Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
LUTHERAN SENIOR SERVICES AT BREEZE PARK
SAINT CHARLES, MO · 50 certified beds · Last Life Safety survey April 2, 2026
CMS Certification Number 265767 · first certified January 2004
Ownership
Operated by EVERTRUE · Non profit - Church related
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within MO
22 citations — more than 58% of the 487 certified nursing homes in MO. Compared within MO rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 8 citations; the earlier surveys in the window averaged 7. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window opens June 2027 — about 8 months from now. This facility’s last Life Safety survey was April 2026. Facilities in MO are typically surveyed 14–21 months after the last one (median 17), measured over 567 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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2 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Physical environment (health survey)
5 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 22 Life Safety citations above. The Physical Environment Index
- F-0880 Provide and implement an infection prevention and control program.
- F-0909 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.
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
How that compares
Compared with the median facility in MO, and nationally. Surveyors differ markedly between states, so the MO figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 22 |
| Median facility in MO | 18 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| June 17, 2022 | 11 |
| March 7, 2024 | 3 |
| April 2, 2026 | 8 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | 2 | 2026-04-02 |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | 2 | 2026-04-02 |
| K-0363 | Install corridor and hallway doors that block smoke. | 2 | 2024-03-07 |
| K-0920 | Ensure proper usage of power strips and extension cords. | 2 | 2026-04-02 |
| K-0131 | Meet requirements for sections of health care facilities separated by fire resistive construction. | 2 | 2026-04-02 |
| K-0222 | 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. | 2 | 2026-04-02 |
| K-0923 | Have proper medical gas storage and administration areas. | 1 | 2026-04-02 |
| K-0347 | Properly provide smoke detection systems in areas open to corridors. | 1 | 2022-06-17 |
What the citations cover
- Smoke Deficiencies 11
- Gas, Vacuum, and Electrical Systems Deficiencies 5
- Construction Deficiencies 3
- Egress Deficiencies 2
- Other 1
| Category | Citations |
|---|---|
| Smoke Deficiencies | 11 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 5 |
| Construction Deficiencies | 3 |
| Egress Deficiencies | 2 |
| Miscellaneous Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
April 2, 2026 — 8 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0131 | Meet requirements for sections of health care facilities separated by fire resistive construction. | Deficient, Provider has date of correction (May 15, 2026) |
| K-0222 | 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. | Deficient, Provider has date of correction (May 15, 2026) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (May 15, 2026) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (May 15, 2026) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (May 15, 2026) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (May 15, 2026) |
| K-0921 | Ensure that testing and maintenance of electrical equipment is performed. | Deficient, Provider has date of correction (May 15, 2026) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (May 15, 2026) |
March 7, 2024 — 3 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (April 19, 2024) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (April 19, 2024) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (April 19, 2024) |
June 17, 2022 — 11 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0131 | Meet requirements for sections of health care facilities separated by fire resistive construction. | Deficient, Provider has date of correction (July 29, 2022) |
| K-0161 | Use approved construction type or materials. | Deficient, Provider has date of correction (July 29, 2022) |
| K-0222 | 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. | Deficient, Provider has date of correction (July 29, 2022) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (July 29, 2022) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (July 29, 2022) |
| K-0347 | Properly provide smoke detection systems in areas open to corridors. | Deficient, Provider has date of correction (September 9, 2022) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (July 29, 2022) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (July 29, 2022) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Waiver has been granted |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (July 29, 2022) |
| K-0932 | Meet other general requirements. | Deficient, Provider has date of correction (July 29, 2022) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.