Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lutheran Senior Services At Breeze Park during CMS and state inspections, most recent first.
Accumulated debris was found on ice and beverage dispensing units in three dining rooms/satellite kitchens. Surveyors observed crusty and dark-colored debris inside ice and water spouts, fuzzy debris on exterior vents, and multi-colored liquid and debris around beverage nozzles and backsplashes. The Dietary Mgr stated dietary staff cleaned the units daily in the evening, the facility had no policy for cleaning beverage station equipment, and the Mnt Dir stated the vendor cleaned the ice/water units quarterly while dietary staff cleaned beverage units regularly.
The facility failed to monitor its water system with a complete water management process, including cold water temperatures, and staff failed to perform hand hygiene during observed incontinence care. Hot water temperatures were checked only in limited locations, cold water was not monitored, and the Maintenance Director stated there was no procedure for monitoring corrosion buildup or biofilm. During care for two residents and one additional resident, CNAs and an LPN removed soiled briefs, changed gloves, and moved from dirty to clean tasks without washing hands, and one LPN handled a resident’s water pitcher while wearing gloves used during perineal care.
The facility failed to provide ordered restorative nursing services for three residents who had severe cognitive impairment and impaired mobility/ROM needs. A restorative aide was repeatedly pulled to CNA duties, and the DON stated no one else was available to provide the services. One resident with a left hand splint order was observed without the splint on, and the flow sheets for the other residents showed missed or undocumented ROM and transfer restorative programs despite care plans calling for services multiple times per week.
Bed rail assessments and consent documentation missing: The facility failed to document accurate entrapment risk assessments and informed consent for several residents with bed rails. Records for residents with severe cognitive and functional impairment showed inconsistent Bed Assistive Device Assessments, care plans, and physician orders, while observations confirmed raised side rails or assist rails in use. Staff interviews indicated assessments were often marked as not using bed rails even when rails were present, and the DON said consent was required for every resident with bed rails.
Broda chairs were used to keep two residents in their chairs without evaluating whether the chairs functioned as restraints or whether they were the least restrictive option. Both residents had severe cognitive impairment and significant fall histories, and observations showed them repeatedly trying to climb out of reclined Broda chairs with fixed footrests and caster wheels. Staff interviews confirmed the chairs were used for comfort and safety, kept the residents in place, and required staff assistance for standing, transfers, and propulsion, while the DON stated no restraint assessment had been completed.
A resident with Parkinson's Disease and dysphagia began choking during a meal, but staff failed to call EMS as required by the facility's policy. Despite attempts to manage the situation internally with back thrusts, suctioning, and the Heimlich maneuver, the resident became unresponsive and later expired. Interviews revealed that staff did not call EMS, highlighting a significant deficiency in emergency response.
Accumulated debris on ice and beverage dispensing units
Penalty
Summary
The facility failed to ensure ice and beverage dispensing units in three dining rooms/satellite kitchens were free of accumulated debris. Observations in the Lindenwood dining room showed a combination ice/water dispensing unit with white crusty debris and dark-colored debris in the ice and water spouts, along with fuzzy debris on the exterior vents. The beverage dispensing unit in that room had four nozzles for orange juice, grape cocktail, lemonade, and cranberry cocktail, and the nozzles and surrounding areas had multi-colored liquid and debris, with numerous purple splatters on the metal backsplash behind the nozzles. Similar conditions were observed in the Sycamore dining room, where the ice/water dispensing unit had dark-colored debris inside both spouts and fuzzy debris on the exterior vents, and the beverage dispensing unit had multi-colored liquid and debris around the nozzles. In the Cherry Blossom dining room, the ice/water dispensing unit had white crusty debris on the exterior of the ice spout, dark-colored debris inside the ice spout, and fuzzy debris on the exterior vents. During interview, the Dietary Manager stated dietary staff cleaned the ice/beverage dispensing units daily in the evening, maintenance staff did not clean them, the facility did not have a policy for cleaning the beverage station equipment, and maintenance staff was responsible for contacting the ice machine vendor for deep cleaning. The Maintenance Director stated the vendor cleaned the ice/water dispensing units quarterly, dietary staff were responsible for cleaning the beverage dispensing units regularly, and maintenance staff cleaned the exterior vents quarterly.
Water Management and Hand Hygiene Failures
Penalty
Summary
The facility failed to develop a system to monitor its water supply, including assessment of cold and hot water temperatures, to ensure control parameters intended to prevent growth of Legionella. The facility’s Water Management Plan, revised May 2025, stated it was intended to reduce Legionella risk in healthcare facility water systems and required identification of potable and non-potable systems, establishment of control limits, and procedures for monitoring control measures and taking corrective actions when limits were not maintained. The facility also failed to ensure staff performed hand hygiene during incontinence care for two residents and one additional resident during observed care events. Review of the weekly water temperature log dated 12/01/25-03/26/26 showed hot water temperatures were monitored only at the hot water supply, hot water supply mixing valve on the LTC and REACH units, two resident rooms, and the T-hall office. There was no documentation that cold water temperatures were monitored. During observation on 04/01/26, hot water temperatures were measured at 107 degrees F in one room, 105 degrees F at the spa faucet eye wash station and 102 degrees F at the handheld shower head on Sycamore hall, and 100 degrees F at a sink and handheld shower head in another room. The Maintenance Director stated staff monitored hot water temperatures in the hot water heaters, boilers, and mixing valves, monitored hot water monthly at the beginning and end of the loop, did not check temperatures in the middle of the loop, did not monitor cold water, and did not have a procedure for monitoring corrosion buildup and biofilm. The Administrator stated the water management plan followed state regulations for hot water temperature monitoring. Resident #48 had severe cognitive impairment and required substantial to maximal assistance for personal hygiene, toileting hygiene, lower body dressing, and chair/bed-to-chair transfer. During observed incontinence care, LPN B and CNA D entered the room without hand hygiene, transferred the resident with a mechanical lift, and CNA D removed a urine-soiled brief and performed perineal care. CNA D then removed gloves, reached into a pocket for new gloves, and put them on without hand hygiene before assisting with turning the resident, removing the sling and soiled linens, and placing a new brief. CNA D again removed gloves, retrieved new gloves from a pocket, and put them on without hand hygiene. LPN B, wearing the same gloves used during the dirty-to-clean task, picked up the resident’s water pitcher and held the straw while the resident drank. Both staff then removed gloves and left without washing hands. CNA D stated hand hygiene was required before and after care and between glove changes, but was not performed because he/she forgot. LPN B stated staff should wash hands when moving from contaminated to clean tasks. Resident #6 was always incontinent of bladder and bowel and required partial to moderate assistance for personal hygiene. During observed incontinence care, CNA G removed a feces-soiled brief, provided peri care, removed gloves, and put on clean gloves without hand hygiene before placing a clean brief and then assisting the resident with pants and shoes. CNA G stated hands should be washed before putting on gloves and after removing gloves, and that hand hygiene should have been performed after glove removal during peri care. Resident #35 was always incontinent of bladder and occasionally incontinent of bowel, required dependent toileting assistance and partial to moderate assistance for personal hygiene. During observed care, CNA F removed a urine-soaked brief, performed peri care, removed gloves, and put on new gloves without hand hygiene before placing a clean brief. CNA F stated gloves should be changed and hands washed when moving from dirty to clean tasks and that hands should have been washed after glove removal.
Failure to Provide Ordered Restorative Nursing Services
Penalty
Summary
The facility failed to provide restorative nursing services to residents identified as needing assistance to maintain or improve range of motion and mobility. The deficiency involved three residents: one resident with severe cognitive impairment, impaired functional ROM, and a left hand splint order; another resident with stroke and severe cognitive impairment; and a third resident with severe cognitive impairment and declining ADL self-performance. Facility policy required individualized restorative nursing care, monthly progress notes, quarterly evaluations, and restorative interventions such as ROM exercises and splint assistance when indicated. The restorative aide’s schedule showed repeated reassignment from restorative duties to CNA work on the floor during March 2026. The DON stated there was no one else to provide restorative nursing services when the restorative aide was pulled to the floor or was off work. The restorative aide said she was pulled often from restorative work to work as a CNA, and that if she were able to remain in the restorative aide role every day, she could complete the restorative services. The RN/MDS Coordinator said she reviewed the restorative documentation, knew the services were not being completed, and that the DON took over oversight because of these issues. For the resident with the left hand splint order, the MDS showed severe cognitive impairment, impaired functional ROM, dependence for multiple ADLs, and no therapy or restorative services at the time of assessment. The restorative evaluation and care plan called for passive ROM to both upper and lower extremities and splint/brace assistance, including ensuring the hand splint was on and providing passive stretch to the digits every 24 hours. However, the clinical flow sheet showed no restorative nursing services for an eight-day period, and the resident was observed sitting in a Broda chair and later lying in bed without the splint or brace on the left hand. For the resident with stroke, the restorative program called for upper and lower extremity passive ROM two to three times per week, but the flow sheet showed no documentation that the resident was offered, received, or refused restorative services during multiple weeks, with only one day of documented ROM services in one week. For the resident with worsening ADL performance, the restorative program included upper and lower extremity ROM and transfer restorative services two to three times per week, but the flow sheet showed only one day of documented restorative services in one week and no documentation of services offered, received, or refused during another week. The resident’s MDS showed worsening self-performance in several ADLs and no therapy or restorative nursing services.
Bed rail assessments and consent documentation missing
Penalty
Summary
The facility failed to maintain documentation showing that staff accurately assessed the risk of entrapment from bed rails and failed to maintain documentation showing that informed consent was obtained from residents’ representatives before bed rail use for four sampled residents. The facility policy stated that bed assistive devices, including side rails and assist rails, required assessment of the resident’s symptoms or reason for use, inclusion in the care plan, and consent from the resident or representative documented per community protocol. Resident #48 had diagnoses including dementia, weakness, and physical debilitation, and had a POA for health care decisions. The resident’s MDS showed severe cognitive impairment, impaired functional range of motion, and dependence on staff for rolling and transfers. Although the physician order sheet listed an assist side rail for mobility and the care plan described use of an enabler side rail, the quarterly Bed Assistive Device Assessment stated the resident did not use a bed assistive device and the entrapment risk assessment was not completed. During observation, the resident had 1/8 bed rails raised on both sides, held the rail during care, but could not pull his/her body weight or maintain a side-lying position while using the rail. The record contained no documentation of an entrapment risk assessment or informed consent from the representative. Resident #3 had a POA for health care decisions and an MDS showing severe cognitive impairment, Alzheimer’s disease, impaired range of motion, and dependence for rolling and transfers. The Bed Assistive Device Assessment stated the resident did not use a bed assistive device and the entrapment risk assessment was not completed. The care plan identified use of a right assist grab bar for bed mobility, but the physician order sheet had no order for bed rails. Observation showed the resident in bed with a 1/8 bed rail raised on the right side and a bolstered mattress. Resident #29 had severe cognitive impairment and required extensive assistance for bed mobility and transfers; the care plan listed bed rails as an intervention to assist with transfers and bed mobility, but the Bed Assistive Device Assessment stated the resident did not use a bed assistive device and the entrapment risk assessment was not completed. Observation showed 1/8 bed rails raised on both sides of the bed, and the record had no documentation of entrapment assessment or informed consent. Resident #12 had severe cognitive impairment and unilateral upper and lower extremity impairment; the care plan listed side rails and assist rails for bed mobility, and the physician order sheet included an assist rail/grab bar order. The Bed Assistive Device Assessment stated the resident did not have bed rails and no consent was needed because the resident was not using a bed assistive device, yet observations on multiple occasions showed a half side rail raised on the right side of the bed.
Broda Chairs Used Without Restraint Evaluation
Penalty
Summary
The facility failed to evaluate Broda chairs as physical restraints and failed to ensure the chairs were the least restrictive device while maintaining safety for two residents. The report states that staff used the Broda chairs to keep the residents in their chairs, and staff identified that the chairs prevented the residents from standing or propelling without staff assistance. The facility’s policy required restraint assessment, physician order, informed consent, and ongoing evaluation, and the RAI manual defined physical restraints and identified chairs that prevent rising as restraints in certain circumstances. Resident #9 had severe cognitive impairment, used a manual wheelchair, required assistance with transfers and mobility, and had a history of multiple falls with and without injury. The resident’s care plan allowed use of a Broda chair, and the record noted the chair was ordered from hospice to assist with positioning while up in a chair. The resident later fell forward after attempting to self-transfer from the Broda chair and sustained an injury. Observation showed the resident seated in a reclined Broda chair with a fixed footrest and caster-style wheels, and the resident repeatedly tried to rise by pushing on the armrests and moving legs around the footrest. Staff documented that the resident could not get out of the Broda chair safely without help and that the resident had fallen from the chair trying to get up on his/her own. Resident #45 also had severe cognitive impairment, Alzheimer’s disease, a history of stroke, poor vision, mobility and balance problems, psychotropic medication use, and multiple falls. The care plan identified the Broda chair as an intervention to prevent falling and directed staff to monitor positioning and safety while seated. The resident’s record showed worsening mobility, repeated falls, and no documentation that staff evaluated the restraining properties of the Broda chair. Observation showed the resident seated in a reclined Broda chair with caster-style wheels and a footrest elevated above the floor, repeatedly trying to climb out by lifting a leg over the footrest and pushing off the armrest. Staff interviews confirmed that the facility used Broda chairs to keep both residents in their chairs, that the residents tried to climb out during the night, and that the DON did not think Broda chairs were restraints despite acknowledging the residents could not stand or propel the chairs without assistance.
Failure to Call EMS During Choking Incident
Penalty
Summary
The facility failed to adhere to its Emergency First Aid policy and acceptable standards of practice when a resident began choking on food during a meal and required emergency treatment. Despite the resident showing signs of choking, such as gagging and a change in color, staff did not call Emergency Medical Services (EMS) as required by the facility's policy. Instead, staff attempted to manage the situation internally by performing back thrusts, using a suction machine, and attempting the Heimlich maneuver, all of which were unsuccessful. The resident, who had diagnoses of Parkinson's Disease and dysphagia, was initially assisted with eating and showed no difficulty until the choking incident. During the event, staff moved the resident to their room and continued to attempt various interventions, including abdominal thrusts and suctioning, but failed to clear the airway. The resident eventually became unresponsive, and staff continued their efforts until the resident no longer had a heartbeat or respirations. Interviews with staff, including a CNA, LPN, and the Director of Nursing, revealed that no one called EMS during the incident, despite the facility's policy and the emergent nature of the situation. The administrator and the resident's physician both confirmed that EMS should have been called in such an emergency. The failure to call EMS was identified as a deficiency at the immediate and serious jeopardy level, indicating a significant lapse in following emergency protocols.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Saint Charles
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Delmar Gardens Of O'fallon | 4.2 mi | ★★★★★ | 1 | 0 |
| Mcclay Senior Care | 4.5 mi | ★★★★★ | 0 | 0 |
| St Peters Rehab And Healthcare Center | 5.3 mi | ★★★★★ | 8 | 0 |
| Garden View Care Center | 5.6 mi | ★★★★★ | 3 | 0 |
| St Peters Post Acute | 5.6 mi | ★★★★★ | 10 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.