All citations for Lutheran Senior Services at Breeze Park

State inspectors check nursing homes that take Medicare or Medicaid against federal rules, usually about once a year, and also look into complaints. Each rule a home did not meet is a citation.

Back to Lutheran Senior Services at Breeze Park

Last standard health inspection on record

April 2, 2026

Showing 1 to 25 of 37 citations

Immediate jeopardy to resident health or safety
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Isolated (one or a few residents). CMS level J.
Health citation F-0684, Quality of Life and Care Deficiencies. Inspection of December 5, 2024. Found during a complaint inspection.
The home gave a date the problem would be corrected (December 6, 2024).
No harm, with potential for more than minimal harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Widespread (many residents). CMS level F.
Health citation F-0812, Nutrition and Dietary Deficiencies. Inspection of April 2, 2026. Found during a standard inspection.
The home gave a date the problem would be corrected (May 15, 2026).
No harm, with potential for more than minimal harm
Provide and implement an infection prevention and control program.
Widespread (many residents). CMS level F.
Health citation F-0880, Infection Control Deficiencies. Inspection of April 2, 2026. Found during a standard inspection.
The home gave a date the problem would be corrected (May 15, 2026).
No harm, with potential for more than minimal harm
Have generator or other power source capable of supplying service within 10 seconds.
Widespread (many residents). CMS level F.
Fire safety citation K-0918, Gas, Vacuum, and Electrical Systems Deficiencies. Inspection of March 7, 2024. Found during a standard inspection.
The home gave a date the problem would be corrected (April 19, 2024).
No harm, with potential for more than minimal harm
Meet other general requirements.
Widespread (many residents). CMS level F.
Fire safety citation K-0932, Smoke Deficiencies. Inspection of June 17, 2022. Found during a standard inspection.
The home gave a date the problem would be corrected (July 29, 2022).
No harm, with potential for more than minimal harm
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Pattern (more than a few residents). CMS level E.
Health citation F-0688, Quality of Life and Care Deficiencies. Inspection of April 2, 2026. Found during a standard inspection.
The home gave a date the problem would be corrected (May 15, 2026).
No harm, with potential for more than minimal harm
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Pattern (more than a few residents). CMS level E.
Health citation F-0700, Quality of Life and Care Deficiencies. Inspection of April 2, 2026. Found during a standard inspection.
The home gave a date the problem would be corrected (May 15, 2026).
No harm, with potential for more than minimal harm
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.
Pattern (more than a few residents). CMS level E.
Fire safety citation K-0222, Egress Deficiencies. Inspection of April 2, 2026. Found during a standard inspection.
The home gave a date the problem would be corrected (May 15, 2026).
No harm, with potential for more than minimal harm
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Pattern (more than a few residents). CMS level E.
Fire safety citation K-0321, Smoke Deficiencies. Inspection of April 2, 2026. Found during a standard inspection.
The home gave a date the problem would be corrected (May 15, 2026).
No harm, with potential for more than minimal harm
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Pattern (more than a few residents). CMS level E.
Fire safety citation K-0372, Smoke Deficiencies. Inspection of April 2, 2026. Found during a standard inspection.
The home gave a date the problem would be corrected (May 15, 2026).
No harm, with potential for more than minimal harm
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Pattern (more than a few residents). CMS level E.
Fire safety citation K-0374, Smoke Deficiencies. Inspection of April 2, 2026. Found during a standard inspection.
The home gave a date the problem would be corrected (May 15, 2026).
No harm, with potential for more than minimal harm
Ensure proper usage of power strips and extension cords.
Pattern (more than a few residents). CMS level E.
Fire safety citation K-0920, Gas, Vacuum, and Electrical Systems Deficiencies. Inspection of April 2, 2026. Found during a standard inspection.
The home gave a date the problem would be corrected (May 15, 2026).
No harm, with potential for more than minimal harm
Ensure that testing and maintenance of electrical equipment is performed.
Pattern (more than a few residents). CMS level E.
Fire safety citation K-0921, Gas, Vacuum, and Electrical Systems Deficiencies. Inspection of April 2, 2026. Found during a standard inspection.
The home gave a date the problem would be corrected (May 15, 2026).
No harm, with potential for more than minimal harm
Have proper medical gas storage and administration areas.
Pattern (more than a few residents). CMS level E.
Fire safety citation K-0923, Gas, Vacuum, and Electrical Systems Deficiencies. Inspection of April 2, 2026. Found during a standard inspection.
The home gave a date the problem would be corrected (May 15, 2026).
No harm, with potential for more than minimal harm
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Pattern (more than a few residents). CMS level E.
Health citation F-0657, Resident Assessment and Care Planning Deficiencies. Inspection of March 7, 2024. Found during a standard inspection.
The home gave a date the problem would be corrected (April 19, 2024).
No harm, with potential for more than minimal harm
Provide and implement an infection prevention and control program.
Pattern (more than a few residents). CMS level E.
Health citation F-0880, Infection Control Deficiencies. Inspection of March 7, 2024. Found during a standard inspection.
The home gave a date the problem would be corrected (April 19, 2024).
No harm, with potential for more than minimal harm
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.
Pattern (more than a few residents). CMS level E.
Health citation F-0909, Environmental Deficiencies. Inspection of March 7, 2024. Found during a standard inspection.
The home gave a date the problem would be corrected (April 19, 2024).
No harm, with potential for more than minimal harm
Install corridor and hallway doors that block smoke.
Pattern (more than a few residents). CMS level E.
Fire safety citation K-0363, Smoke Deficiencies. Inspection of March 7, 2024. Found during a standard inspection.
The home gave a date the problem would be corrected (April 19, 2024).
No harm, with potential for more than minimal harm
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Pattern (more than a few residents). CMS level E.
Fire safety citation K-0372, Smoke Deficiencies. Inspection of March 7, 2024. Found during a standard inspection.
The home gave a date the problem would be corrected (April 19, 2024).
No harm, with potential for more than minimal harm
Provide care and assistance to perform activities of daily living for any resident who is unable.
Pattern (more than a few residents). CMS level E.
Health citation F-0677, Quality of Life and Care Deficiencies. Inspection of June 17, 2022. Found during a standard inspection.
The home gave a date the problem would be corrected (July 29, 2022).
No harm, with potential for more than minimal harm
Provide and implement an infection prevention and control program.
Pattern (more than a few residents). CMS level E.
Health citation F-0880, Infection Control Deficiencies. Inspection of June 17, 2022. Found during a standard inspection.
The home gave a date the problem would be corrected (July 29, 2022).
No harm, with potential for more than minimal harm
Meet requirements for sections of health care facilities separated by fire resistive construction.
Pattern (more than a few residents). CMS level E.
Fire safety citation K-0131, Construction Deficiencies. Inspection of June 17, 2022. Found during a standard inspection.
The home gave a date the problem would be corrected (July 29, 2022).
No harm, with potential for more than minimal harm
Use approved construction type or materials.
Pattern (more than a few residents). CMS level E.
Fire safety citation K-0161, Construction Deficiencies. Inspection of June 17, 2022. Found during a standard inspection.
The home gave a date the problem would be corrected (July 29, 2022).
No harm, with potential for more than minimal harm
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.
Pattern (more than a few residents). CMS level E.
Fire safety citation K-0222, Egress Deficiencies. Inspection of June 17, 2022. Found during a standard inspection.
The home gave a date the problem would be corrected (July 29, 2022).
No harm, with potential for more than minimal harm
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Pattern (more than a few residents). CMS level E.
Fire safety citation K-0321, Smoke Deficiencies. Inspection of June 17, 2022. Found during a standard inspection.
The home gave a date the problem would be corrected (July 29, 2022).

Source: CMS Provider Information, Fire Safety Deficiencies, Health Deficiencies, Citation Code Look-up, data as of September 30, 2026. Inspection results describe the home at the time of each inspection.