Sunterra Springs Dardenne Prairie: Catheter Neglect - MO
The tubing was not anchored to the resident's leg. There was sediment visible inside it. The drainage bag had no cover and was visible from the hallway doorway. And the resident, when offered catheter care by the facility's Assistant Director of Nursing, said it had been several days since anyone had provided it.
The inspection report does not say how many days.
The Assistant Director of Nursing and a registered nurse, identified in the report as RN A, were both present during the 2:35 p.m. observation. The ADON offered to perform catheter care on the spot. To do so, staff helped the resident rise to a standing position. As the resident stood, the unanchored tubing pulled. The resident said they could feel it pulling down.
RN A acknowledged the tubing should not have been on the floor. She said she was going to call the physician about the sediment.
The Director of Nursing, interviewed earlier that same morning, laid out exactly what should have been happening. Catheter care should be done every shift. The tubing should be anchored to the resident's leg to prevent pulling and should be changed weekly, with the date marked when changed. The tubing should never be on the floor. The drainage bag should be covered.
None of that had been done.
A catheter tube lying on a floor picks up whatever is on that floor. For a resident already using an indwelling urinary catheter, the path from a contaminated tube to a urinary tract infection is short. Urinary tract infections in elderly residents can progress rapidly, causing confusion, sepsis, and hospitalization. The inspection report classified the harm level as minimal harm or potential for actual harm, and noted few residents were affected.
The sediment visible in the tubing was enough that a nurse said she needed to call a physician. The report does not say what the physician was told, or what they said back.
What the report makes clear is that the resident knew. They knew they hadn't received catheter care in days. They felt the tube pulling when they stood up. They were sitting in a wheelchair with a drainage bag visible to anyone who walked past their open door, no cover, no anchor, tubing on the floor.
The Director of Nursing told inspectors she would expect staff to provide catheter care every shift, keep the tubing off the floor, secure it with an anchor, and date the anchor when applied. She described a standard of care that the inspection found had not been met for this resident over a period of at least several days.
The complaint inspection was completed November 5, 2025. Sunterra Springs Dardenne Prairie is located at 7275 State Highway N in Dardenne Prairie, Missouri.
The resident felt the catheter pulling as they tried to stand up. That is where the record ends.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Sunterra Springs Dardenne Prairie from 2025-11-05 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 23, 2026 · Our methodology
SUNTERRA SPRINGS DARDENNE PRAIRIE in DARDENNE PRAIRIE, MO was cited for neglect violations during a health inspection on November 5, 2025.
The tubing was not anchored to the resident's leg.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.