Sunterra Springs Dardenne Prairie

Inspectors wroteBased on interview and record review, the facility failed to provide documentation of ongoing assessments of a surgical wound as directed in facility policy for one resident (Resident #1), in a review of eight sampled residents, when the resident's wound deteriorated. The facility failed to notify the surgeon when the wound had an increase in bleeding for four days which caused a delay in the resident being sent to the emergency department following a miscommunication and a missed appointment with the surgeon. The facility census was 32. [...]

Inspectors wroteBased on interview and record review, the facility failed follow discharge process per facility policy. Staff failed to provide a copy of bed hold policy and written notice of transfer to the resident and/or the resident's representative when four residents (Residents #42, #34, #9 and #47), in a review of 15 sampled residents, were transferred/discharged from the facility. The facility census was 32. Review of the facility's policy for transfer/discharge notices, last revised April 2025, showed the following:-The facility's transfer/discharge notice will be provided to the resident and resident's representative in a language and way they can understand. The notice will include all the following at the time it is provided: -The specific reason and basis for transfer or discharge; -The effective date of transfer or discharge; [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to ensure one resident (Resident #34), in a review of 14 residents and two additional residents (Resident # 100 and # 101) were free from significant medication errors. Staff failed to prime (remove the air) insulin (injectable medication to treat diabetes (inability to control the amount of sugar in the blood)) pens prior to administration of the physician ordered dose, as the facility policy and manufacturer's instructions directed, resulting in administration of less than the ordered dose of insulin. The facility census was 32. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow current infection control standards for five residents (Resident #4, #40, #41, #56 and #57), in a review of 15 sampled residents, when staff failed to perform proper hand hygiene, change gloves, properly handle contaminated linens and follow enhanced barrier precautions (EBP) by wearing personal protective equipment (PPE) to prevent infection while providing personal care. The facility census was 32. Review of the facility policy, Hand Hygiene, revised 04/2025, showed the following:-All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow current infection control standards for four residents (Resident #1, #3, #7 and #10), in a review of ten sampled residents when staff failed to perform proper hand hygiene and change gloves to prevent infection during personal care for Resident #1, #3, #7 and #10, and failed to properly handle soiled linens during personal care for Resident #10. The facility census was 29. Review of the facility policy for Hand Hygiene with a revision date of 4/2025 showed the following:-All staff will perform proper hand hygiene procedures to prevent the spread of infection to tother personnel, residents and visitors. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff followed physician orders for two residents (Resident #4 and #5) of ten sampled residents. Staff failed to follow physician orders for dressing changes to intravenous (IV) sites and wounds and failed to follow physician orders to secure an indwelling catheter. The facility census was 29. The facility provided no policy for following physician orders upon request. Review of the facility policy Wound Treatment Management with a revision date of 4/2025 showed the following:-To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders;-The facility will follow specific physician orders for providing wound care. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to secure indwelling catheter drainage tubing and bags for two residents (Resident 4, and #5), in a review of ten residents with indwelling catheters. These failures increased the residents' risk for urinary tract infections. The facility census was 29. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the safety of one resident (Resident #1), of seven sampled residents. While assisting the resident to transfer from the toilet to his/her new motorized chair, staff ran the motorized chair over the resident's left foot. The resident sustained a fractured toe. The facility census was 66. Review of the facility policy for Accidents and Supervision dated 07/2024 showed the following:-The resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devises to prevent accidents. This includes identifying hazards(s) and risk(s); evaluating and analyzing hazards(s) and risk(s); implementing interventions to reduce hazards(s) and risk(s); [...]

Inspectors wroteBased on interview and record review, the facility failed to notify one resident's (Resident #1) physician, in a review of three sampled residents, that ordered medications were not available for administration. The census was 36. Review of the facility policy, Notification of Changes, last revised 4/2025 showed the following: -The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician, and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification; -The facility must inform the resident, consult with the resident's physician and /or notify the resident's family member or legal representative when there is a change requiring such notification; [...]

Inspectors wroteBased on interview and record review, the facility failed to follow physician orders for one resident (Resident #1), in a review of three sampled residents, when staff did not administer medications or complete assessments as ordered. Further review showed the medications not administered were available through the facility Pyxis (emergency medication supply available for the facility to pull medication from and use for resident administration) system and as stock medications. The census was 36. Review of the facility policy, Medication Administration, last revised 7/2024, showed: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice; Policy Explanation and Compliance Guidelines: 9. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete weekly skin assessments per facility policy for two residents, (Resident #1 and #2), of five sampled residents. Resident #1 admitted to the facility with no pressure ulcers (a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Staff failed to identify any issue with the resident's skin before the resident presented with a Stage III pressure ulcer on the resident's buttocks on 1/19/25 (Full thickness skin loss involving damage to, or necrosis of, subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue). [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the physician and/or responsible parties when two residents (Residents #1 and Resident #2), in a review of six sampled residents, had a change in condition. The facility census was 34. Review of the facility policy for Notification of Changes dated 7/2024 showed the following: -The purpose of this policy is to ensure the facility promptly inform the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification; -Circumstances requiring notification include significant change in the residents physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status, and transfer or discharge of a resident from the facility; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the safety of one resident (Resident #1), of four sampled residents, who was dependent upon staff for transfers and at risk for falls. The facility failed to ensure staff followed facility policy for using a sit to stand lift. Certified Nurse Aide (CNA) A transferred Resident #1 using the sit to stand lift without assistance of an additional staff to transfer the resident. The resident sustained significant pain and bruising from the improper transfer. The facility census was 36. The administrator was notified on 9/30/24 at 3:00 P.M , of the Past Non-Compliance which occurred on 9/24/24. [...]

Inspectors wroteRefer to ES4312 Based on observation, interview, and record review, the facility failed to promote self-determination through support of resident choice by failing to ensure staff provided three residents (Resident #8, #9 and #10), in a review of 12 sampled residents, showers per their preferences. The facility census was 29. Review of the facility policy for Activities of Daily Living (ADLs) dated 6/2023 showed the following: -The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable; -Care and services will be provided for the following activities of daily living: bathing, dressing, grooming and oral care; transfer and ambulation; toileting; eating to include meals and snacks; [...]

Inspectors wroteRefer to ES4312 Based on interview and record review, the facility failed to follow professional standards of practice for two residents (Residents #11 and #12), in a review of 21 sampled residents. The facility failed to document the administration of narcotics. The facility census was 29. Review of facility policy for Medication Administration dated 6/2023 showed the following: -Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection; -Review the Medication Administration Record (MAR) to identify the medication to be administered; -Administer medication as ordered; -Sign the MAR after administration; -If the medication is a controlled substance, sign the narcotic bock. [...]

Inspectors wroteRefer to ES4312 Based on observation, interview, and record review, the facility failed to provide timely assistance for one dependent resident (Resident #10), in a review of 12 sampled residents when the resident was incontinent. Staff failed to provide incontinence care when staff found the resident incontinent of feces. The resident lay soiled for approximately two hours and reported staff would turn off her call light and not assist him/her. The resident reported he/she had to eat breakfast while wearing a soiled brief. The facility census was 29. Review of the facility policy for Activities of Daily Living (ADLs) dated 6/2023 showed: -The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADL's do not deteriorate unless deterioration is unavoidable; [...]

Inspectors wroteBased on observation, staff interview, and facility policy review, the facility failed to ensure clean pans were air dried prior to storage and not stacked wet. This failure had the potential to increase the risk of foodborne illness and had the potential to affect 38 of 38 residents in the facility who received dietary services at the time of the survey. The census was 38.

Inspectors wroteBased on observations, interviews, record review, and review of facility policies, the facility failed to ensure that staff and visitors were wearing the appropriate personal protective equipment (PPE) for one resident of two residents (Resident (R) 90) on isolation precautions. The facility failed to ensure the water management program was consistently maintained. The census was 38.

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote self-determination through support of resident choice by failing to ensure staff provided three residents (Resident #8, #9 and #10), in a review of 12 sampled residents, showers per their preferences. The facility census was 29. Review of the facility policy for Activities of Daily Living (ADLs) dated 6/2023 showed the following: -The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable; -Care and services will be provided for the following activities of daily living: bathing, dressing, grooming and oral care; transfer and ambulation; toileting; eating to include meals and snacks; and using speech, language or other functional communication systems; [...]

Inspectors wroteBased on interviews, record review, and review of facility policy the facility failed to ensure that baseline care plans were developed and/or presented to the resident and/or the responsible party within 48 hours of admission for 13 residents (Resident (R) 1, R83, R90, R14, R15, R20, R30, R3, R4, R18, R29, R134, and R135) reviewed for baseline care plans. The census was 38.

Inspectors wroteBased on observations, interviews, and review of facility policy, the facility failed to ensure that two of two medication carts and one of two treatment were locked and secured on two of two resident halls. This failure creates a risk of medications being misappropriated or tampered with. The census was 38.

Inspectors wroteBased on observation, interview, and review of facility policy the facility failed to maintain a clean environment for one of two residents (Resident (R )90) in contact isolation from a sampled 15 residents. The census was 38.

Inspectors wroteBased on interview and record review, the facility failed to notify the resident and/or resident's responsible party and the Ombudsman of a transfer or discharge in writing for two of two residents (Resident (R) 18 and R30) reviewed for hospitalization. The census was 38. Review of the facility policy Notification of Changes dated 06/2023 (sic), revealed, the purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. The facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification. [...]

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed ensure two of two residents (Resident (R) 18, and R30) reviewed for hospital transfers were given a written copy of a bed hold notice prior to or within 24-hours of emergency transfer to the hospital. This failure created the potential for residents and/or responsible parties to not have the information needed to safeguard their return to the facility. The census was 38.

Inspectors wroteBased on interview and record review, the facility failed to follow professional standards of practice for two residents (Residents #11 and #12), in a review of 21 sampled residents. The facility failed to document the administration of narcotics. The facility census was 29. Review of facility policy for Medication Administration dated 6/2023 showed the following: -Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection; -Review the Medication Administration Record (MAR) to identify the medication to be administered; -Administer medication as ordered; -Sign the MAR after administration; -If the medication is a controlled substance, sign the narcotic bock. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide timely assistance for one dependent resident (Resident #10), in a review of 12 sampled residents when the resident was incontinent. Staff failed to provide incontinence care when staff found the resident incontinent of feces. The resident lay soiled for approximately two hours and reported staff would turn off her call light and not assist him/her. The resident reported he/she had to eat breakfast while wearing a soiled brief. The facility census was 29. Review of the facility policy for Activities of Daily Living (ADLs) dated 6/2023 showed: -The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADL's do not deteriorate unless deterioration is unavoidable; [...]

Inspectors wroteBased on observations, interview, record review, and review of facility the facility failed to properly secure foley catheters and position the urinary drainage bags for two residents from four residents (Resident (R) 3 and R90) with indwelling catheters. These failures increased the risk for urinary tract infections in the residents. The census was 38.

Inspectors wroteBased on observation, interview, record review, and review of facility policy, the facility failed to ensure a medication error rate below five percent. During medication administration two medication errors for Resident (R) 92 were made from 25 opportunities during medication administration. The medication error rate was 8.0 percent. The census was 38.

Inspectors wroteBased on observation, interview, record review, and review of facility policy, the facility failed to ensure that one resident out of 15 sampled residents (Resident (R) 92) received the anticoagulant medication according to the physician's orders. This failure to provide the anticoagulant had the potential to contribute to the development of thrombosis (blood clots). The census was 38.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to ensure garbage was properly disposed of and contained for one of one facility dumpsters. The census was 38.

Inspectors wroteBased on interview, review of facility documentation, and review of facility policy, the Quality Assurance and Performance Improvement (QAPI) committee failed to ensure the required members of the committee attended the quarterly meetings for two of four quarters reviewed. The census was 38.