Lutheran Senior Services at Breeze Park

In the surveyor’s words

From the most serious findings on record at Lutheran Senior Services at Breeze Park, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684Dec 5, 2024

  Based on interview and record review, the facility failed to follow acceptable standards of practice and their Emergency First Aid policy when staff failed to call Emergency Medical Services (EMS) when one resident (Resident #1), in a review of eight sampled residents, began choking on food during a meal and required emergency treatment. The resident expired. The facility census was 48. The administrator was notified of the Immediate Jeopardy (IJ) on [DATE] at 1:28 P.M., which began on [DATE]. The IJ was removed on [DATE] as confirmed by surveyor onsite verification. […]

• No harm, potential for more than minimal, widespreadF812Apr 2, 2026

  Based on observation, interview, and record review, the facility failed to ensure ice and beverage dispensing units in three of three dining rooms/satellite kitchens were free of an accumulation of debris. The facility census was 47. 1. Observation on 3/30/26 at 11:20 A.M. and on 3/31/26 at 10:14 A.M., inside the Lindenwood dining room, showed the following:-A combination ice/water dispensing unit had two separate dispensing spouts. The ice dispensing spout had a buildup of white crusty debris on the exterior of the spout and dark-colored debris inside the spout. The water dispensing spout had a buildup of white crusty debris inside the spout. […]

• No harm, potential for more than minimal, widespreadF880Apr 2, 2026

  Based on observation, interview, and record review, the facility failed to develop a system to monitor the facility's water supply, including assessment of cold and hot water temperatures, to ensure specific control parameters to prevent growth of Legionella (a bacterium that can cause a serious type of pneumonia called Legionnaires' Disease) in accordance with the Centers for Disease Control and Prevention (CDC) and American Society of Heating, Refrigerating and Air Conditioning Engineers (ASHRAE)) standards. The facility failed to ensure staff performed hand hygiene when providing incontinence care to two residents (Residents #48 and #6), in a review of 12 sampled residents, and for one additional resident (Resident #35). The facility census was 47.1. […]

• No harm, potential for more than minimal, patternF688Apr 2, 2026

  Based on observation, interview, and record review, the facility failed to provide restorative nursing services to assist two residents (Resident #3 and #4), in a review of 12 sampled residents, and one additional resident (Resident #45), to attain or maintain his/her highest level of functioning. The facility census was 47.Review of the facility policy, Restorative Nursing, dated 04/26/19, showed the following:-Residents will receive restorative nursing care as needed to help promote optimal safety and independence;-Restorative nursing care consists of nursing interventions that may or may not be accompanied by formalized rehabilitative services (e.g., physical, occupational or speech therapies);-Residents may be started on a restorative nursing program upon admission, during the course… […]

• No harm, potential for more than minimal, patternF700Apr 2, 2026

  Based on observation, interview, and record review, the facility failed to maintain documentation to show staff accurately assessed the risk of entrapment from bed rails and failed to maintain documentation staff obtained informed consent from the residents' representatives prior to bed rail use for four residents (Residents #48, #3, #29, an #12) with bed rails, in a review of 12 sampled resident. The facility census was 47.Review of the facility policy, Proper Use of Bed Assistive Devises, dated 05/19/26, showed the following:-The purposes of these guidelines are to ensure the safe use of bed assistive devices as resident mobility aids and to prohibit the use of bed assistive devices as restraints unless necessary to treat a resident's medical symptoms;-Bed assistive devices include side… […]