm sensitivity testing and documentation, sprinkler system maintenance and inspections, corridor doors not closing/latching, unsealed smoke barrier penetrations, missing required fire drills, and missing generator inspection/testing documentation.
Deficiencies (6)
K345 Fire Alarm System - Testing and Maintenance: Record review and interview revealed the facility failed to conduct and document required sensitivity testing of the smoke detectors (bi-annual sensitivity calibration was not documented).
K353 Sprinkler System - Maintenance and Testing: Based on observation, interview, and record review, the facility failed to maintain the sprinkler system in accordance with NFPA 25 and did not conduct required weekly inspections of gauges on the dry sprinkler system.
K363 Corridor - Doors: Based on observation and interview, corridor doors to multiple rooms and the dining room failed to close and positively latch into the frame. The deficient practice had the potential to affect 20 residents.
K372 Subdivision of Building Spaces - Smoke Barrier Construction: Observation and interview revealed unsealed gaps and penetrations in smoke barriers (including a 3 inch hole behind a mechanical room door and a 2 inch unsealed overcut around an oxygen pipe) and the facility failed to ensure smoke barriers were continuous.
K712 Fire Drills: Record review and interview revealed the facility failed to conduct required fire drills at least quarterly on each shift, including a missing first-shift drill for the second quarter of 2023.
K918 Electrical Systems - Essential Electric System: Record review and interview revealed missing documentation of required generator inspections and monthly/under-load tests for multiple months in 2023.
Report Facts
residents potentially affected: 20
Inspection Report — Nov 30, 2023
Routine
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 — Jun 14, 2023
Complaint Investigation
Date: Jun 14, 2023
Visit Reason
Federal health survey (CMS-2567) with accompanying Missouri State Form; complaint investigation citing MO219823.
Complaint Details
MO219823; substantiation not stated.
Findings
Four deficiencies were cited: two federal health survey deficiencies involving abuse/neglect and failure to report alleged violations, and two Missouri licensure deficiencies related to developing/implementing abuse/neglect policies and reporting to DHSS/DMH.
Deficiencies (2)
F600 Free from Abuse and Neglect: Based on interview and record review the facility failed to ensure one resident was free from abuse when a Certified Nurse Aide moved and transferred the resident roughly, causing the resident to hit his/her back and head and report pain and fear.
F609 Reporting of Alleged Violations: Based on interview and record review the facility failed to ensure staff reported all allegations of abuse for one resident; Resident #1 reported a CNA threw him/her onto the toilet, was afraid of the CNA, and staff did not report as required.
Report Facts
residents sampled: 3
Inspection Report — Sep 22, 2022
Routine
Date: Sep 22, 2022
Visit Reason
Federal health survey (CMS-2567) and Missouri state licensure survey (State Form); the survey type is not stated.
Findings
Five deficiencies were cited: two federal health deficiencies for failure to notify the physician/responsible party after a resident fall and failure to complete neurological assessments after an unwitnessed fall, and three Missouri state licensure deficiencies referencing nursing care and notification requirements.
Deficiencies (2)
F580 Notify of Changes (Injury/Decline/Room, etc.): Based on interview and record review, the facility failed to notify one resident's responsible party and physician when the resident experienced an unwitnessed fall.
F658 Services Provided Meet Professional Standards: The facility failed to complete and document neurological assessments for one resident after an unwitnessed fall.
Report Facts
residents sampled: 5
residents affected: 1
Inspection Report — Apr 12, 2022
Routine
Date: Apr 12, 2022
Visit Reason
Federal health survey (CMS-2567) and Missouri state licensure survey (State Form); the survey type is not stated.
Findings
Four deficiencies were cited: two federal deficiencies involving failures in medication availability, wound assessment, documentation and treatment, and two Missouri state deficiencies for nursing care per resident condition and pressure sore prevention/treatment referring to the federal findings.
Deficiencies (2)
F658 Services Provided Meet Professional Standards: The facility failed to follow physician orders and ensure availability of medications and wound treatment supplies for multiple residents and did not document detailed wound assessments and measurements.
F686 Treatment/Svcs to Prevent/Heal Pressure Ulcer: The facility failed to provide timely treatment and monitoring to promote healing for a resident with multiple pressure ulcers and did not identify or treat wounds, resulting in deterioration and hospitalization.
Report Facts
residents sampled: 5
closed records selected: 6
Inspection Report — Dec 18, 2020
Life Safety
Date: Dec 18, 2020
Visit Reason
Federal CMS-2567 life safety and emergency preparedness forms and a Missouri state licensure State Form are included; the survey type is not stated.
Findings
No federal life safety or emergency preparedness deficiencies were cited and no state licensure deficiencies were cited.
Inspection Report — Dec 18, 2020
Original Licensing
Date: Dec 18, 2020
Visit Reason
This file contains a CMS-2567 federal health survey (initial certification) and a Missouri Department of Health and Senior Services state licensure inspection; the survey is an initial certification/initial licensure.
Findings
No deficiencies were cited on the federal health survey and no state licensure deficiencies were cited; a total of 0 deficiencies.
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