Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Sunterra Springs Dardenne Prairie during CMS and state inspections, most recent first.
Staff failed to perform proper hand hygiene and change gloves between clean and dirty tasks while providing personal care to multiple residents with complex medical needs, and did not handle soiled linens according to facility policy, resulting in lapses in infection prevention and control.
Staff did not follow physician orders for wound and catheter care for two residents, resulting in missed and undocumented dressing changes, lack of catheter care, and failure to secure indwelling catheters. Observations showed overdue and soiled dressings, catheter tubing touching the floor, and missing documentation, with staff and leadership confirming these deficiencies.
Two residents with indwelling urinary catheters did not receive required catheter care every shift, and their catheter tubing was not anchored or kept off the floor. Catheter drainage bags were left uncovered and visible, and residents reported not receiving catheter care for several days, contrary to facility policy and physician orders.
A deficiency was cited due to the facility's failure to keep an area free from accident hazards and to provide adequate supervision to prevent accidents. The environment did not meet safety standards, and there was insufficient supervision in the area.
A resident with multiple chronic conditions missed several doses of prescribed medications due to unavailability, and nursing staff did not notify the physician as required. Documentation showed the missed doses, but there was no evidence of physician notification, as confirmed by staff interviews and review of progress notes.
A resident with multiple chronic conditions did not receive several ordered medications or required pain assessments due to staff not utilizing available medications in the Pyxis system and stock supplies. Documentation was incomplete, and an agency LPN reported not having access to the Pyxis, resulting in missed doses and assessments despite facility policy and available resources.
Two residents at risk for pressure ulcers did not receive weekly skin assessments as required by facility policy, and their care plans lacked appropriate interventions for pressure relief. As a result, one developed a Stage III pressure ulcer on the buttocks, and the other developed unstageable pressure ulcers and a suspected deep tissue injury on the feet, which were only discovered after significant progression. Staff interviews confirmed that assessments and documentation were incomplete, and care plans were not updated to address the residents' needs.
The facility failed to notify responsible parties when two residents were hospitalized due to changes in their conditions. One resident, with multiple health issues, was sent to the hospital after exhibiting delusions, but their contact information was missing from the face sheet. Another resident experienced shortness of breath and was hospitalized, but their emergency contact was not informed. The facility's process for recording and updating contact information was flawed, leading to these notification failures.
A resident with multiple health conditions and requiring full assistance for transfers was improperly transferred by a CNA using a sit-to-stand lift without the required second staff member. This resulted in significant pain and bruising for the resident. The CNA, an agency employee, was aware of the policy but proceeded alone due to the resident's request and lack of available help.
Failure to Follow Infection Control Protocols During Resident Care
Penalty
Summary
Staff failed to follow established infection prevention and control protocols during personal care for four residents, as observed and documented by surveyors. In multiple instances, certified nurse aides (CNAs) did not perform proper hand hygiene before donning gloves, after removing gloves, or between clean and dirty tasks. For example, a CNA provided incontinence care to a resident with an indwelling catheter without washing hands before or after glove use, and handled clean items such as briefs and ointment with soiled gloves. Similar lapses were observed with other residents, where CNAs applied creams, changed briefs, and touched various surfaces and resident belongings without changing gloves or performing hand hygiene between tasks. Additionally, staff did not adhere to facility policy regarding the handling of soiled linens. In one case, a CNA placed soiled washcloths and briefs on the resident's bed and later disposed of them without changing gloves or washing hands. In another instance, a soiled washcloth was thrown on the floor, and a plastic bag containing soiled wipes and gloves was tossed onto the hallway floor. These actions were inconsistent with the facility's policy, which requires soiled linens to be bagged at the point of use and handled with minimal agitation to prevent contamination. The residents involved had significant medical needs, including indwelling catheters, incontinence, and conditions such as spinal stenosis, diabetes, kidney failure, and dementia. They were dependent on staff for personal hygiene and toileting. Despite these vulnerabilities, staff did not consistently follow infection control standards, as confirmed by both observation and staff interviews. The Director of Nursing acknowledged that staff should perform hand hygiene before and after care, and that soiled linens should not be placed on the floor.
Failure to Follow Physician Orders for Wound and Catheter Care
Penalty
Summary
Staff failed to follow physician orders for two residents, resulting in missed and undocumented treatments for wounds, intravenous (IV) sites, and indwelling catheters. For one resident with osteomyelitis, multiple sclerosis, and a stage 4 pressure ulcer, physician orders required weekly skin checks, specific wound care, regular PICC line dressing changes, and routine catheter care. Documentation revealed that several ordered dressing changes and skin checks were not completed or recorded, and catheter care and anchor changes were not included on the treatment records for staff to document. Observations confirmed that the PICC line dressing was overdue for change, the wound dressing was soiled and not changed as ordered, and there was no anchor securing the urinary catheter. Another resident with a history of urinary tract infection, urinary retention, and chronic kidney disease also had physician orders for weekly skin assessments, catheter care every shift, and regular anchor changes. Observations showed the resident's catheter tubing was touching the floor, there was visible sediment in the tubing, and no anchor was securing the catheter to the leg. The resident reported not receiving catheter care for several days, and staff confirmed that the catheter tubing should not be on the floor and that the anchor was missing. Interviews with nursing staff and the Director of Nursing confirmed that staff did not follow physician orders for wound and catheter care, and that required documentation was missing from the treatment records. The facility was unable to provide a policy for following physician orders when requested, and the observed failures were not in accordance with the facility's own wound treatment and skin assessment policies.
Failure to Provide Proper Catheter Care and Securement
Penalty
Summary
The facility failed to provide appropriate care for residents with indwelling urinary catheters, as evidenced by observations and interviews involving two residents. For one resident with multiple sclerosis and neurogenic bladder, the catheter drainage bag was not covered with a dignity bag, and the catheter tubing was not anchored to the resident's leg as required by facility policy. The resident reported that catheter care had not been performed for several days, despite orders and care plans specifying catheter care every shift and the use of a drainage bag cover. Observations confirmed the absence of a drainage bag cover and anchor during wound care provided by the ADON and RN. Another resident with urinary retention, chronic kidney disease, and a history of urinary tract infection was observed with catheter tubing hanging down and touching the floor, visible sediment in the tubing, and no dignity cover on the drainage bag. The resident also reported not receiving catheter care for several days. During further observation, the catheter tubing was still not anchored, and the resident experienced discomfort from the tubing pulling when standing. The DON confirmed that catheter care should be performed every shift, the tubing should be anchored and not touch the floor, and the drainage bag should be covered, all of which were not followed for these residents.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which could contribute to the risk of accidents for residents. Specific actions or inactions leading to this deficiency include the lack of proper hazard identification and insufficient supervision in the affected area. No additional details about specific residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Notify Physician of Missed Medication Doses
Penalty
Summary
The facility failed to notify a resident's physician when ordered medications were not available for administration. A review of the medical record for a resident admitted with diagnoses including hypertension, hyperlipidemia, anxiety disorder, acid reflux, and uncontrolled diabetes mellitus type II showed that several prescribed medications—gabapentin, Pepcid, rosuvastatin, and extra strength Tylenol—were not administered as ordered due to unavailability. Documentation on the Medication Administration Record (MAR) and progress notes indicated that the medications were not given, but there was no evidence that the physician was notified of the missed doses. Interviews with nursing staff confirmed that the physician should have been notified when medications could not be administered, but this was not done. The Director of Nursing also stated that it was the responsibility of nursing staff to notify the physician and document such notifications, but was unaware of the missed medications. The resident missed a total of seven doses across multiple medications, and the lack of physician notification was not documented in the progress notes as required by facility policy.
Failure to Administer Ordered Medications and Complete Assessments
Penalty
Summary
The facility failed to follow physician orders and professional standards of quality for one resident by not administering prescribed medications and not completing required assessments as ordered. The resident, who had diagnoses including hypertension, hyperlipidemia, anxiety disorder, acid reflux, and uncontrolled diabetes, was admitted in the evening and had several medications ordered, including gabapentin, Pepcid, rosuvastatin, and extra strength Tylenol. Despite these medications being available through the facility's Pyxis system and as stock medications, staff did not administer them as ordered and did not document appropriate reasons for the omissions. Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) showed that on multiple occasions, the administration boxes for the resident's medications were either marked as not administered or left blank, and pain assessments were not consistently documented. Progress notes indicated that medications were not available, but there was no documentation that staff attempted to obtain the medications from the Pyxis system, even though they were available. Additionally, extra strength Tylenol, which was available as a stock medication, was not administered. Interviews with nursing staff revealed that an agency LPN did not have access to the Pyxis system and therefore did not administer the medications. The DON confirmed that medications should be administered as ordered, and that staff are expected to utilize the Pyxis or stock medications if the resident's medications are unavailable. The facility had processes in place for obtaining medications after hours, but these were not utilized, and there was no documentation to support that all available resources were used to provide the ordered medications and assessments.
Failure to Complete Weekly Skin Assessments and Prevent Pressure Ulcers
Penalty
Summary
The facility failed to complete weekly skin assessments as required by its own policy for two residents who were at risk for pressure ulcers. One resident was admitted with no pressure ulcers and was dependent on staff for activities of daily living, including transfers and walking, and was occasionally incontinent. Despite being identified as at risk for pressure ulcers and having a care plan that included weekly skin checks, there were multiple instances where the skin assessment section in the nursing notes was left blank with no documentation. The resident subsequently developed a Stage III pressure ulcer on the buttocks, which was only identified after it had already progressed to an advanced stage. Staff interviews confirmed that no skin issues were identified prior to the discovery of the ulcer, and the wound was not assessed until it was already open and deep. Another resident, also admitted without pressure ulcers but at risk due to incontinence and dependence on staff, did not have interventions in the care plan to address pressure relief for the heels, despite being known to slide down in bed and not consistently keeping pressure off the heels. The resident's care plan did not include specific interventions for heel protection, and weekly skin assessments were not documented. Therapy staff discovered wounds on the resident's feet, including unstageable pressure ulcers and a suspected deep tissue injury, which had not been previously identified or addressed in the care plan. Nursing notes for this resident also showed multiple dates where skin assessments were not documented. Interviews with staff, including CNAs, RNs, the DON, and the facility's medical director, confirmed that the facility's policy required weekly skin assessments and documentation, as well as prompt notification and intervention for any skin issues. However, the required assessments were not consistently performed or documented, and interventions for pressure relief were not implemented or updated in the care plans. The lack of timely assessment and intervention led to the development and progression of pressure ulcers in both residents.
Failure to Notify Responsible Parties of Residents' Hospitalization
Penalty
Summary
The facility failed to notify the physician and/or responsible parties when two residents experienced a change in condition. Resident #1, who was admitted with diagnoses including diabetes with a foot ulcer, vascular disease, stage four kidney disease, and atrial fibrillation, was sent to a local hospital after exhibiting delusions and confusion. Despite being alert and oriented upon admission, the resident's face sheet lacked emergency or family contacts. The Social Services Director acknowledged that Family Member A was the responsible party, but this information was not recorded on the face sheet. Consequently, Family Member A was not informed by the facility about the resident's hospitalization. Resident #2, who was also alert and oriented, experienced shortness of breath and was sent to the hospital after 911 was called. The resident's face sheet listed Family Member B as the emergency contact, but there was no documentation that the facility notified Family Member B about the resident's condition change or hospitalization. Family Member B only learned of the hospitalization through the hospital's notification. Interviews with facility staff, including the Director of Nursing and the Administrator, revealed that the facility's process for recording and updating contact information was flawed. The Central Intake, responsible for inputting resident information, failed to ensure that contact details were accurately recorded on the face sheets. The Director of Nursing expected nurses to document contact attempts and escalate issues if contact could not be made, but this protocol was not followed in these cases.
Improper Transfer Leads to Resident Injury
Penalty
Summary
The facility failed to ensure the safety of a resident who was dependent on staff for transfers and at risk for falls. The deficiency occurred when a Certified Nurse Aide (CNA) used a sit-to-stand lift to transfer the resident without the assistance of an additional staff member, contrary to the facility's policy. This improper transfer resulted in the resident experiencing significant pain and bruising. The resident involved had a medical history that included coronary heart disease, atrial fibrillation, diabetes, and peripheral vascular disease. The resident required total staff assistance with transfers and had impairments in both lower extremities. On the day of the incident, the resident reported severe pain during the transfer, describing a popping sensation in the right shoulder and subsequent bruising. The CNA involved was an agency employee who did not receive a report from the previous staff member and was unaware of the resident's specific transfer needs. Despite knowing the policy required two staff members for mechanical lift transfers, the CNA proceeded alone due to the resident's request to be put to bed and the inability to find assistance. The CNA acknowledged awareness of the policy but chose to operate the lift independently, leading to the resident's injury.
Removal Plan
- Staff did not follow the facility policy for a sit to stand transfer.
- In-servicing all staff on safety, the facility policy to use two staff members for all mechanical lift transfers, and competencies for staff on the use of the sit to stand lift.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Dardenne Prairie
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cottages Of Lake St Louis | 1.4 mi | — | 1 | 0 |
| Delmar Gardens Of O'fallon | 2 mi | — | 1 | 0 |
| Garden View Care Center | 4.1 mi | — | 2 | 0 |
| Abbey Senior Health | 4.3 mi | — | 1 | 0 |
| Lutheran Senior Services At Breeze Park | 6.1 mi | — | 0 | 0 |
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