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
Staffing
Hours and turnover
RN hours / resident day
0.77
Registered nurse staffing
LPN hours / resident day
1.25
Licensed practical nurse staffing
Aide hours / resident day
2.81
Nurse aide staffing
Weekend hours
4.23
Weekend nurse staffing
RN turnover
50%
Annual RN turnover
Total nurse turnover
55%
Annual nurse turnover
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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
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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