Quarters at Des Peres: Fall Documentation Failure - MO
Federal inspectors arrived on August 29 and began asking questions. LPN C told them that neuro checks are completed after any fall, witnessed or not, and that the Assistant Director of Nursing makes sure of it. The administrator said the same thing: neuro checks are done on paper, then scanned into the medical record.
The Director of Nursing said she expected the fall assessment to be completed on admission, the neuro checks to be done immediately, and PRN pain medications to be offered and documented. She expected all of it.
None of it was there.
"It is not in the medical record, it was not scanned in," the Director of Nursing told inspectors. She said she expected staff to be knowledgeable of and follow facility policies. She expected physician's orders to be followed. She expected documentation.
The emergency room record from August 25 showed the resident was alert and oriented, reported the fall had happened three days earlier, and presented with the forehead injury and complaints of dizziness. Whether anyone at the facility had offered pain medication in the days between the fall and the ER visit, or completed any assessment at all, could not be confirmed from the medical record because the record did not reflect it.
The inspection was filed as a complaint. The level of harm was listed as minimal harm or potential for actual harm, and few residents were listed as affected. The facility is located at 13230 Manchester Road.
The resident had been spinning for three days before anyone outside the building knew about it.
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.
Download the official CMS inspection PDF from Medicare.gov
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 19, 2026 · Our methodology
QUARTERS AT DES PERES, THE in DES PERES, MO was cited for violations during a health inspection on August 29, 2025.
Federal inspectors arrived on August 29 and began asking questions.
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.