Quarters at Des Peres: Fall Safety Failures After Injury - MO
The resident was a patient at The Quarters at Des Peres, a nursing facility on Manchester Road. A complaint inspection completed August 29, 2025 documented what happened in the days between the first fall on August 22 and the emergency room visit on August 25.
When the resident arrived at the ER, they told staff they had fallen on Friday, which was August 22, and again that day. The ER record described a hematoma and abrasion on the left forehead. The resident reported a headache and said the room was spinning.
The nursing home's own care plan, dated August 25, the same day as the second fall and the ER visit, listed the resident as being at risk for falls and confusion. The interventions included a low bed with a fall mat, appropriate footwear, and a family request to place the bed against the wall. The plan called for reviewing past falls, identifying root causes, and educating staff, family, and the care team.
None of that prevented the resident from falling twice.
After falls, the facility's standard practice required neuro checks, pain assessments, and skin assessments, whether the fall was witnessed or not. LPN C told inspectors on the morning of August 29 that neuro checks are always completed 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 told inspectors she expected fall assessments to be completed upon admission, neuro checks to be done immediately after any fall, and pain medications to be offered and documented. Then she looked at the record.
The neuro checks were not there. They had not been scanned in.
"It is not in the medical record, it was not scanned in," the Director of Nursing told inspectors. She said she expected staff to follow physician orders and to be knowledgeable of facility policies.
There was also the matter of the pain medication. A physician had ordered acetaminophen 325 mg, one tablet via NG tube every six hours as needed for pain, starting August 21. The medication was not administered on August 21 or August 22. On August 22, the order was discontinued. A second medication order was also discontinued on August 28. The inspection report noted there were no progress notes at all for August 24 or August 25.
The resident who fell twice, who went to the emergency room with a head wound and reported dizziness, received none of the ordered pain medication in the days before the second fall. Whether anyone assessed whether they were in pain during that window is not documented, because the documentation does not exist.
CMS rated the deficiency at a level of minimal harm or potential for actual harm, the lower end of the harm scale. The inspection covered only a few residents.
The Director of Nursing said she expected physician orders to be followed. The orders were not followed. She said neuro checks should be completed immediately. They were completed, if staff accounts are accurate, but then they disappeared. She said pain assessments are part of the fall risk assessment form. The form, or whatever was on it, was never added to the record where anyone could review it.
What the record does contain is the emergency room report. A resident who a care plan described as at risk for falls and confusion, who had a fall mat and a bed pushed against the wall, fell on a Friday and again three days later, and told ER staff about both falls. The forehead injury was visible. The headache was reported. The dizziness was reported.
The nursing home's records for those three days are largely silent.
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: 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: August 5, 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 a patient at The Quarters at Des Peres, a nursing facility on Manchester Road.
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.