Inspection visit
Fire Safety inspection
Citations
11 citations recorded*CMS
This is a Fire Safety survey. CMS cites these findings under the Life Safety Code and Emergency Preparedness rules, a separate set from the health (F-tag) deficiencies. The codes and grading differ, so these do not link to the health violation pages.
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
- 0131GeneralS&S Epotential for harm
Meet requirements for sections of health care facilities separated by fire resistive construction.
- 0161GeneralS&S Epotential for harm
Use approved construction type or materials.
- 0222GeneralS&S Epotential for 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.
- 0321GeneralS&S Epotential for harm
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- 0324GeneralS&S Epotential for harm
Provide properly protected cooking facilities.
- 0347GeneralS&S Epotential for harm
Properly provide smoke detection systems in areas open to corridors.
- 0353GeneralS&S Epotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0363GeneralS&S Epotential for harm
Install corridor and hallway doors that block smoke.
- 0761GeneralS&S Epotential for harm
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
- 0920GeneralS&S Epotential for harm
Ensure proper usage of power strips and extension cords.
- 0932GeneralS&S Fpotential for harm
Meet other general requirements.
FAQ · About this visit
Common questions about this visit
What happened during the June 17, 2022 survey of LUTHERAN SENIOR SERVICES AT BREEZE PARK?
This was a inspection survey of LUTHERAN SENIOR SERVICES AT BREEZE PARK on June 17, 2022. The surveyor cited 11 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at LUTHERAN SENIOR SERVICES AT BREEZE PARK on June 17, 2022?
Yes, 11 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Meet requirements for sections of health care facilities separated by fire resistive construction."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.