Quarters at Des Peres, The

In the surveyor’s words

From the most serious findings on record at Quarters at Des Peres, The, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jan 17, 2024

  37681 Based on observation, interview and record review, the facility failed to keep the second floor unit with functioning, alarmed doors for one of three second floor stairwell doors. Observation on 1/9/24 at 10:40 A.M. and 1/10/24 at 8:00 A.M., showed the second floor door to the stairwell, adjacent to room [ROOM NUMBER], alarmed at the nurse's station with the same sound as the call light system. The door was also equipped with a local alarm, but the local alarm did not function when the door was opened. The door's delayed-egress function did not operate, and the door opened immediately when pushed. Observation on 1/9/24 at 11:05 A.M. […]

• Actual harm, patternF677Oct 31, 2024

  See Event ID 0WE512. Based on observation, interview and record review, the facility failed to ensure dependent residents who were unable to carry out activities of daily living, including toileting and incontinence care, received the necessary services to maintain good personal hygiene. This affected four out of four residents who were incontinent of bowel and/or bladder (Resident #33, #34, #45 and #46) when staff failed to provide incontinence care in a timely manner. Two additional residents (Residents #43 and #44) said staff frequently did not check them for incontinence every two hours and failed to answer their call lights timely when they needed to be changed. They were left wet for extended periods of time. […]

• Actual harm, patternF684Oct 31, 2024

  See Event ID 0WE512. This deficiency is uncorrected. For previous examples, refer to the Statement of Deficiencies dated 9/18/24. Based on interview and record review, the facility failed to ensure staff were readily available to respond to residents' needs as evidenced by not answering call lights timely. One resident, with a history of bypass surgeries (Resident #24) was having chest pains, turned on his/her call light and when staff did not respond in 10 minutes the resident called 911. Emergency Medical Services (EMS) responded but could not find facility staff until they found one staff member curled up on the couch asleep. The resident was admitted to the hospital with atrial fibrillation (a-fib, abnormal heart rhythm characterized by a rapid and irregular heartbeat). […]

• Actual harm, patternF725Oct 31, 2024

  See Event ID 0WE512. Based on observation, interview and record review, the facility failed to provide sufficient nursing staff to ensure residents received prompt and adequate care. This affected four out of four residents who were incontinent of bowel and/or bladder (Residents #33, #34, #45 and #46), when staff failed to provide incontinence care in a timely manner. Three additional residents (Residents #31, #43 and #44) said staff do not check on them every two hours, leaving them wet for extended periods of time, and it can take hours for staff to answer call lights. In addition, one resident, with a history of bypass surgeries (Resident #24) contacted Emergency Medical Services (EMS) with chest pains after he/she used his/her call light and staff did not respond in 10 minutes. […]

• Actual harm, patternF600Sep 18, 2024

  Based on observation, interview and record review, the facility failed to ensure residents were free from neglect. Facility staff failed to provide prompt and adequate incontinence care. Four out of four sampled residents, who were incontinent of bowel and/or bladder (Residents #33, #34, #45 and #46), were observed with two incontinence briefs on, both of which were saturated and with strong odors of urine and feces. Three residents (Residents #31, #43 and #44) said staff do not check on them every two hours, leaving them wet for extended periods of time, and it can take several hours for staff to answer call lights. […]