Lutheran Senior Services at Breeze Park

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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 12/2/24 at 1:28 P.M., which began on 11/26/24. The IJ was removed on 12/4/24 as confirmed by surveyor onsite verification. Review of the facility policy, titled Emergency First Aid, revised 10/23/24, showed it directs staff to contact EMS in the event emergency first aid intervention is required, including choking. Review of the American Red Cross training resources for choking showed the following: [...]

Inspectors wroteBased 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).

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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; [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]