Bernard Care Center

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

they must focus on the biggest issues first. The baseboards and floors in the hallway did not look like they had been cleaned. If something was damaged or needed repair, he/she would tell the Maintenance Director. Report forms were by the time clock. 14. During an interview on 12/18/25 at 10:05 A.M. and 2:30 P.M., the Director of Housekeeping and Laundry said they used to have four designated housekeepers and two floor technicians. That was cut back to three housekeepers and one floor technician. There were a few months when there were only two housekeepers, so staff would be pulled from laundry when they were short staffed. They hired another housekeeper yesterday. The floor technician was in an accident and has been out for the last three weeks. The elevator has also been broken which complicates staff ability to do their jobs. They have not been able to do their jobs to his expectations. He has been helping out to cover for laundry and housekeeping as well. They usually do not have issues, but the last seven to eight months have been a challenge. Some things were not getting done. The floor technician was responsible for cleaning the cove bases and thresholds. All housekeeping staff were responsible for wiping down the handrails and dusting the baseboards. The ceilings were not frequently dusted. He was aware the smoker was broken. When staff tried to move it, the legs broke. He thought maintenance was going to fix it.

Housekeeping staff were supposed to clean the inside of the windows in resident rooms. He cleaned the windows, on the outside. Staff selected the rooms they would deep clean. There was not a set schedule.

Staff were doing their best to provide a clean, comfortable and homelike environment for the residents. 15.

During an interview on 12/18/25 at 10:43 A.M., the Administrator said they were in the process of replacing handrails. Residents were hard on the environment. The basketball sized patch was from a resident punching the wall but should have been painted. Residents in wheelchairs bumped into walls and doorframes. If staff saw something that needed to be repaired or replaced, they were supposed to put in a maintenance request or use the walkie/talkie to alert the Maintenance Director. Sometimes the housekeeping staff could only get the basics accomplished when cleaning resident rooms. Some rooms were more challenging than others. The floor technician was responsible for emptying the trash for the whole building and maintaining the floors for the whole building which included stripping, waxing, buffing and shining. The floor technician has been out for three weeks. They were trying to provide a clean and comfortable homelike environment for their residents. 1710443

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Facility ID:

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/19/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Bernard Care Center

4335 West Pine Blvd Saint Louis, MO 63108

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0687 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

his/her toenails to get the long nail trimmed. During an interview on 12/17/25 at 1:43 P.M., the Social Service Designee (SSD) said the resident has not been seen by a podiatrist and does have a history of refusals. 6. During an interview on 12/17/25 at 10:15 A.M., CMT B nursing staff are expected to notify the Director of Nursing (DON) or Assistant Director of Nursing (ADON) if residents require toenail trimming.

Moisturizing a resident's feet can be done anytime by any nursing staff member. If a resident is unable to apply lotion to their feet, then the facility will supply them with some type of moisturizer. Staff should change

a resident's socks if they are soiled or have holes in them. If a resident refuses any type of care staff should let the nurse know and document the refusals. 7. During an interview on 12/18/25 at 8:15 A.M., Licensed Practical Nurse (LPN) F said the nurses complete weekly skin assessments on the residents. The assessment includes removing the resident's socks and examining the resident's feet. Podiatry is consulted for diabetics and for residents that have extremely thick toenails. The nurse can trim or file toenails for residents who are not diabetic. 8. During an interview on 12/17/25 at 8:30 A.M., the DON said some residents refuse to have foot care completed by staff and the podiatrist. The podiatrist comes to the facility about every two to three months. If a resident refuses foot care, staff is expected to document this in the medical record and on the care plan. She expects staff to moisturize the resident's feet on their shower days and as needed. She expects staff to notify her or the charge nurse if the resident needs their toenails trimmed. She expects staff to change the resident's socks if soiled or if there are holes in the socks. 9.

During an interview on 12/17/25 at 1:43 P.M., the SSD said staff notifies her of residents that need to be seen by the podiatrist. She will obtain a consent and schedule the resident to be seen. The aides are responsible for notifying the nurses of a resident's toenail needs and the nurses should assess and determine if the residents need to be seen by the podiatrist. Refusals should be documented in the resident's medical record. 2686150

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/19/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Bernard Care Center

4335 West Pine Blvd Saint Louis, MO 63108

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, interview and record review, the facility failed to ensure food was served at a palatable and appetizing temperature during tray service by failing to maintain the temperature of hot food at least at 120 degrees Fahrenheit (F) and failed to ensure food was palatable for two of 29 sampled residents (Residents #11 and #13). The census was 131. Review of the facility's dietary food preparation policy, dated 7/5/23, showed:-Food temperatures: foods will be served at proper temperature to ensure food safety;-Acceptable serving temperatures: eggs should be between 135 degrees F and 155 degrees F. Meat should be 135 degrees F;-If temperatures are not at acceptable levels and cannot be corrected in time for meal service, make an appropriate menu substitution and discarded out of temperature range foods. 1. Review of Resident #11's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/4/25, showed:-Diagnoses included major depressive disorder, schizoaffective disorder (mental health condition that includes features of both schizophrenia and a mood disorder), and epilepsy (seizure disorder);-Moderately impaired cognition. During an interview on 12/17/25 at 11: 29 A.M., the resident said the food is not good. The food is not always warm, and the taste is bad. 2.

Review of Resident #13's annual MDS, dated [DATE REDACTED], showed:-Diagnoses included bipolar disorder (mood disorder that can cause intense mood swings), major depressive disorder, type two diabetes, and schizoaffective disorder;-Cognitively intact. During an interview on 12/15/25 at 2:00 P.M., the resident said

the food tastes okay but could be better. The food is cold a lot. 3. Observation on 12/17/25 at 8:08 A.M., of

the breakfast meal service on the 300 hall, showed:-Sausage patty measured 93 degrees F and felt cold.

The sausage tasted rubbery;-Scrambled eggs measured 115.9 degrees F and felt cold. 4. Observation on 12/17/25 at 12:45 P.M., of the lunch meal service on the 100 hall, showed:-The plate covered with plastic wrap and contained 3 chicken strips, a slice of white bread, green beans and mashed potatoes;-The chicken strips had a piece of sliced bread on top. The bread was limp and damp;-The chicken strips tasted rubbery;-The mashed potatoes tasted very dry, bland, and powdery. The mashed potatoes did not have gravy. 5. During an interview on 12/19/25 at 9:22 A.M., the Food Service Manager said food should be palatable and taste good. He would expect food to be served at a safe and palatable temperature. He said

the reason the food temperatures are not good is because the elevator breaks frequently so dietary staff have to carry the food up the stairs, which takes longer. 6. During an interview on 12/19/25 at 1:15 P.M., the Administrator said she would expect food to be served at a safe and palatable temperature. She would expect food to be palatable. 17104431710440

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/19/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Bernard Care Center

4335 West Pine Blvd Saint Louis, MO 63108

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0908

Keep all essential equipment working safely.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, interview and record review, the facility failed to maintain essential equipment in a safe and operable working condition by not maintaining a consistently operating elevator. This deficient practice had

the potential to affect all residents. In addition, one resident (Resident #2) did not have access to his/her wheelchair while being repaired because the repair needed to occur in the lower level of the facility, and the resident did not have access to an alternate wheelchair during the repair. The sample size was 29. The facility census was 131.Review of Resident #2's face sheet, showed:-admitted on [DATE REDACTED];-Diagnoses included high blood pressure, chronic atrial fibrillation (irregular heart rhythm), acquired absence of right leg below the knee, and acquired absence of left leg below the knee.Review of the resident's care plan, in use

during survey, showed:-Problem: Resident has limited physical mobility and needs assistance with Activities of Daily Living (ADLs). He/She needs encouragement to get out of bed. He/She needs total assistance with care. He/She uses an electric wheelchair for locomotion. He/She is a bilateral knee amputee;-Interventions: Monitor/document/report as needed (PRN) any signs or symptoms of immobility, contractures (fixed tightening of muscle, tendons, ligaments, or skin, preventing normal movement) forming or worsening, thrombus (blood clot) formation, skin breakdown, and fall related injury;-Provide supportive care, assistance with mobility as needed. Document assistance as needed;-Problem: Resident is at risk for psychosocial problems related to depression and acceptance surrounding his/her diagnosis, specifically the loss of his/her legs. He/She is working on getting prosthetics and if often frustrated about the process. Resident complains daily to staff about his/her wheelchair and other issues;-Interventions: Anticipate and meet the resident's needs;-Administer medications as ordered. Monitor/document for side effects and effectiveness;-Explain all procedures to the resident before starting and allow the resident time to adjust to changes;-Praise any indication of the resident's progress/improvement in behavior.Observation and

interview on 12/16/25 at 8:53 A.M., showed the resident sat in his/her wheelchair. The resident has bilateral knee amputations (BKA). The tilted electric wheelchair was missing the support limb for the right thigh. The resident said it broke two weeks ago. Someone is coming to fix it on 12/18/25.Observation and interview on 12/19/25 at 8:26 A.M., showed the resident in bed. The resident said he/she was upset because his/her wheelchair was in the basement to get repaired, but the elevator was out of service. At 8:45 A.M., the resident told Licensed Practical Nurse (LPN) N that he/she wanted to get his/her wheelchair. He/She is having company. and Christmas is next week. The resident said he/she likes to come and go and does not like being in bed. He/She was once in bed for four months because of a wound, and he/she did not want to do that anymore. The resident said, if God gives me the strength, I will get up. During an interview on 12/19/25 at 8:59 A.M., the Administrator said the elevator stopped working yesterday. In the last year, it has broken more times than ever. As soon as the company comes out, it will be fixed. They have been called but there is no estimated time of when they will arrive. During an interview on 12/19/25 at 1:00 P.M., the Director of Nursing (DON) said she spoke to the resident. The company had to use the basement to repair

the wheelchair; they could not use the resident's room or hallway. The resident likes to leave and go around to the store. The wheelchair may be fixed, but it is in the basement. She believed the resident was offered a geri-chair (medical reclining chair), but the resident has no trunk control, and she did not believe they had anything that reclines or had a seatbelt that would keep the resident positioned well. 1710443

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/19/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Bernard Care Center

4335 West Pine Blvd Saint Louis, MO 63108

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0923

Have enough outside ventilation via a window or mechanical ventilation, or both.

Level of Harm - Minimal harm or potential for actual harm

Based on observation, interview and record review, the facility failed to maintain an appropriate exhaust system to remove cigarette smoke from the facility's indoor smoke room. This affected all residents who sat

in the 300 Hall dining room or walked from the 300 Hall to the 400 Hall. The facility census was 131.Review of the facility's Safe and Homelike Environment policy, last revised on 6/5/25, showed:-Purpose: In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment;-Environment refers to any environment the facility that is frequented by residents, including hallways and dining rooms;-General considerations: Have adequate outside ventilation by means of windows, or mechanical ventilation or a combination of the two. 1. Observations of the smoke room on 12/15/25 at 11:50 A.M. and 6:00 P.M., 12/16/25 at 11:06 A.M.,1:24 P.M. and 3:41 P.M., 12/17/25 at 7:45 A.M., 8:49 A.M., and 3:00 P.M., 12/18/25 at 9:59 A.M. and 4:00 P.M. and 12/19/25 at 7:30 A.M. showed:-Multiple residents and staff entered and exited the smoke room;-Multiple residents sat in the smoke room to smoke;-The smoke odor began at the entrance from the lobby and could be smelled to the end of the hallway at the top of the 400 Hall and inside and outside the 300 Hall dining room;-Two floor fans not turned on;-Two garage fans not turned on.2. Observation of the 300 Hall outside the smoke room on 12/15/25 at 6:00 P.M., showed a visible haze of smoke.3. During an interview on 12/17/25 at 9:15 A.M., a resident who lived on the 400 Hall said he/she could smell smoke when the door to his/her room was open.4. During an interview on 12/17/25 at 8:59 A.M., Housekeeper D said there was a strong smoke odor outside the smoke room and in the 300 Hall dining room. It smelled more when there were more residents smoking inside the smoke room.5. During an interview on 12/18/25 at 9:54 A.M. Certified Nurse Aide A said he/she had seen smoke in the hallway outside the smoke room. He/She wouldn't want his/her house to smell like smoke. He/She did not smoke. 6. During an interview on 12/18/25 at 10:23 A.M., the Maintenance Director said it smelled like smoke outside the smoke room. The ceiling tiles in the hallway outside the smoke room had yellowed due to the smoke. The fans in the smoke room should be on, but residents turned them off. He installed two new garage fans, but there was a power issue, and they did not work. 7.

During an interview on 12/18/25 at 10:43 A.M., the Administrator said she did not like the smoke odor, and

she could smell it in her office. There were exhaust fans, but they were broken. The smell was worse in the colder weather when more residents sat inside to smoke. The other fans were used in the warmer weather to cool down the smoke room.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/19/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Bernard Care Center

4335 West Pine Blvd Saint Louis, MO 63108

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0924

Put firmly secured handrails on each side of hallways.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, interview and record review, the facility failed to ensure all corridors had handrails and failed to ensure existing handrails were securely affixed to the wall. The census was 131.Review of the Facility Area Audit, Preventative Maintenance Inspection, undated, showed handrails listed as an item for staff to inspect. 1. Observation of the 100 Hall on 12/16/25 at 8:16 A.M., showed:-No railings between room [ROOM NUMBER] and the 100 hall dining room;-No railings around the perimeter of the 100 hall nurse's station;-Broken railing that pulled away from the wall outside of room [ROOM NUMBER]. 2. Observation of

the 400 Hall on 12/16/25 at 10:42 A.M., showed:-No railing outside the enclosed nurse's station;-Loose railing to the right of the nurse's station window;-Loose railing outside of room [ROOM NUMBER];-Loose railing pulled away from the wall between rooms [ROOM NUMBERS]. Observation on 12/16/25 at 11:05 A.M., showed a staff member stood next to a resident who held on to the handrail outside the 400 hall dining room. 3. Observation of the 300 hall on 12/16/25 at 11:18 A.M., showed:-No railings between the doors to the lobby and the Director of Nurse's (DON) office;-No railings between the DON's office and the women's restroom;-No railings between the men's restroom and staff office;-No railings from the staff office to the end of the wall extending approximately 13 feet. 4. Observations of the 200 hall on 12/16/25 at 1:37 P.M., showed:-No railings on either side of a hallway leading to a designated exit door by the nurses' station;-No railings around the perimeter of the enclosed nurses' station;-No railings between rooms [ROOM NUMBERS]. 5. During an interview on 12/18/25 at 10:23 A.M. the Maintenance Director said he checked the status of the facility's handrails every three months. He was aware there were handrails that needed to be replaced or were missing. He did not have the needed replacement parts because the current handrails were plastic. [NAME] railings were being used to replace the plastic handrails. Some handrails had been completely removed around the beginning of the month but had not yet been replaced. He knew handrails needed to be firmly affixed to the wall. He was not aware handrails were needed outside the nurses' stations and on both sides of all corridors used by residents. If staff noticed something needed to be repaired or replaced, they would either tell him directly or fill out a maintenance request form. 6. During an

interview on 12/18/25 at 10:44 A.M., the Administrator said they were in the process of replacing and repairing handrails throughout the facility. Orders were placed to replace the handrails. Old fashioned wood railings were being used because they did not know where the plastic handrails were ordered from. She knew handrails needed to be firmly affixed to the wall and on both sides of the hall. She was not aware they needed to be located outside the nurses' stations or in the hallway near the lobby or the designated exit door on the 200 hall.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet