LUTHERAN SENIOR SERVICES AT BREEZE PARK Inspection Report, Violations & Safety Grade (SAINT CHARLES, Missouri)

600 BREEZE PARK DRIVE, SAINT CHARLES, Missouri 63304

Phone: 6369395223

CMS Overall:3/5

Overview & Bed Count

Certified Beds

Avg Residents/Day

46.6

Ownership

Non profit - Church related

Provider Type

Medicare and Medicaid

County

St. Charles

Sprinkler Systems

Yes

Special Focus

None

Abuse Icon

CMS Star Ratings

Overall3/5

Health3/5

Staffing4/5

Quality3/5

Nurse Staffing Check

Metric	This Facility	Missouri Avg	Difference
RN Hours per Resident per Day	0.57	0.46	+0.11
Total Nurse Hours per Resident per Day	4.60	3.40	+1.20
CMS Staffing Rating	4/5	2.2/5	-
Nursing Staff Turnover	40.0%	56.9%	-

Health Citation History

15 health citations on record

Date	Category	Description	Severity
2026-04-02	Nutrition and Dietary Deficiencies	Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.	F – Moderate Harm Potential
2026-04-02	Infection Control Deficiencies	Provide and implement an infection prevention and control program.	F – Moderate Harm Potential
2026-04-02	Quality of Life and Care Deficiencies	Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.	E – Moderate Harm Potential
2026-04-02	Quality of Life and Care Deficiencies	Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.	E – Moderate Harm Potential
2026-04-02	Freedom from Abuse, Neglect, and Exploitation Deficiencies	Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.	D – Moderate Harm Potential
2024-12-05	Quality of Life and Care Deficiencies	Provide appropriate treatment and care according to orders, resident’s preferences and goals.	J – Immediate Jeopardy
2024-03-07	Resident Assessment and Care Planning Deficiencies	Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.	E – Moderate Harm Potential
2024-03-07	Infection Control Deficiencies	Provide and implement an infection prevention and control program.	E – Moderate Harm Potential
2024-03-07	Environmental Deficiencies	Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.	E – Moderate Harm Potential
2024-03-07	Quality of Life and Care Deficiencies	Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.	D – Moderate Harm Potential
2022-06-17	Quality of Life and Care Deficiencies	Provide care and assistance to perform activities of daily living for any resident who is unable.	E – Moderate Harm Potential
2022-06-17	Infection Control Deficiencies	Provide and implement an infection prevention and control program.	E – Moderate Harm Potential
2022-06-17	Quality of Life and Care Deficiencies	Provide appropriate pressure ulcer care and prevent new ulcers from developing.	D – Moderate Harm Potential
2022-06-17	Quality of Life and Care Deficiencies	Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	D – Moderate Harm Potential
2022-06-17	Quality of Life and Care Deficiencies	Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.	D – Moderate Harm Potential

Fire Safety Citation History

22 fire safety citations on record

Date	Category	Description	Severity
2026-04-02	Egress Deficiencies	Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.	E – Moderate Harm Potential
2026-04-02	Smoke Deficiencies	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.	E – Moderate Harm Potential
2026-04-02	Smoke Deficiencies	Ensure smoke barriers are constructed to a 1 hour fire resistance rating.	E – Moderate Harm Potential
2026-04-02	Smoke Deficiencies	Install smoke barrier doors that can resist smoke for at least 20 minutes.	E – Moderate Harm Potential
2026-04-02	Gas, Vacuum, and Electrical Systems Deficiencies	Ensure proper usage of power strips and extension cords.	E – Moderate Harm Potential
2026-04-02	Gas, Vacuum, and Electrical Systems Deficiencies	Ensure that testing and maintenance of electrical equipment is performed.	E – Moderate Harm Potential
2026-04-02	Gas, Vacuum, and Electrical Systems Deficiencies	Have proper medical gas storage and administration areas.	E – Moderate Harm Potential
2026-04-02	Construction Deficiencies	Meet requirements for sections of health care facilities separated by fire resistive construction.	D – Moderate Harm Potential
2024-03-07	Gas, Vacuum, and Electrical Systems Deficiencies	Have generator or other power source capable of supplying service within 10 seconds.	F – Moderate Harm Potential
2024-03-07	Smoke Deficiencies	Install corridor and hallway doors that block smoke.	E – Moderate Harm Potential
2024-03-07	Smoke Deficiencies	Ensure smoke barriers are constructed to a 1 hour fire resistance rating.	E – Moderate Harm Potential
2022-06-17	Smoke Deficiencies	Meet other general requirements.	F – Moderate Harm Potential
2022-06-17	Construction Deficiencies	Meet requirements for sections of health care facilities separated by fire resistive construction.	E – Moderate Harm Potential
2022-06-17	Construction Deficiencies	Use approved construction type or materials.	E – Moderate Harm Potential
2022-06-17	Egress Deficiencies	Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.	E – Moderate Harm Potential
2022-06-17	Smoke Deficiencies	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.	E – Moderate Harm Potential
2022-06-17	Smoke Deficiencies	Provide properly protected cooking facilities.	E – Moderate Harm Potential
2022-06-17	Smoke Deficiencies	Properly provide smoke detection systems in areas open to corridors.	E – Moderate Harm Potential
2022-06-17	Smoke Deficiencies	Inspect, test, and maintain automatic sprinkler systems.	E – Moderate Harm Potential
2022-06-17	Smoke Deficiencies	Install corridor and hallway doors that block smoke.	E – Moderate Harm Potential
2022-06-17	Miscellaneous Deficiencies	To conduct inspection, testing and maintenance of fire doors by qualified individuals.	E – Moderate Harm Potential
2022-06-17	Gas, Vacuum, and Electrical Systems Deficiencies	Ensure proper usage of power strips and extension cords.	E – Moderate Harm Potential

Total Penalties & Fines

$41,347

Total Fine Amount (CMS)

Number of Fines

Total Penalties

Date	Type	Fine Amount	Payment Denial
2024-12-05	Fine	$41,347	-

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