Sunterra Springs Dardenne Prairie

In the surveyor’s words

From the most serious findings on record at Sunterra Springs Dardenne Prairie, in the surveyor’s own words.

• Actual harm, isolatedF689Jul 17, 2025

  Based 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. […]

• Actual harm, isolatedF686Mar 19, 2025

  Based 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. […]

• Actual harm, isolatedF689Sep 30, 2024

  Based 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. […]

• Actual harm, isolatedF600Jun 14, 2023

  Based on interview and record review the facility failed to ensure one resident (Resident #1) in a review of three sampled residents, was free from abuse when Certified Nurse Aide (CNA) A picked the resident up out of bed with his/her arms and aggressively transferred the resident from the wheelchair to the toilet, causing the resident to hit his/her back and head. The resident reported pain at the time and continued pain after the incident. The resident reported feeling helpless and was afraid of CNA A. The facility census was 29. […]

• Actual harm, isolatedF686Apr 12, 2022

  Based on interview and record review the facility failed to provide treatment and monitoring to promote healing for one resident with pressure ulcers and wounds (Resident #5). Resident #5 was admitted to the facility with a Stage III pressure ulcer on 1/27/21. The facility did not obtain or provide treatment to the pressure ulcer until 2/4/21. The wound deteriorated. The resident was hospitalized on [DATE] with deep tissue, unstageable, wounds to the right heel, right buttocks, right lateral foot, right leg and thigh, left mid spine, and left ankle. The resident also had unstageable wounds to the right ankle. These wounds were not identified or treated by the facility. A sample of five residents and six closed records were selected for review. The facility census was 16. […]