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Complaint Investigation

Quarters At Des Peres, The

August 29, 2025 · Des Peres, MO · 13230 Manchester Road
Citations 4
CMS Rating 1/5
Beds 147
Provider ID 265834
Healthcare Facility
Quarters At Des Peres, The
Des Peres, MO  ·  View full profile →
Inspection Summary

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.

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Inspection Findings

FF0628
Resident Rights Deficiencies
Potential for More Than Minimal Harm

progress note.

She expected nursing staff to report if a resident was sent to the hospital. 2571345

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/29/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Quarters at Des Peres, The

13230 Manchester Road Des Peres, MO 63131

SUMMARY STATEMENT OF DEFICIENCIES

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

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/29/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Quarters at Des Peres, The

13230 Manchester Road Des Peres, MO 63131

SUMMARY STATEMENT OF DEFICIENCIES

Review of the progress notes, showed no entries for 8/24/25 and 8/25/25.

Review of the resident's care plan, dated 8/25/25, showed:-Focus: The resident is at risk for falls, confusion, and deconditioning;-Goal: The 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 hospital emergency room record, dated 8/25/25, showed:-Alert and oriented;-Reported he/she fell Friday (8/22/25) and today;-Hematoma/abrasion on left forehead;-Patient reports headache and room is spinning.

During an interview on 8/29/25 at 9:24 A.M., LPN C said if a resident had a fall, neuro checks are completed, regardless if it was witnessed or not.

The Assistant Director of Nursing (ADON) makes sure it is 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

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/29/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Quarters at Des Peres, The

13230 Manchester Road Des Peres, MO 63131

SUMMARY STATEMENT OF DEFICIENCIES

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

Facility ID:

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in DES PERES, MO, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from QUARTERS AT DES PERES, THE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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