Bernard Care Center: Foot Care Neglect Violations - MO
The December 2025 inspection, completed on the 19th, focused on a narrow but telling category of care: what happens to a nursing home resident's feet when staff aren't paying close attention. The answer at Bernard Care Center, a 126-bed facility on West Pine Boulevard, was not much.
Inspectors found that staff had not been consistently moisturizing residents' feet, not changing socks that were soiled or full of holes, and not ensuring that residents who needed toenail trimming were actually seen by someone qualified to do it. The violations were cited under the federal standard requiring facilities to maintain residents' grooming and personal hygiene.
The Director of Nursing, interviewed on the morning of December 17, laid out what she expected from her staff with some precision. She said she expected nurses to moisturize residents' feet on shower days and as needed. She expected staff to notify her or the charge nurse if a resident's toenails needed trimming. She expected staff to swap out socks that were soiled or had holes. If a resident refused care, she expected that refusal to be written down in the medical record and on the care plan.
None of that, apparently, was happening reliably.
A certified medication technician, also interviewed on December 17, confirmed that nursing staff are supposed to alert the Director of Nursing or the Assistant Director of Nursing when a resident needs toenail trimming. Moisturizing feet, the technician said, can be done anytime, by anyone on the nursing staff. Soiled socks or socks with holes should be changed. Refusals should go to the nurse, who documents them.
A licensed practical nurse, speaking the following morning, added that weekly skin assessments are supposed to include removing residents' socks and examining their feet. The nurse said podiatry is consulted for diabetic residents and for those with especially thick toenails. For residents who aren't diabetic, the nurse said, staff can trim or file the nails themselves.
The gap between those stated expectations and what inspectors actually found is the story. A resident who needed podiatry care had not been seen. The Social Service Designee, who is responsible for obtaining consent and scheduling podiatry appointments after aides notify nurses and nurses assess residents and nurses notify the designee, confirmed the resident had not been seen. She attributed it partly to the resident's history of refusing care.
Refusal is a real and recurring challenge in nursing home settings. Residents have the right to decline treatment. But the facility's own policies, as described by three separate staff members during the inspection, require that refusals be documented every time they occur. That documentation creates a record, and the record drives the care plan. Without it, a resident's unmet need can simply disappear into the daily routine of a busy facility, untouched and untracked.
The podiatrist, the Director of Nursing noted, comes to the facility roughly every two to three months. That schedule means a missed appointment isn't easily corrected the following week.
For diabetic residents especially, foot care is not a cosmetic matter. Circulation problems and nerve damage associated with diabetes make foot wounds difficult to detect and slow to heal. An untrimmed nail can curl into skin. Dry, cracked skin can open. A small wound in a diabetic resident can become something much worse before anyone notices, particularly if weekly sock-off assessments aren't being done.
The inspection report does not describe a resident who was injured. The harm level was listed as minimal harm or potential for actual harm, and the number of residents affected was listed as few. Those are the lowest and second-lowest categories on the federal scale.
But the facility's own staff described a system with multiple checkpoints: aides notice, aides tell nurses, nurses assess, nurses tell the director or designee, the designee schedules care. Every one of those handoffs has to work. At Bernard Care Center in December 2025, at least one resident sat with long toenails and no podiatry appointment while staff pointed at the next person in the chain.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Bernard Care Center from 2025-12-19 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 19, 2026 · Our methodology
BERNARD CARE CENTER in SAINT LOUIS, MO was cited for neglect violations during a health inspection on December 19, 2025.
The answer at Bernard Care Center, a 126-bed facility on West Pine Boulevard, was not much.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.