Quarters at Des Peres: Dialysis Tracking Failures - MO
At The Quarters at Des Peres, nobody told the doctor.
A complaint inspection completed August 29, 2025 found that when two residents had their dialysis treatments end early on August 16 and August 26, staff did not notify the physician or the responsible party. Inspectors classified the violations as causing minimal harm or the potential for actual harm, and noted that some residents were affected.
The early terminations were only part of what inspectors found.
For Resident 19, a person living with kidney failure, heart failure, high blood pressure, weakness, and problems with gait and mobility, the facility's own dialysis communication forms were missing for twelve separate dates between July and August: July 18, July 23, July 25, July 30, August 4, August 11, August 15, August 18, August 22, August 25, August 27, and August 29. Those forms are supposed to be completed every time a resident attends dialysis and then scanned into the medical record. On each of those twelve days, there is no documentation of what happened at treatment.
Resident 19's care plan did identify dialysis as a focus area. It listed goals for immediate intervention if complications arose, and it named specific warning signs staff were supposed to watch for: bleeding, hemorrhage, bacteremia, septic shock. It acknowledged that septic shock is a life-threatening condition that can follow infection entering the bloodstream. What the care plan did not include was the scheduled chair time for when the resident would receive treatment.
That same gap appeared in the care plans for two other residents.
Resident 2, whose diagnoses included dependence on renal dialysis, respiratory failure with hypoxia, heart failure, and high blood pressure, had a care plan dated August 8 that did not mention dialysis at all. The order summary showed dialysis on Mondays, Wednesdays, and Fridays, but the order itself listed neither the location where the resident would receive treatment nor the scheduled chair time.
Resident 4, who has diabetes, high blood pressure, cognitive communication deficits, and weakness in addition to kidney failure requiring dialysis three times a week, had a care plan dated August 20. It described the dialysis schedule and listed interventions for monitoring complications. It did not list the scheduled chair time.
The Administrator and Director of Nursing were interviewed together on August 28. They said they expected staff to follow physician orders and to be knowledgeable of facility policies. They expected dialysis communication forms to be completed each day a resident attended dialysis and then scanned into the medical record. They expected care plans for dialysis residents to include the location of treatment, the days of the week, and the chair time.
What inspectors documented was something different from those expectations. Twelve missing communication forms. Two care plans without a chair time. One care plan that did not identify dialysis at all. Two instances of early treatment termination with no physician notification.
Dialysis is not an optional appointment. For a person whose kidneys have failed, it performs the work the kidneys no longer can, filtering waste and excess fluid from the blood. A treatment that ends early does not fully complete that work. A physician who does not know a treatment ended early cannot assess whether the resident needs monitoring, a follow-up, or a change in care.
The communication forms that were missing for Resident 19 across twelve dates represent the facility's own mechanism for tracking what happened at each session, what the resident's condition was, and whether anything required a clinical response. Twelve dates without that record means twelve sessions with no documented loop closed.
The Administrator and Director of Nursing said they expected those forms to exist. For Resident 19, across more than six weeks of treatment this summer, they did not.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Quarters At Des Peres, The from 2025-08-29 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 27, 2026 · Our methodology
QUARTERS AT DES PERES, THE in DES PERES, MO was cited for violations during a health inspection on August 29, 2025.
At The Quarters at Des Peres, nobody told the doctor.
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.