Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 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.
A resident with a left hip surgical incision, anemia, diabetes, multiple myeloma, and anticoagulant use developed increased wound drainage and bleeding. Staff documented heavy sanguineous drainage and contacted the surgeon’s office, but communication broke down around the earlier office visit, the resident was not seen as planned, and there was no documented ongoing wound assessment for several days. The incision later dehisced with staples detached and bulging tissue, and the resident was then sent to the hospital.
The facility failed to consistently provide written transfer/discharge notices and bed-hold information when four residents were sent to the hospital. Records showed transfers for cough and dyspnea, low blood sugar and lethargy, unsafe behaviors, and aggressive behaviors/agitation, but there was no evidence that the residents or their representatives received the required notices. Interviews confirmed nursing staff were responsible for the paperwork and that notices were being missed.
Insulin pens were not primed before administration for three residents with diabetes. An ADON administered Lispro and Lantus without priming the pens for two residents, and an LPN administered Aspart and Lantus without priming for another resident. Facility policy and the manufacturers’ instructions required priming before each injection, and the ADON later stated the pens were only primed when first opened rather than before every dose.
Staff failed to follow hand hygiene, glove changes, contaminated linen handling, and EBP/PPE requirements during direct resident care. Observations showed CNAs and an RN moving between dirty and clean tasks without hand hygiene, handling wounds, catheters, ostomy care, and incontinence care with the same gloves, and entering rooms requiring EBP without gowns despite posted signs and available PPE. Residents involved had catheters, PICC lines, wounds, ostomies, and incontinence needs.
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 Monitor and Report Worsening Surgical Wound
Penalty
Summary
The facility failed to provide documentation of ongoing assessments of a surgical wound as directed by its wound treatment management policy for one resident whose left hip surgical incision deteriorated. The resident had diagnoses including a pathological fracture of the left femur, orthopedic aftercare, acute posthemorrhagic anemia, diabetes, and multiple myeloma, and was receiving apixaban. The care plan identified the resident as at risk for bleeding, skin impairment, wound complications, and infection, and the physician ordered daily wound care to the left hip incision with a pressure dressing. The resident’s wound was initially documented as approximated with no dehiscence, but later staff noted increased bleeding and drainage from the incision. On 05/06/26, the ADON assisted with a dressing change and observed moderate to heavy sanguineous drainage from the distal end of the incision; the nurse documented that the surgeon would be updated. Staff contacted the surgeon’s office that day, and the surgeon’s nurse requested that the resident be seen the next morning because of the increased drainage. LPN A reported that transportation could not confirm the earlier appointment, so the afternoon appointment was kept, but when the resident arrived, the appointment had been canceled and the surgeon was gone for the day. The medical record contained no documentation of wound assessments from 05/06/26 until 05/11/26. During that interval, staff did not document ongoing evaluation of the wound despite the increased bleeding and drainage. On 05/11/26, the incision was found dehisced with staples detached and red/brown tissue bulging from the wound, and staff then contacted the surgeon and the on-call physician, who ordered transfer to the hospital. The resident’s family member stated the facility did not react sooner to the bleeding and drainage, and the surgeon’s office staff reported they did not receive follow-up communication from the facility after the missed office visit. The resident’s physician stated that if the facility had contacted him after the surgeon did not see the resident, he would have contacted the surgeon for further instructions, and that the resident could have been sent to the ED a couple of days earlier.
Missing transfer/discharge and bed-hold notices
Penalty
Summary
The facility failed to follow its discharge and transfer notice process for four residents who were transferred from the facility to the hospital. The facility’s April 2025 policy required that residents and/or their representatives receive a written transfer/discharge notice in a language and manner they could understand, including the reason for transfer or discharge, the effective date, and the specific location of transfer. The policy also required written bed-hold information to be provided before and upon transfer, including the duration of any state bed-hold, reserve bed payment policy, facility bed-hold policies, and conditions for return. For Resident #42, who was cognitively intact and his/her own responsible party, staff documented transfer to the hospital for increased cough and dyspnea, but there was no documentation that anyone was notified or that written transfer or bed-hold information was provided. The resident later returned from the hospital, and during interview stated the facility did not explain or give a written copy of the transfer/discharge and bed-hold process when sent out, and that staff told him/her he/she needed to go to the hospital due to cough and dyspnea. For Resident #34, whose family member was the responsible party, staff documented transfer to the hospital for low blood sugar and lethargy, but the record showed no evidence that the resident’s representative received a written transfer notice. For Resident #9, who was documented as having severe cognitive impairment on the MDS, staff recorded transfer to the hospital for unsafe behaviors, but there was no documentation that anyone was notified or that bed-hold information was provided, and no evidence of a written transfer notice to the resident or representative. For Resident #47, who was his/her own responsible party, staff documented transfer to the hospital for aggressive behaviors/agitation, but the record showed no evidence that the resident received a written transfer/discharge notice or bed-hold information. Interviews with an agency RN, the regional nurse, and the administrator confirmed that nursing staff were responsible for completing and providing these notices, and the regional nurse stated notices were not completed consistently and were being missed.
Insulin pens were not primed before administration
Penalty
Summary
Facility staff failed to ensure residents were free from significant medication errors when insulin pens were not primed before administration, as required by facility policy and the manufacturers’ instructions. The facility policy stated insulin pens are to be primed prior to each use to avoid air in the insulin reservoir, and the package inserts for Lispro Kwik Pen, Lantus Solostar Pen, and Aspart Flex Pen stated that if the pen is not primed before each injection, too much or too little insulin may be given. For one resident with type II diabetes, the January 2026 physician orders included Lispro insulin three units with meals and additional Lispro per sliding scale. During observation, the ADON obtained the resident’s Lispro pen, removed the cap, cleansed the tip, attached a new sterile needle, did not prime the pen, dialed up six units for the sliding scale dose and three units for the scheduled dose, and administered the insulin in the resident’s abdomen. The resident’s Accu check that morning was 276 mg/dL, and the ADON stated she was helping the nurse complete Accu checks and insulin administrations because the nurse was running late. For another resident with type II diabetes and hypoglycemia, the January 2026 orders included Lantus 14 units daily and Lispro per sliding scale. During observation, the ADON again obtained the resident’s Lispro pen and Lantus pen, cleaned each tip, attached new sterile needles, did not prime either pen, dialed up the ordered doses, and administered both injections in the resident’s abdomen. The ADON later stated insulin pens were to be primed with two units when first opened and used, not with each injection. For a third resident with type II diabetes, hyperglycemia, and diabetic polyneuropathy, an LPN obtained the resident’s Aspart pen and Lantus pen, attached new sterile needles, did not prime either pen, and administered the ordered one-unit Aspart sliding scale dose and 47-unit Lantus dose.
Infection Control Failures During Resident Care
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program when staff did not follow hand hygiene, glove-changing, contaminated linen handling, and enhanced barrier precautions (EBP) practices during resident care. The report identified failures for five residents with wounds, catheters, or other devices requiring EBP, and described multiple observations in which staff wore gloves without gowns when gowns were required, moved between dirty and clean tasks without changing gloves or performing hand hygiene, and touched clean items after contact with contaminated items. For one resident with an indwelling urinary catheter, bowel incontinence, osteomyelitis, and a stage IV sacral/coccyx pressure ulcer, CNAs provided incontinence care while wearing gloves and gowns, but one CNA removed the catheter drainage bag and handled clean items without removing gloves or performing hand hygiene, and both CNAs later repositioned the resident and assisted with dressing care while one CNA continued wearing the same gloves used during incontinence care. In a later observation, the same resident was repositioned by the CNAs while both wore gloves but no gowns, despite the EBP sign posted outside the room and PPE available in the hallway. For another resident with a urinary catheter, colostomy, stage IV sacral wound, and wound vac, a CNA entered the room wearing gloves but no gown, removed the resident’s gown, performed perineal and ostomy care, handled the catheter tubing and drainage bag, and exited and re-entered the room without hand hygiene. The CNA also handled the colostomy bag, soiled trash, and catheter equipment while alternating between contaminated and clean tasks without hand hygiene or gown use. Similar failures were observed with other residents: a RN performed wound care on multiple wounds and then handled the catheter bag and room items without hand hygiene or PPE; CNAs provided a bed bath to a resident with a PICC line and incontinence while wearing gloves but no gowns and touching soiled briefs, towels, and personal items with the same gloves; and a CNA provided incontinence care to another resident, placed soiled linens on the floor and in the bathroom, and moved from dirty to clean tasks without changing gloves or performing hand hygiene.
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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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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