Quarters At Des Peres, The
QUARTERS AT DES PERES, THE in DES PERES, MO — inspection on August 29, 2025.
Found 4 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Review of the resident's care plan, dated
resident will be free of minor injury;-Interventions: Anticipate and meet the resident's needs; -Encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility; -Ensure that the resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair; -Family request bed to be placed up against wall; -Low bed with fall mat; -Review information on past falls and attempt to determine cause of falls.
Record possible root causes.
After remove any potential causes if possible.
Educate resident, family, caregiver, Interdisciplinary team (IDT) as to causes; -The resident needs activities that minimize the potential for falls while providing diversion and distraction.
Review of the resident's progress notes, showed:-On 8/22/25 at 6:50 A.M., resident noted to have slid out of bed and on to the floor trying to ambulate without assistance.
This nurse assessed resident for injury, bruising and redness, none noted at this time.
Per resident he/she is having pain to left arm and right shoulder.
New order for x-ray to both extremities.
Given Tylenol 325 milligrams (mg) for pain.
Resident placed back into bed by Certified Nurse Aide (CNA) x 2.
Bed locked and lowered for safety.
Call light in reach;-On 8/22/25 at 6:30 P.M., resident's female family advocate at bedside request information regarding resident medication orders.
Resident in bed aware/talkative with visitor and stated ok to speak with her/him.
Resident son also present on the phone to verify information.
Request resident to have x-ray left arm s/p fall related to complaints of pain.
Resident in bed with discomfort noted with care/repositioning.
Physician made aware.
Given new order x-ray lower upper extremities (LUE). X-ray company made aware;-On 8/22/25 at 8:01 P.M., X-ray tech here at this time to perform exam.
Resident resting in bed.
Cooperative with care. No acute distress noted;-On 8/23/25 at 7:12 A.M., rested safely/comfy in low bed.
Aroused easily to stimuli.
Voices needs.
Continued left side weakness.
Positioned comfortably with no acute distress noted. G-tube p/i flushed without difficulty.
Peri care provided with incontinence. No acute distress noted.
Head of bed (HOB) elevated.
Bed low.
Call light in reach.
Review of the medical record, showed no documentation of the resident transported to the hospital. 4.
During an interview on 8/29/25 at 1:33 P.M., the Director of Nursing (DON) said staff completes a change in condition form and transfer form when a resident is transported to the hospital.
They receive orders from the physician and notify the resident representative if it is not the resident. If the resident is unresponsive, they will notify the family.
She expected there to be a progress note.
The progress note should include the vital signs and who was notified. If it is not documented in real time, they will document what time the resident was transported by Emergency Medical Technician (EMT).
Most of the time, they do not know where they are transporting the resident. If staff are aware, it should be included in the progress note.
She expected nursing staff to report if a resident was sent to the hospital. 2571345
265834 08/29/2025
Quarters at Des Peres, The 13230 Manchester Road Des Peres, MO 63131
Review of the resident's care plan, dated 8/8/25, showed:-Focus:
through 8/13/25;-Goal: Will not have complications or adverse reactions when receiving IV therapy for 30 days;-Interventions: -Administer IV therapy as ordered, explain procedure to the resident; -Change dressing to insertion site as ordered/ indicated; -Observe for possible side effects- report abnormal symptoms to physician; -Observe the IV site for edema (swelling), redness, drainage, etc.
Report abnormal findings to physician.
Review of the resident's MAR and progress notes, dated 8/7/25 through 8/26/25, showed:-Acyclovir powder, use 730 milligrams (mg) IV three times a day for viral infection until 08/13/25, order date 8/7/25 at 5:37 P.M., DC 8/10/25 at 12:39 A.M.; -On 8/7/25 at 10:00 P.M., blank (no documentation); -On 8/8/25 at 6:00 A.M., blank; -On 8/8/25 at 2:00 P.M., blank; -On 8/8/25 at 10:00 P.M., blank; -On 8/9/25 at 6:00 A.M., blank; -On 8/9/25 at 2:00 P.M., blank; -On 8/9/25 at 10:00 P.M., blank;-Progress note dated 8/11/25 at 10:03 A.M., Pharmacy called and relayed problem with acyclovir IV medication.
Due to dosage, storage and reconstitution needed, pharmacy would like the physician to be called and possibly change the dosage to ensure integrity of medication.
Please follow up with pharmacy about new order;-Progress note dated 8/11/25 at 10:56 A.M., Nurse verified Acyclovir dose with physician per pharmacy inquiry, give 1000 mg IV three times a day.
Call placed to pharmacy to provide updated order;-Acyclovir powder, use 1000 mg IV three times a day for viral infection, order date 8/11/25 at 10:48 A.M., DC on 8/12/25 at 1:59 P.M.: -On 8/12/25 at 6:00 A.M., NA;-Progress note, dated 8/13/25 at 3:03 P.M., IDT Risk Meeting held today regarding the resident is currently receiving Acyclovir prophylaxis (action taken to prevent disease) without a designated stop date related to a viral infection/outbreak.
Resident is compliant with the medication regimen and tolerating it well with no reported side effects at this time;-Progress note, dated 8/13/25 at 10:43 P.M., Resident still remains on ABT for viral outbreak. No adverse reactions noted at this time;-Acyclovir powder, use 750 mg IV every eight hours for viral infection until 08/18/25, order date 8/14/25 at 10:53 A.M.; -On 8/15/25 at 6:00 A.M., NA; -On 8/15/25 at 2:00 P.M., NA; -On 8/15/25 at 10:00 P.M., NA; -On 8/16/25 at 6:00 A.M., NA;-Progress note, dated 8/16/25 at 10:32 P.M., Resident remains on ABT Acyclovir 750mg intravenously. No adverse reaction noted;-No progress notes regarding missed doses of IV ABT;-No progress notes with notification to physician and RR regarding missed doses of IV ABT.
During an interview on 8/29/25 at 9:55 A.M., PR said the acyclovir was first sent out on 8/11/25 and the last time it was sent to the facility was on 8/15/25.
The pharmacy sent out a seven-day supply total to the facility. 4.
During an interview on 8/28/25 at 1:18 P.M., the DON and Administrator said they expected staff to follow physician orders.
They expected staff to be knowledgeable of and to follow the facility policies.
They expected if staff documented NA in the resident's MAR for a progress note to be entered on why the medication was not administered. On 8/29/25 at 1:23 P.M., the DON and Administrator said if an IV ABT was not administered as ordered, they expected notifications to the physician and RR to be documented in the resident's progress notes. 2593947
265834 08/29/2025
Quarters at Des Peres, The 13230 Manchester Road Des Peres, MO 63131
Review of the hospital emergency room
interview on 8/29/25 at 9:24 A.M., LPN C said if a resident had a fall, neuro checks are completed,
completed. He/She believed it would be scanned into the medical record.
They also complete pain and skin assessments. If there is an open area, they will notify the physician and receive treatment orders.
During an interview on 8/29/25 at 9:29 A.M., the Administrator said neuro checks are completed on paper.
Once the neuro checks are completed, it is scanned into the medical record.
During an interview on 8/29/25 at 1:33 P.M., the Director of Nursing (DON) said she expected the fall assessment to be completed upon admission.
The admitting nurse on the floor is responsible.
She expected falls to be documented and neuro checks are expected to be completed immediately regardless if it was witnessed or unwitnessed.
The skin and pain assessments are on the form called the fall risk assessment. It should be completed.
The neuro checks are scanned in. It is not in the medical record, it was not scanned in.
She expected staff to offer PRN pain medications and document in the medical record.
She expected physician's orders to be followed and for staff to be knowledgeable of and follow facilities policies. 2599861
265834 08/29/2025
Quarters at Des Peres, The 13230 Manchester Road Des Peres, MO 63131
Review of the resident's care plan, dated 8/8/25, showed no identification of the
Wednesday and Friday, order date 8/8/25.
The order did not show the location the resident would receive dialysis or the scheduled chair time. 3.
Review of Resident #19's face sheet, showed his/her diagnoses included dependence on renal dialysis, kidney failure, weakness, abnormalities of gait and mobility, heart failure and high blood pressure.
Review of the resident's care plan, dated 7/9/25, showed:-Focus: The resident receives hemodialysis three times a week in facility Monday, Wednesday and Friday related to renal failure;-Goal: The resident will have immediate intervention should any signs or symptoms of complications from dialysis occur through the review date;-Interventions: -Check and change dressing daily at access site.
Document; -Monitor and document report to physician signs and symptoms of depression.
Obtain order for mental health consult if needed; -Monitor, document and report PRN any signs and symptoms of infection to access site: Redness, swelling, warmth or drainage;-Monitor/document/report PRN for signs and symptoms of the following: Bleeding, hemorrhage (bleeding from a broken blood vessel, either inside or outside the body), bacteremia (presence of bacteria in bloodstream), septic shock (life-threatening condition that occurs when an infection triggers a widespread inflammatory response that leads to dangerously low blood pressure and organ failure);-The care plan did not list the scheduled chair time.
Review of the resident's dialysis communication forms, showed the facility was missing sheets for the following dates, 7/18/25, 7/23/25, 7/25/25, 7/30/25, 8/4/25, 8/11/25, 8/15/25, 8/18/25, 8/22/25, 8/25/25, 8/27/25 and 8/29/25. 4.
Review of Resident #4's face sheet, showed his/her diagnoses included dependence on renal dialysis, high blood pressure, diabetes, cognitive communication deficit, weakness and need for assistance with personal care.
Review of the resident's care plan, dated 8/20/25, showed: -Focus: The resident needs dialysis three times a week related to renal failure;-Goal: -The resident will have immediate intervention should any sign or symptoms of complications from dialysis occur through the review date; -The resident will have no signs or symptoms of complications from dialysis through the review date;-Interventions: -Check and change dressing daily at access site.
Document; -Encourage resident to go for the scheduled dialysis appointments.
Resident receives hemodialysis in facility Tuesday, Thursday and Saturday; -Monitor and document report to physician signs and symptoms of depression.
Obtain order for mental health consult if needed; -Monitor, document and report as needed (PRN) any signs and symptoms of infection to access site: Redness, swelling, warmth or drainage; -Monitor, document and report PRN for signs and symptoms of renal insufficiency: changes in level of consciousness, changes in skin turgor, oral mucosa (moist, inner lining of mouth), changes in heart and lung sounds;-The care plan did not list the scheduled chair time. 5.
During an interview on 8/28/25 at 1:18 P.M., the Administrator and Director of Nursing (DON) said they expected staff to be knowledgeable of and to follow the facility policies.
They expected physician orders to be followed.
They expected the dialysis communication forms to be completed each day a resident went to dialysis.
They expected the completed dialysis communication forms to be scanned into the resident's medical record.
They expected residents who receive dialysis to have orders and a care plan that lists the location the resident attends dialysis, the chair time the resident would attend dialysis and the days of the week the resident would attend dialysis. 2571345
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.