Lutheran Senior Services At Breeze Park

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. The exterior of the ice/water dispensing unit had vents on either side with a buildup of fuzzy debris;-A beverage dispensing unit had four dispensing nozzles for orange juice, grape cocktail, lemonade and cranberry cocktail. The nozzles and areas around the nozzles had a buildup of multi-colored liquid and debris. The metal backsplash behind the nozzles had numerous splatters and splashes of purple liquid. Observation on 3/30/26 at 11:30 A.M.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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. Review of the facility policy, Water Management Plan, revised May 2025, showed the following:-The policy is specifically to reduce Legionella risk in healthcare facility water systems to prevent cases and outbreaks of Legionnaires' disease (LD);-Outbreaks have…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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 of stay or when discharged from rehabilitative care;-Restorative goals and objectives are individualized and resident-centered, and are outlined in the resident's plan of care;-The resident or representative will be included in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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 rails, assist rails, and other bed positioning devices;-An assessment will be made to determine the resident's symptoms or reason for using the bed assistive device upon initiation, quarterly, and as needed;-The use of bed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to evaluate Broda chairs (a padded reclining chair on wheels) as a physical restraint and failed to ensure the chairs were the least restrictive device while maintaining safety for two residents (Resident #9 and #45), in a review of 12 sampled residents. Staff identified the Broda chairs were utilized to keep the residents in their chair and prevented the residents from standing or propelling without staff assistance. The facility census was 47. Review of the facility's policy, Restraints, last reviewed 03/03/25, showed the following:-The resident has the right to be free from any physical restraints imposed for purposes of discipline or convenience and not required to treat the resident's medication symptoms;-Restraints should only be used when there is no other option for treating a medical symptom;-Restraints will not be used to control resident behavior or as a punishment;-Restraints will only be used when it has been determined that…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview, and review of facility policy, the facility failed to ensure that care plans were revised for four residents (R)6, R27, R28, and R44 that experienced changes in their conditions and/or care from a total sample of 13 residents. R6 experienced syncopal episodes (a sudden drop in heart rate and blood pressure leading to fainting) on [DATE], [DATE], and [DATE]. R27's care plan was not revised to reflect a left ankle ulcer and that the left ankle ulcer and right buttock ulcers were healed. R28's care plan was not revised to reflect the resident's suprapubic catheter was draining bloody urine and the interventions to flush the catheter as needed. R44's care plan documented the resident was a full code when the resident's Advance Directive indicated the resident was a Do Not Resuscitate (DNR). Findings include: Review of facility policy titled Care Plans - Comprehensive Person Centered with a review date of [DATE], indicated The comprehensive, person-centered care plan…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview, and review of facility policy, the facility failed to ensure staff's adherence to use of personal protective equipment (PPE) for three of four residents (Resident (R) 6, R27, and R28) on droplet precautions and enhanced precaution isolations from a total sample of 13 residents. Findings include: Review of the facility's policy titled COVID 19 Infection Control Measures reviewed 01/30/24 revealed .Post visual alerts (e.g. signs, posters) at the entrance and in strategic places (e.g. waiting areas, elevators, cafeterias). These alerts should provide instructions about current IPC [Infection Prevention and Control] recommendations. Review of droplet precautions signage posted on residents' room doors revealed staff were to wear N95 face masks, isolation gowns, gloves, and face shield, and perform hand hygiene after resident care. During an observation on 03/05/24 at 12:09 PM, Certified Nursing Assistant (CNA)1 was observed donning N95 face mask, gown, and gloves.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and policy and bed specifications review, the facility failed to ensure that regular inspections of bed rails, mattresses, and bed frames were conducted for 41 of 47 occupied beds with enabler bars attached. Findings include: Review of the facility policy titled Proper Use of Bed Assistive Devices revised on 01/30/24, revealed Plant operations will inspect all beds for safety annually, when new device is installed, and as needed when notified by nursing. Review of the undated bed specifications titled SS Retractabed User Manual, Revision 03 revealed no reference to the placement or inclusion of an enabler as part of the bed system. During an observation on 03/07/24 at 9:15 AM, an enabler bar was observed on Resident(R)38's bed located in the bedroom. During an interview on 03/07/24 at 10:15 AM, the Director of Nursing verified the use of the enabler on R38's bed. During an interview 03/07/24 at 10:30 AM, the Maintenance Director verified the facility has no record of bed side rails, mattress, and bed frame inspections in the past twelve months.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, interview, and review of facility policy, the facility failed to follow acceptable standards of practice when they failed to follow physician orders for administering medications through one resident of two residents (Resident (R) 28) receiving enteral (tube feeding) tube from a sampled 13 residents. The nurse failed to crush medications separately and mix with the prescribed amount of water. Findings include: Review of the facility policy titled Administering Medications Through an Enteral Tube with a review date 01/20/24, indicated Flush tubing with 15-30 ml [milliliters] of water unless otherwise specified. Dilute the crushed or split medication with 15-30 ml of warm water unless otherwise specified. Administer the medication by gravity flow. If administering more than one medication flush with 15 ml, unless otherwise specified, between each medication. When last medication drains from tubing, use a final flush of 15 ml of warm water (or prescribed amount). Clamp tubing when finished, and/or reattach to pump if continuous feeding. During an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure staff provided grooming and hygiene needs for three residents (Residents #1, #8, and #20), who were unable to perform their own activities of daily living (ADLs), in a review of 12 sampled residents. The facility's certified census was 24. 1. Review of the facility's policy, Perineal Care, dated 5/26/21, showed the following: -The purpose of this procedure is to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition; -For a female resident: a. Wet washcloth and apply soap or skin cleansing agent or use a perineal wipe; b. Wash perineal area, wiping front to back; c. Continue to wash the perineum moving from inside outward to and including thighs, alternating from side to side, and using downward strokes. Do not reuse the same area of the washcloth and/or perineal wipe to clean the urethra or labia; d. If using soap and water, rinse perineum thoroughly…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to use appropriate infection control procedures for hand hygiene, changing gloves, and use of a barrier to prevent the spread of bacteria or other infection causing contaminants for three residents (Residents #1, #14, and #20) during personal cares and dressing changes, in a review of 12 sampled residents. The facility certified census was 24. 1. Review of the facility's policy, Handwashing/Hand Hygiene, dated last reviewed 4/28/21, showed the following: -Wash hands with soap (antimicrobial or non-antimicrobial) and water for the following situations: a. When hands are visibly soiled; b. After personal use of the toilet or conducting personal hygiene; c. After contact with a resident with infectious diarrhea including, but not limited to infections caused by Norovirus, bacillus antracis, salmonella, shigella and C. difficile; -Use an alcohol-based hand rub containing at least 62% alcohol or alternatively, soap (antimicrobial or…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure staff followed physician orders when providing treatment to a pressure ulcer (damage to an area of the skin caused by constant pressure on the area for a long time) for one resident (Resident #1), in a review of 12 sampled residents. The facility census was 24. Review of the facility policy, Pressure Injury Treatment Protocol, reviewed 5/28/22, showed the following: -Purpose: The purpose of this procedure is to provide guidelines for the care of existing pressure injuries and the prevention of additional pressure injuries; -Interventions/Care Strategies: Pressure injury treatment requires a comprehensive approach, including, debridement, managing infections, managing systemic issues (edema, venous insufficiency, etc.), maximizing the potential for healing, and pain control; -Stage III (full thickness tissue loss; subcutaneous fat may be visible but bone, tendon or muscle is not exposed; slough may be present but does not obscure the depth of tissue loss; may include undermining and tunneling) protocol:…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, facility staff failed to safely transfer one resident (Resident #20), in a review of 12 sampled residents. Staff did not properly apply or use the gait belt (an assistive device which can be used to help safely transfer a person from a bed to a wheelchair or assist with sitting and standing) during the transfer. The facility certified census was 24. Review of the facility policy, Safe Lifting and Movement of Residents, dated 10/14/19 and last reviewed on 5/28/21, showed the following: -Resident safety, dignity, comfort and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents; -Nursing staff, in conjunction with therapy staff, will assess individual resident's needs for transfer assistance on an ongoing basis. Staff will document resident's transferring and lifting needs in the care plan. Such assessment will include: a. Resident's preferences for assistance; b. Resident's mobility (degree of dependency); c. Resident's size; d. Weight-bearing ability; e. Cognitive status;…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to provide appropriate treatment and services consistent with acceptable standards of practice to prevent urinary tract infections (UTIs) for one resident (Resident #14), who had a urinary catheter (a sterile tube inserted into the bladder to drain urine), in a review of 12 sampled residents. The facility reported one resident with a urinary catheter. The facility census was 24. Review of the facility's policy, Perineal Care, dated 5/26/21, showed the following: -The purpose of this procedure is to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition; -If the resident has an indwelling catheter, gently wash the juncture of the tubing from the insertion site down the catheter about three inches. If using soap and water, gently rinse and dry the area. Review of the facility's policy, dated 11/4/19 and last reviewed 5/28/21, showed the following: -The purpose of this procedure is to prevent catheter-associated urinary tract…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.