Inspection Report Summary
The most recent inspection on February 10, 2025, identified deficiencies related to trauma informed care for a resident with PTSD, insufficient nursing staff to respond to call lights timely, and inconsistent use of Enhanced Barrier Precautions during care. Earlier inspections showed a pattern of issues including medication management discrepancies, wound care documentation delays, and multiple care planning and staff training deficiencies. Complaint investigations found some substantiated concerns, such as missing controlled medication and delayed abuse reporting, but enforcement actions like fines or license suspensions were not listed in the available reports. Most complaints were substantiated, with corrective actions including staff education and suspension of an employee. The facility’s inspection history reflects ongoing challenges in nursing care and infection control, with no clear trend of improvement or worsening over time.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
5.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
4% better than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
38 residents
Based on a February 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Inspection Report
Complaint Investigation
Census: 38
Deficiencies: 3
Date: Feb 10, 2025
Visit Reason
The inspection was conducted based on complaints regarding failure to provide trauma informed care for a resident with PTSD, insufficient nursing staff to meet resident needs and respond to call lights timely, and failure to implement Enhanced Barrier Precautions during resident care.
Complaint Details
The investigation was complaint-driven based on allegations of failure to provide trauma informed care, insufficient nursing staff, and inadequate infection control practices.
Findings
The facility failed to provide trauma informed care for a resident with PTSD by not including mental health diagnoses and triggers in the care plan and staff were unaware of these triggers. The facility also failed to ensure sufficient nursing staff to respond to call lights in a timely manner, with documented delays up to 39 minutes. Additionally, the facility failed to ensure staff used Enhanced Barrier Precautions (gowns and gloves) consistently when providing care to residents with wounds or on isolation precautions.
Deficiencies (3)
Failure to provide trauma informed care for a resident with PTSD, including lack of care plan focus on PTSD and triggers, and staff unawareness of resident's triggers.
Failure to provide enough nursing staff to meet resident needs and respond to call lights in a timely manner, with documented call light response delays up to 39 minutes.
Failure to ensure staff used Enhanced Barrier Precautions (gowns and gloves) consistently when providing care to residents with wounds or on isolation precautions.
Report Facts
Residents affected: 1
Residents affected: 2
Residents affected: 3
Call light response times (minutes): 39
Facility census: 38
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA C | Certified Nursing Assistant | Observed failing to don PPE when required for resident on Enhanced Barrier Precautions |
| CMT A | Certified Medication Technician | Observed failing to don PPE when required for resident on Enhanced Barrier Precautions |
| LPN B | Licensed Practical Nurse | Observed failing to don PPE when required for resident on Enhanced Barrier Precautions |
| Interim Social Services Director | Responsible for care planning PTSD and triggers for resident; acknowledged many residents lacked mental health diagnoses on care plans | |
| Director of Nursing | Director of Nursing | Provided expectations for trauma informed care, call light response times, and Enhanced Barrier Precautions |
| Nurse Practitioner | Nurse Practitioner | Expected mental health diagnoses and PTSD triggers to be on resident care plans |
| Administrator | Administrator | Acknowledged call light response times were substantial and needed staff education |
| CNA A | Certified Nursing Assistant | Unaware of resident's PTSD triggers and how to access care plan |
| Agency RN A | Registered Nurse | Unaware of resident's PTSD diagnosis and triggers |
| LPN A | Licensed Practical Nurse | Reported complaints about call light response times and expected 3-5 minute response |
Inspection Report
Annual Inspection
Census: 36
Deficiencies: 1
Date: Dec 10, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with wound care standards, specifically regarding the documentation and physician orders for pressure ulcer care upon admission.
Findings
The facility failed to document a comprehensive wound assessment and obtain physician's orders for a pressure ulcer on admission for one sampled resident. The wound care orders were obtained two days after admission, and the comprehensive wound assessment was delayed by four days. Nursing staff did not document detailed wound assessments as expected.
Deficiencies (1)
Failure to document a comprehensive wound assessment and obtain physician's order for a pressure ulcer upon admission.
Report Facts
Residents Affected: 36
Residents Affected: 1
Days delay: 2
Days delay: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN B | Licensed Practical Nurse | Assessed resident's coccyx wound on admission but did not document comprehensive wound assessment |
| RN A | Registered Nurse | Transcribed physician order for wound care and treated wound; forgot to transcribe order initially |
| Director of Nursing | Director of Nursing | Provided expectations for wound assessment documentation and physician orders |
Inspection Report
Complaint Investigation
Census: 37
Deficiencies: 1
Date: Dec 26, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding a missing controlled drug card of 30 oxycodone tablets for one sampled resident (Resident #1).
Complaint Details
The investigation was triggered by a missing card of oxycodone 5 mg, quantity 30 for Resident #1. The facility discovered the medication was missing between 11/29/23 and 12/2/23. A staff member (LPN B) was suspended pending investigation. Surveillance footage showed discrepancies in medication card handling. The Director of Nursing filed a police report and notified the resident and pharmacy. Staff were re-educated on medication handling and reporting procedures.
Findings
The facility failed to ensure that a controlled drug card of 30 oxycodone tablets was properly accounted for, locked, and immediately reported as missing after delivery. Surveillance footage and investigation revealed discrepancies in medication card handling by staff, leading to the missing medication. The deficiency was corrected with staff education and suspension of a suspected employee.
Deficiencies (1)
Failed to ensure a controlled drug card of 30 oxycodone tablets was accounted for, locked, and immediately reported as missing after delivery.
Report Facts
Residents census: 37
Missing oxycodone tablets: 30
Controlled medication cards added: 4
Controlled medication cards delivered: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN B | Licensed Practical Nurse | Suspected of mishandling controlled medication cards leading to missing oxycodone |
| LPN A | Licensed Practical Nurse | Reported missing oxycodone to Director of Nursing |
| Unit Manager | Registered Nurse | Signed for medication delivery and handed medication cards to LPN B |
| RN A | Agency Nurse | Counted narcotic cards with LPN B |
| DON | Director of Nursing | Led investigation, filed police report, educated staff on medication procedures |
Inspection Report
Routine
Census: 31
Deficiencies: 9
Date: Jun 8, 2023
Visit Reason
Routine inspection of Sunterra Springs Independence nursing home to assess compliance with regulatory requirements including resident rights, staff background checks, care planning, respiratory care, dialysis care, and arbitration agreements.
Findings
The facility had multiple deficiencies including failure to ensure residents' rights to formulate advanced directives were fully honored and documented; incomplete background screening for new employees; failure to provide baseline care plans to residents within 48 hours of admission; lack of discharge recapitulation summaries; inadequate CPR certification tracking; failure to properly assess and educate staff on insulin pump use; improper management and documentation of CPAP and oxygen therapy; incorrect identification and assessment of dialysis access; and incomplete and unclear arbitration agreements.
Deficiencies (9)
Failed to ensure residents were offered the right to formulate and/or obtain existing advanced directives and failed to document efforts.
Failed to ensure background screening through the Certified Nurse Assistant Registry was completed prior to hire for four out of ten new employees.
Failed to provide residents and/or their representatives with a summary of a Baseline Care Plan developed within 48 hours of admission for four sampled residents.
Failed to ensure recapitulation of stay was completed for two sampled residents.
Failed to have a process to ensure CPR certified staff were available on all shifts and to identify CPR certified staff on schedules.
Failed to assess one resident to ensure he could monitor and maintain his insulin pump and failed to educate staff on insulin pumps.
Failed to ensure physician's orders for one resident's CPAP and oxygen use until five days after readmission, failed to ensure proper cleansing and storage of CPAP equipment, and failed to ensure oxygen tubing was dated and properly stored for two residents.
Failed to ensure one resident's hemodialysis access was correctly identified in physician's orders, treatment records, and care plan, and was correctly assessed by licensed nurses.
Failed to ensure arbitration agreements signed by three residents included explanation in a manner understood, that arbitration was not a condition of admission, residents' right to communicate with state officials, and contained a neutral arbitrator and agreed venue.
Report Facts
Facility census: 31
Sampled residents: 12
New employees sampled: 10
Residents affected by advanced directives deficiency: 5
Residents affected by baseline care plan deficiency: 4
Residents affected by discharge summary deficiency: 2
CPR certified staff: 11
Residents affected by insulin pump deficiency: 1
Residents affected by CPAP and oxygen care deficiency: 2
Residents affected by dialysis care deficiency: 1
Residents affected by arbitration agreement deficiency: 3
Inspection Report
Complaint Investigation
Census: 37
Deficiencies: 7
Date: Sep 29, 2021
Visit Reason
The inspection was conducted due to complaints and allegations involving failure to notify physicians of resident condition changes, diversion of controlled medications, failure to report abuse and injuries of unknown origin, failure to respond appropriately to alleged violations, failure to withhold CPR per resident's DNR order, and failure to ensure proper narcotic counts and staff training.
Complaint Details
The complaint investigation involved multiple allegations including failure to notify physicians, diversion of medications, failure to report abuse and injuries, failure to investigate abuse allegations, failure to withhold CPR per DNR, and narcotic count discrepancies. The facility census was 37 residents. Several residents and staff were interviewed, and multiple records were reviewed. The investigation found multiple deficiencies in compliance with regulatory requirements.
Findings
The facility failed to notify a physician of significant weight gain for a resident, failed to prevent diversion of Lorazepam from one resident to others, failed to timely report and fully investigate allegations of abuse and injuries of unknown origin, failed to withhold CPR per a resident's DNR order, failed to ensure narcotic counts were properly documented and signed, and failed to provide required CNA training hours. Investigations were incomplete or delayed, and policies were not fully followed.
Deficiencies (7)
Failed to notify physician of weight gain for Resident #37 being treated for edema.
Failed to prevent diversion of Lorazepam from Resident #41 to Residents #16 and #149.
Failed to timely report allegations of abuse and injuries of unknown origin to the State Agency for Residents #10 and #16, and misappropriation of controlled substances.
Failed to fully investigate allegations of abuse and injuries of unknown origin for Residents #10 and #16.
Failed to withhold CPR per Resident #150's DNR order.
Failed to ensure shift change narcotic counts were completed and signed by both oncoming and off-going nursing staff.
Failed to ensure Certified Nurse Assistants received twelve hours of training based on performance reviews.
Report Facts
Facility census: 37
Weight gain: 10.4
Weight gain: 4.5
Lorazepam tablets diverted: 5
Narcotic count unsigned opportunities: 12
Narcotic count unsigned opportunities: 14
Narcotic count unsigned opportunities: 17
Narcotic count unsigned opportunities: 12
Narcotic count unsigned opportunities: 2
Narcotic count unsigned opportunities: 12
Narcotic count unsigned opportunities: 8
Narcotic count unsigned opportunities: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Charge Nurse and former Director of Nursing | Named in medication diversion and abuse investigation findings |
| RN B | Charge Nurse and Unit Manager | Named in medication diversion and abuse investigation findings |
| CNA F | Certified Nurse Assistant | Named in abuse allegation involving Resident #16 |
| LPN E | Licensed Practical Nurse | Named in resident injury assessments and incident reporting |
| CNA G | Certified Nurse Assistant | Named in abuse allegation investigation |
| Director of Nursing | Director of Nursing | Responsible for investigations and staff training |
| Administrator | Facility Administrator | Responsible for investigations and reporting |
| Corporate Nurse | Corporate Nurse | Conducted abuse investigation |
| Licensed Practical Nurse A | Licensed Practical Nurse | Named in abuse investigation and medication diversion |
| Certified Medication Technician A | Certified Medication Technician | Named in narcotic count and training interviews |
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