Quarters at Des Peres: Missed IV Doses for Brain Infection - MO
Inspectors from the Centers for Medicare and Medicaid Services cited the Quarters at Des Peres, a nursing home at 13230 Manchester Road, following a complaint inspection completed August 29, 2025. The deficiency was cited at the level of actual harm.
The resident's diagnoses included HHV-6 encephalitis, a form of brain inflammation, along with epilepsy, diabetes, and heart failure. A physician ordered intravenous acyclovir, an antiviral medication, three times daily beginning August 7, 2025. The care plan was explicit: administer the IV therapy as ordered, observe the insertion site for swelling, redness, and drainage, and report abnormal findings to the physician.
The medication administration record told a different story.
From the evening of August 7 through the night of August 9, seven consecutive scheduled doses were left blank. No documentation. No notation of why the medication wasn't given. No call to the physician. On August 11, a pharmacy representative called the facility to flag a problem with the original order — the dosage, storage requirements, and reconstitution process needed adjustment. A nurse verified a new dose with the physician that same morning: 1,000 milligrams three times daily. The pharmacy, according to a representative interviewed by inspectors on August 29, sent the first supply of acyclovir to the facility on August 11. That was four days after the order was written.
A new order for 750 milligrams every eight hours was placed on August 14, running through August 18. The pharmacy sent a seven-day supply. And then the pattern repeated.
On August 15 and 16, across four scheduled doses, nurses again documented "NA." A progress note from the evening of August 16 stated that the resident "remains on ABT Acyclovir 750mg intravenously" with "no adverse reaction noted." There was no acknowledgment that doses had been missed. No note explaining the "NA" entries. No documentation that anyone had told the physician.
The facility's own progress notes from August 13 described an interdisciplinary team meeting in which staff noted the resident was "compliant with the medication regimen and tolerating it well with no reported side effects." That meeting took place while gaps in the medication record remained unexplained.
The director of nursing and the administrator, interviewed together on August 28, told inspectors they expected staff to follow physician orders and to document a reason any time a medication was marked "NA." The following day, interviewed again, they said they expected physician notification and documentation in the progress notes any time an IV antibiotic was not administered as ordered.
None of that happened.
Acyclovir is used to treat serious viral infections of the brain. For a resident whose diagnosis was HHV-6 encephalitis — a condition that causes inflammation of brain tissue — consistent dosing is not a procedural formality. Missing doses of an antiviral prescribed to treat active brain inflammation carries direct consequences for the person receiving it.
The inspection record does not indicate the resident's condition after the gaps in treatment. What it shows is a facility that ordered a medication for a critically ill resident, failed to ensure it arrived for four days, missed multiple doses across two separate prescription periods, documented those misses with a two-letter notation, and produced no record that anyone in a position of authority was ever told.
The last pharmacy shipment arrived August 15. The resident was still on the medication. The inspection was conducted two weeks later.
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 deficiency was cited at the level of actual harm.
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.