Quarters at Des Peres: Fall Documentation Failures - MO
The resident was trying to get up without calling for help.
A nurse assessed for bruising and redness and found none. But the resident reported pain in the left arm and right shoulder. A certified nursing aide helped lift the person back into bed. The bed was lowered and locked. A Tylenol was given.
That same evening, a family advocate arrived at the bedside and asked about the resident's medications. The resident's son joined by phone. There were more concerns about the arm. A physician was contacted. A new order was written for x-rays of the left upper extremity. By 8:01 p.m., an x-ray technician was in the room.
The next morning's note, written at 7:12 a.m., described the resident resting comfortably in a low bed, easily aroused, with continued left-side weakness. Staff flushed the resident's feeding tube. They provided incontinence care. The head of the bed was elevated. The call light was in reach.
After that, the medical record goes quiet.
Inspectors who arrived at the facility on August 29 reviewed the documentation and found no record that the resident had been transported to a hospital. No transfer form. No change-in-condition form. No progress note indicating where the resident went, when, or why.
The Director of Nursing, interviewed that afternoon, described exactly what should have happened. Staff complete a change-in-condition form and a transfer form when a resident leaves for the hospital, she said. They get physician orders. They notify the resident's representative. If a resident is unresponsive, family gets a call. She said she expected there to be a progress note, one that included vital signs and the name of whoever was notified. If staff couldn't document in real time, they should have gone back and recorded what time emergency medical technicians arrived. She said nursing staff were expected to report whenever a resident was sent to the hospital.
None of that was in the record.
The resident's care plan, reviewed by inspectors on the day they arrived, laid out the situation clearly. The resident was at risk for falls, confusion, and physical decline. The goal was for the resident to remain free of minor injury. Interventions included keeping the bed low with a fall mat on the floor, ensuring the bed was placed against the wall at the family's request, reviewing past falls to identify causes, and making sure the resident wore proper footwear whenever moving.
The resident had already fallen before August 22. The care plan called for staff to look at each fall, try to identify the root cause, remove whatever contributed to it, and educate the resident, family, and the entire care team.
What the care plan did not account for was a gap in the record so complete that inspectors could not determine from the facility's own documentation what happened to this person after the x-ray technician left the room.
The Director of Nursing said staff are supposed to know where a resident is being taken when transported by ambulance. If they know, it belongs in the progress note. She said she expected nursing staff to report it.
The inspection was classified as a complaint survey. The level of harm was listed as minimal harm or potential for actual harm. The deficiency affected some residents at the facility.
The resident who fell on August 22 was dealing with consequences of a stroke, a condition called posterior reversible encephalopathy syndrome that causes swelling in the back of the brain, iron deficiency anemia, muscle weakness, and hemiplegia. Getting in and out of bed alone was not safe. The care plan said so. The fall proved it.
What the records do not say is what the x-rays showed, or where the resident was taken, or whether the family was ever told.
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.
The resident was trying to get up without calling for help.
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.