Cycle 1
Health 2024-03-07 · Fire 2024-03-07
4 health deficiencies
Top issue: Environmental (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Saint Charles, MO
Lutheran Senior Services At Breeze Park
4-star overall rating with 4-star inspections with $41,347 in total fines with 4 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
600 Breeze Park Drive, Saint Charles, MO
(636) 939-5223
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
50
Certified beds
Average residents
47
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Evertrue
Operator or chain grouping
Approved since
2004-01-02
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
5 facilities
Chain averages 5 overall / 5 health / 5 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.77
Registered nurse staffing · state 0.46 · national 0.68
LPN hours / resident day
1.25
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
2.81
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
4.82
All reported nurse hours · state 3.47 · national 3.89
Licensed hours
2.01
RN + LPN hours · state 1.14 · national 1.54
Weekend hours
4.23
Weekend nurse staffing · state 3.04 · national 3.43
Weekend RN hours
0.43
Weekend registered nurse coverage · state 0.33 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.78
CMS adjusted RN staffing hours
Adjusted total hours
4.93
CMS adjusted total nurse staffing hours
Case-mix index
1.34
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 51% · national 45%
Total nurse turnover
55%
Annual nurse turnover · state 57% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,814
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
34.93
Composite VBP score used to determine payment impact.
Payment multiplier
0.9887
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
1.91
Baseline 7.98% · Performance 7.26% · Measure score 1.91 · Achievement 1.91 · Improvement 1.90
Total nurse turnover
2.98
Baseline 64.52% · Performance 51.52% · Measure score 2.98 · Achievement 2.98 · Improvement 2.78
Adjusted total nurse staffing
5.59
Performance 4.67 hours · Measure score 5.59 · Achievement 5.59 · This facility did not have sufficient data to calculate a baseline period measure result.
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.33% |
10.72%
0.4 pts better
|
No Different than the National Rate · Eligible stays 49 · Observed rate 8.16% · Lower 95% interval 6.01% |
| Discharge to community | 58.81% |
50.57%
8.2 pts better
|
No Different than the National Rate · Eligible stays 50 · Observed rate 52% · Lower 95% interval 44.1% |
| Medicare spending per beneficiary | 0.92 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 31 · Denominator 31 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 31 |
| Discharge self-care score | 76% |
53.69%
22.3 pts better
|
Numerator 19 · Denominator 25 |
| Discharge mobility score | 48% |
50.94%
2.9 pts worse
|
Numerator 12 · Denominator 25 |
| Pressure ulcers or injuries, new or worsened | 12.9% |
2.29%
10.6 pts worse
|
Numerator 4 · Denominator 31 · Adjusted rate 13.04% |
| Healthcare-associated infections requiring hospitalization | 7.26% |
7.12%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 29 · Observed rate 6.9% · Lower 95% interval 3.12% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 59 |
| Staff flu vaccination coverage | 87.01% |
42%
45 pts better
|
Numerator 67 · Denominator 77 |
| Discharge function score | 64% |
56.45%
7.5 pts better
|
Numerator 16 · Denominator 25 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.8 |
2.1
1.3 pts better
|
1.9
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.6 · Expected 1.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.6 |
2.3
0.7 pts better
|
1.8
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.1 · Expected 1.2 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.1% |
84.8%
13.3 pts better
|
93.4%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.0% · Q2 100.0% · Q3 97.6% · Q4 97.5% · 4Q avg 98.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
90.9%
9.1 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.4% |
4.1%
2.3 pts worse
|
3.3%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 7.1% · Q3 4.9% · Q4 10.0% · 4Q avg 6.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.7% |
14.7%
14 pts better
|
11.4%
10.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.7% · 4Q avg 0.7% |
| Percentage of long-stay residents who lose too much weight | 7.1% |
5.5%
1.6 pts worse
|
5.4%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 10.7% · Q3 0.0% · Q4 15.0% · 4Q avg 7.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 24.2% |
25.3%
1.1 pts better
|
19.6%
4.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.9% · Q2 25.0% · Q3 20.0% · Q4 25.0% · 4Q avg 24.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.9% |
25.0%
9.1 pts better
|
16.7%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.2% · Q2 20.0% · Q3 13.6% · 4Q avg 15.9% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 29.2% |
20.3%
8.9 pts worse
|
16.3%
12.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 29.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.6% |
19.8%
6.2 pts better
|
14.9%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.7% · Q2 16.0% · Q3 9.1% · 4Q avg 13.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.0% |
1.4%
0.4 pts better
|
1.0%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 4.0% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 6.4% |
2.6%
3.8 pts worse
|
1.7%
4.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 11.9% · Q3 4.9% · Q4 2.5% · 4Q avg 6.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 19.0% |
18.1%
0.9 pts worse
|
19.8%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 29.5% · Q2 19.5% · Q3 13.9% · Q4 14.6% · 4Q avg 19.0% |
| Percentage of long-stay residents with pressure ulcers | 4.8% |
5.0%
0.2 pts better
|
5.1%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 4.1% · Q3 8.6% · Q4 4.0% · 4Q avg 4.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 94.4% |
66.4%
28 pts better
|
81.7%
12.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 92.2% · Q2 100.0% · Q3 94.9% · Q4 91.3% · 4Q avg 94.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.5% |
13.4%
5.9 pts better
|
12.0%
4.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.5% · Observed 6.9% · Expected 10.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.2% |
2.2%
About the same
|
1.6%
0.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q4 4.0% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
63.5%
36.5 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.0% |
25.3%
1.3 pts better
|
23.9%
0.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.0% · Observed 20.7% · Expected 20.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-06-17 · Fire 2022-06-17
6 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Cycle 3
Health 2019-10-11 · Fire 2019-10-11
6 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
6 fire-safety deficiencies
Top issue: Miscellaneous (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-03-07
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-04-19
E · Potential for more than minimal harm
2024-03-07
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-04-19
E · Potential for more than minimal harm
2024-03-07
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-04-19
F · Potential for more than minimal harm
2022-06-17
K932 · Smoke Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2022-07-29
E · Potential for more than minimal harm
2022-06-17
K131 · Construction Deficiencies
Fire Safety
Meet requirements for sections of health care facilities separated by fire resistive construction.
Corrected 2022-07-29
E · Potential for more than minimal harm
2022-06-17
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2022-07-29
E · Potential for more than minimal harm
2022-06-17
K222 · Egress Deficiencies
Fire Safety
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.
Corrected 2022-07-29
E · Potential for more than minimal harm
2022-06-17
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2022-07-29
E · Potential for more than minimal harm
2022-06-17
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-07-29
E · Potential for more than minimal harm
2022-06-17
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2022-09-09
E · Potential for more than minimal harm
2022-06-17
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-07-29
E · Potential for more than minimal harm
2022-06-17
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-07-29
E · Potential for more than minimal harm
2022-06-17
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Not marked corrected
E · Potential for more than minimal harm
2022-06-17
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-07-29
F · Potential for more than minimal harm
2019-10-11
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2019-11-22
F · Potential for more than minimal harm
2019-10-11
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2019-11-22
F · Potential for more than minimal harm
2019-10-11
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2019-11-22
F · Potential for more than minimal harm
2019-10-11
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2019-11-22
F · Potential for more than minimal harm
2019-10-11
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2019-11-22
F · Potential for more than minimal harm
2019-10-11
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2019-11-22
Inspection history
Recent health citations
J · Immediate jeopardy
2024-12-05
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-12-06
E · Potential for more than minimal harm
2024-03-07
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-04-19
E · Potential for more than minimal harm
2024-03-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-04-19
E · Potential for more than minimal harm
2024-03-07
F909 · Environmental Deficiencies
Health
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.
Corrected 2024-04-19
D · Potential for more than minimal harm
2024-03-07
F693 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2024-04-19
E · Potential for more than minimal harm
2022-06-17
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-07-29
E · Potential for more than minimal harm
2022-06-17
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-07-29
D · Potential for more than minimal harm
2022-06-17
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-07-29
D · Potential for more than minimal harm
2022-06-17
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-07-29
D · Potential for more than minimal harm
2022-06-17
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2022-07-29
J · Immediate jeopardy
2019-10-11
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2019-08-26
D · Potential for more than minimal harm
2019-10-11
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2019-11-22
D · Potential for more than minimal harm
2019-10-11
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2019-11-22
D · Potential for more than minimal harm
2019-10-11
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2019-11-22
D · Potential for more than minimal harm
2019-10-11
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2019-11-22
D · Potential for more than minimal harm
2019-10-11
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2019-11-22
Penalties and ownership
What sits behind the stars
$41,347
2024-12-05
Fine
Fine · fine $41,347
Fine
Ownership
Lutheran Senior Services
5% Or Greater Direct Ownership Interest · Organization
Anderson, David
Corporate Officer · Individual
Beumer, Brent
Corporate Director · Individual
Brown, Daniel
Corporate Officer · Individual
Christell, Roy
Corporate Director · Individual
Cooper Carcagno, Valerie
Operational/Managerial Control · Individual
Lin, Walter
Operational/Managerial Control · Individual
Lutheran Senior Services
Operational/Managerial Control · Organization
Marles, Adam
Corporate Officer · Individual
Meadows, Megan
Corporate Director · Individual
Mueller, Harry
Corporate Director · Individual
Schaefer, Ronald
Corporate Officer · Individual
Sneed, Chadwick
Corporate Officer · Individual
Sombart, Lisa
Corporate Director · Individual
Sommer, Christopher
Corporate Director · Individual
Tice, Paul
Corporate Officer · Individual
Toon, Norman
Corporate Director · Individual
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#3
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