BERNARD CARE CENTER

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

PRINTED: 7/11/2019
FORM APPROVED
OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265500

(X2) MULTIPLE CONSTRUCTION
A. BUILDING	___________
B. WING	___________

(X3) DATE SURVEY COMPLETED

06/13/2018

NAME OF PROVIDER OF SUPPLIER

BERNARD CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

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 0550 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few	Honor the resident’s right to a dignified existence, self-determination, communication, and to exercise his or her rights. NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a resident’s right to personal privacy was protected during personal care by not ensuring window blinds were keep in good repair. Window blinds were broken and unable to close, exposing the resident during care. This affected two sampled residents (Resident #116 and Resident #4). The census was 139. 1. Review of Resident #116’s care plan, updated 2/28/18, showed the following: -Problem: Requires total assistance with toileting, pericare, lower extremity dressing and dressing related to [MEDICAL CONDITION]; -Approach: Provide good pericare after each incontinent episode. Review of the resident’s Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/17/18, showed the following: -[DIAGNOSES REDACTED]. -No short/long term memory problems; -Required extensive staff assistance for bed mobility, dressing, toilet use, and personal hygiene; -Required total staff assistance for transfers and bathing. During an interview on 6/7/18 at 9:33 A.M., during the tour of the facility, showed the resident lay in bed. He/she said the blinds to his/her window has been broken for some time. He/she does not like to be exposed to the outside while staff provides care. Observation at this time showed several broken and missing vertical window blinds. The view from the resident’s window showed an alley and an apartment building across the alley from the resident’s window. Observation on 6/8/18 at 9:36 A.M. and 6/11/18 at 7:40 A.M., showed missing and broken vertical window blinds. 2. Review of Resident #4’s handwritten POS, dated 5/14/18, showed the following: -[DIAGNOSES REDACTED]. -Hospice. Review of the resident’s significant change in status MDS, dated [DATE], showed the following: -Clear speech – clear distinct intelligible words; -Understood/understands; -Limited assistance of one person required for dressing and personal hygiene. Observation on 6/7/18 at 11:01 A.M., showed the resident lay in bed. His/her bed was against the wall and window. A sheer curtain hung in the window. A long side walk that connected the facility parking lot to the front lobby was located on the outside of the wall. Staff and visitors used the sidewalk. Observation on 6/8/18 at 5:44 A.M., showed the resident lay in bed. Certified Nursing Assistant (CNA) B turned on the room light as it was still relatively dark outside. The CNA removed the resident’s gown and incontinence brief and began to provide incontinence care. The surveyor went outside during the incontinence care observation and looked through the window. The sheer curtain provided no privacy as the surveyor was able to clearly see the CNA fastening a new incontinence brief on the resident. At 6:18 A.M., the Director of Nurses looked through the window from the sidewalk outside. She could clearly see the resident laying in bed. She would not want receive personal care in front of the sheer curtain. She had no idea how long the sheer curtain had been up, but said it was a privacy issue.

(X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)

F 0550

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Honor the resident’s right to a dignified existence, self-determination, communication,
and to exercise his or her rights.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure a
resident’s right to personal privacy was protected during personal care by not ensuring
window blinds were keep in good repair. Window blinds were broken and unable to close,
exposing the resident during care. This affected two sampled residents (Resident #116 and
Resident #4). The census was 139.
1. Review of Resident #116’s care plan, updated 2/28/18, showed the following:
-Problem: Requires total assistance with toileting, pericare, lower extremity dressing and
dressing related to [MEDICAL CONDITION];
-Approach: Provide good pericare after each incontinent episode.
Review of the resident’s Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 5/17/18, showed the following:
-[DIAGNOSES REDACTED].
-No short/long term memory problems;
-Required extensive staff assistance for bed mobility, dressing, toilet use, and personal
hygiene;
-Required total staff assistance for transfers and bathing.
During an interview on 6/7/18 at 9:33 A.M., during the tour of the facility, showed the
resident lay in bed. He/she said the blinds to his/her window has been broken for some
time. He/she does not like to be exposed to the outside while staff provides care.
Observation at this time showed several broken and missing vertical window blinds. The
view from the resident’s window showed an alley and an apartment building across the alley
from the resident’s window.
Observation on 6/8/18 at 9:36 A.M. and 6/11/18 at 7:40 A.M., showed missing and broken
vertical window blinds.
2. Review of Resident #4’s handwritten POS, dated 5/14/18, showed the following:
-[DIAGNOSES REDACTED].
-Hospice.
Review of the resident’s significant change in status MDS, dated [DATE], showed the
following:
-Clear speech – clear distinct intelligible words;
-Understood/understands;
-Limited assistance of one person required for dressing and personal hygiene.
Observation on 6/7/18 at 11:01 A.M., showed the resident lay in bed. His/her bed was
against the wall and window. A sheer curtain hung in the window. A long side walk that
connected the facility parking lot to the front lobby was located on the outside of the
wall. Staff and visitors used the sidewalk.
Observation on 6/8/18 at 5:44 A.M., showed the resident lay in bed. Certified Nursing
Assistant (CNA) B turned on the room light as it was still relatively dark outside. The
CNA removed the resident’s gown and incontinence brief and began to provide incontinence
care. The surveyor went outside during the incontinence care observation and looked
through the window. The sheer curtain provided no privacy as the surveyor was able to
clearly see the CNA fastening a new incontinence brief on the resident. At 6:18 A.M., the
Director of Nurses looked through the window from the sidewalk outside. She could clearly
see the resident laying in bed. She would not want receive personal care in front of the
sheer curtain. She had no idea how long the sheer curtain had been up, but said it was a
privacy issue.

LABORATORY DIRECTOR’S OR PROVIDER/SUPPLIER REPRESENTATIVE’S SIGNATURETITLE(X6) DATE

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

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

Event ID: YL1O11

Facility ID: 265500

If continuation sheet
Page 1 of 7

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

PRINTED: 7/11/2019
FORM APPROVED
OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265500

(X2) MULTIPLE CONSTRUCTION
A. BUILDING	___________
B. WING	___________

(X3) DATE SURVEY COMPLETED

06/13/2018

NAME OF PROVIDER OF SUPPLIER

BERNARD CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

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 0550 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few	(continued… from page 1) Observation on 6/8/18 at 9:06 A.M., showed staff had replaced the sheer curtain with a curtain that provided privacy. During an interview on 6/11/18 at 10:14 A.M., the resident was told that the sheer curtains that were in his/her window provided no privacy as anyone walking on the sidewalk could see him/her as staff provided care. The resident said, I don’t like that. 3. During an interview on 6/13/18 at 12:25 P.M., the Maintenence Director said he was aware of broken blinds in resident’s rooms. New blinds have been ordered three weeks ago. The facility has considered putting up curtains until the blinds are delivered but they don’t have any curtains.
	F 0568 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some	Properly hold, secure, and manage each resident’s personal money which is deposited with the nursing home. Based on interview and record review, the facility failed to reconcile the resident trust fund account for four of the 11 months reviewed. The census was 139 Review of the resident trust accounts statements showed no reconciliation for (MONTH) (YEAR) through (MONTH) (YEAR). During an interview on 6/13/18 at 10:10 A.M., the Director of Finance said the reconciliation was not completed due to a research concern. There was money taken out twice and sent to the Social Security Office. The company was waiting for a refund before during the reconciliations.
	F 0570 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some	Assure the security of all personal funds of residents deposited with the facility. Based on interview and record review, facility staff failed to purchase a surety bond in an amount sufficient to assure security of all personal funds the facility holds for 112 residents. The census was 139. Review of the resident trust fund account for (MONTH) (YEAR) through (MONTH) (YEAR), showed an average monthly balance of $101,241.37 which requires a surety bond of $153,000.00. The current ledger amount is $133,023.79. Review of the Department of Health and Senior Services (DHSS) database, showed the facility has an approved non-cancelable Escrow Agreement Account in the amount of $90,000.00. Review of the resident trust fund showed no reconciliation for (MONTH) (YEAR) through (MONTH) (YEAR) to determine an correct average monthly balance. During an interview on 6/13/18 at 9:20 A.M., the administrator said she was not aware there were high balances on the resident trust bank statements. She was not aware the bond needed to be increased.
	F 0658 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few	Ensure services provided by the nursing facility meet professional standards of quality.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

PRINTED: 7/11/2019
FORM APPROVED
OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265500

(X2) MULTIPLE CONSTRUCTION
A. BUILDING	___________
B. WING	___________

(X3) DATE SURVEY COMPLETED

06/13/2018

NAME OF PROVIDER OF SUPPLIER

BERNARD CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

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 0658 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to follow their policy regarding blood sugars and failed to monitor a resident’s low air loss mattress which was deflated for two days. This affected three of 34 residents sampled. (Resident #3, #89 and #4). The census was 139. Review of the facility’s policy on Blood Glucose Monitoring, dated 4/6/17, showed the following: -Purpose: To define accurate procedures to be followed when checking a blood sugar. To identify what measures will be taken in the event that a blood sugar falls out of the defined therapeutic range; -#7: In the event the blood sugar is greater than 250, sliding scale insulin will be given per the physician’s orders [REDACTED]. -#8. If the resident’s blood sugar over 400, the physician will be notified and orders followed. 1. Review of Resident #3’s quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/8/18, showed the following: -[DIAGNOSES REDACTED]. -No short/long term memory problems; -Required staff supervision for dressing, personal hygiene and bathing; -Received insulin injections seven of the last seven days. Review of the resident’s Medication Administration Record [REDACTED] -Blood glucose checks with meals; -Notify physician of blood sugars (normal blood sugar range 70 to 99) greater than 450; -4/7/18 at 7:30 A.M. a blood sugar of 566. No documentation whether staff recheck blood sugar; -4/8/18 at 7:30 A.M. a blood sugar of 572. No documentation whether staff rechecked the resident’s blood sugar. Review of the resident’s nurse’s notes, showed the following: -4/7/18 at 11:40 A.M., showed no documentation whether rechecked the resident’s blood sugar after administering sliding scale insulin; -No documentation in the nurse’s notes for 4/8/18. Review of the resident’s physician’s orders [REDACTED]. -Order dated 12/1/17 for blood glucose checks four times per day; -Blood sugars greater than 450 call the physician. 2. Review of Resident #89’s admission MDS, dated [DATE], showed the following: -[DIAGNOSES REDACTED]. -Short/Long term memory loss; -Independent with bed mobility; -Required limited staff assistance for transfers, dressing, toilet use and personal hygiene; -Extensive staff assistance for bathing; -Received insulin during the last seven days. Review of the resident’s nurse’s note, dated 3/9/18 at 12:28 P.M., showed the following: -Blood sugar registered Hi on the blood glucose machine; -Physician notified; -New order for sliding scale insulin of [MEDICATION NAME] three times per day and at bedtime; -No documentation whether staff rechecked the resident’s blood sugar. Review of the resident’s written POS, showed the following:

(X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)

F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to follow their
policy regarding blood sugars and failed to monitor a resident’s low air loss mattress
which was deflated for two days. This affected three of 34 residents sampled. (Resident
#3, #89 and #4). The census was 139.
Review of the facility’s policy on Blood Glucose Monitoring, dated 4/6/17, showed the
following:
-Purpose: To define accurate procedures to be followed when checking a blood sugar. To
identify what measures will be taken in the event that a blood sugar falls out of the
defined therapeutic range;
-#7: In the event the blood sugar is greater than 250, sliding scale insulin will be given
per the physician’s orders [REDACTED].
-#8. If the resident’s blood sugar over 400, the physician will be notified and orders
followed.
1. Review of Resident #3’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 3/8/18, showed the following:
-[DIAGNOSES REDACTED].
-No short/long term memory problems;
-Required staff supervision for dressing, personal hygiene and bathing;
-Received insulin injections seven of the last seven days.
Review of the resident’s Medication Administration Record [REDACTED] -Blood glucose checks with meals;
-Notify physician of blood sugars (normal blood sugar range 70 to 99) greater than 450;
-4/7/18 at 7:30 A.M. a blood sugar of 566. No documentation whether staff recheck blood
sugar;
-4/8/18 at 7:30 A.M. a blood sugar of 572. No documentation whether staff rechecked the
resident’s blood sugar.
Review of the resident’s nurse’s notes, showed the following:
-4/7/18 at 11:40 A.M., showed no documentation whether rechecked the resident’s blood
sugar after administering sliding scale insulin;
-No documentation in the nurse’s notes for 4/8/18.
Review of the resident’s physician’s orders [REDACTED].
-Order dated 12/1/17 for blood glucose checks four times per day;
-Blood sugars greater than 450 call the physician.
2. Review of Resident #89’s admission MDS, dated [DATE], showed the following:
-[DIAGNOSES REDACTED].
-Short/Long term memory loss;
-Independent with bed mobility;
-Required limited staff assistance for transfers, dressing, toilet use and personal
hygiene;
-Extensive staff assistance for bathing;
-Received insulin during the last seven days.
Review of the resident’s nurse’s note, dated 3/9/18 at 12:28 P.M., showed the following:
-Blood sugar registered Hi on the blood glucose machine;
-Physician notified;
-New order for sliding scale insulin of [MEDICATION NAME] three times per day and at
bedtime;
-No documentation whether staff rechecked the resident’s blood sugar.
Review of the resident’s written POS, showed the following:

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

PRINTED: 7/11/2019
FORM APPROVED
OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265500

(X2) MULTIPLE CONSTRUCTION
A. BUILDING	___________
B. WING	___________

(X3) DATE SURVEY COMPLETED

06/13/2018

NAME OF PROVIDER OF SUPPLIER

BERNARD CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

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 0658 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few	(continued… from page 3) -Order dated 3/9/18; -Blood glucose checks three times per day; -[MEDICATION NAME] sliding scale insulin three times per day and at bedtime; -Call physician for blood sugars greater than 450. Review of the resident’s care plan, updated 4/17/18, showed the following: -Problem: At risk for hyper/hypoglycemic episodes related to a [DIAGNOSES REDACTED].>-Approach: Monitor blood glucose checks as ordered. Monitor for signs and symptoms of hyper (hi blood sugar) hypo (low blood sugar) episodes. During an interview on 6/12/18 at 11:30 A.M., the Assistant Director of Nursing (ADON) said she would expect the staff to recheck the blood sugar. 3. Review of Resident #4’s handwritten POS, dated 5/14/18, showed the following: -[DIAGNOSES REDACTED]. -Hospice. Review of the resident’s significant change in status MDS, dated [DATE], showed the following: -Clear speech – distinct intelligible words; -Understood/understands; -Independent for bed mobility; -Limited assistance of one person required for transfers; -No pressure ulcers. Observation on 6/7/18 at 11:01 A.M., showed the resident lay on a low air loss (LAL) mattress (The mattress is inflated with air and there is an on/off switch on a control panel at the foot of the bed. If the control panel is turned off, the mattress deflates. It’s purpose is to prevent or assist in healing pressure ulcers by alleviating pressure.). The switch on the control panel had been turned off. Observation on 6/8/18 at 5:44 A.M., showed the resident lay on a LAL mattress. The switch on the control panel remained in the off position. During an interview, the resident said the mattress felt lumpy. At 5:58 A.M., Certified Nursing Assistant B said he/she had been taking care of the resident all night and had been in the resident’s room a couple of times. He/she did not notice the LAL control panel had been turned off. He/she turned the switch on the control panel to the on position and the mattress began to inflate. During an interview on 6/8/18 at 6:18 A.M., the DON said the LAL mattress, in this resident’s case, is for pressure ulcer prevention. Staff have been trained to monitor the control panels to ensure they are on. She did not know why the LAL mattress had been turned off.
	F 0700 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some	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. NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure side/bed rails were thoroughly assessed for risks of entrapment and/or the resident had an order to use the side/bed rail. The facility identified 13 residents that were present during the survey as having orders for side/bed rails. Of Of those 13, seven were sampled and problems were found with six. (Residents #45, #113, #119, #4, #22 and #108). The census

(X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)

F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 3)
-Order dated 3/9/18;
-Blood glucose checks three times per day;
-[MEDICATION NAME] sliding scale insulin three times per day and at bedtime;
-Call physician for blood sugars greater than 450.
Review of the resident’s care plan, updated 4/17/18, showed the following:
-Problem: At risk for hyper/hypoglycemic episodes related to a [DIAGNOSES
REDACTED].>-Approach: Monitor blood glucose checks as ordered. Monitor for signs and
symptoms of hyper (hi blood sugar) hypo (low blood sugar) episodes.
During an interview on 6/12/18 at 11:30 A.M., the Assistant Director of Nursing (ADON)
said she would expect the staff to recheck the blood sugar.
3. Review of Resident #4’s handwritten POS, dated 5/14/18, showed the following:
-[DIAGNOSES REDACTED].
-Hospice.
Review of the resident’s significant change in status MDS, dated [DATE], showed the
following:
-Clear speech – distinct intelligible words;
-Understood/understands;
-Independent for bed mobility;
-Limited assistance of one person required for transfers;
-No pressure ulcers.
Observation on 6/7/18 at 11:01 A.M., showed the resident lay on a low air loss (LAL)
mattress (The mattress is inflated with air and there is an on/off switch on a control
panel at the foot of the bed. If the control panel is turned off, the mattress deflates.
It’s purpose is to prevent or assist in healing pressure ulcers by alleviating pressure.).
The switch on the control panel had been turned off.
Observation on 6/8/18 at 5:44 A.M., showed the resident lay on a LAL mattress. The switch
on the control panel remained in the off position. During an interview, the resident said
the mattress felt lumpy. At 5:58 A.M., Certified Nursing Assistant B said he/she had been
taking care of the resident all night and had been in the resident’s room a couple of
times. He/she did not notice the LAL control panel had been turned off. He/she turned the
switch on the control panel to the on position and the mattress began to inflate.
During an interview on 6/8/18 at 6:18 A.M., the DON said the LAL mattress, in this
resident’s case, is for pressure ulcer prevention. Staff have been trained to monitor the
control panels to ensure they are on. She did not know why the LAL mattress had been
turned off.

F 0700

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure side/bed
rails were thoroughly assessed for risks of entrapment and/or the resident had an order to
use the side/bed rail. The facility identified 13 residents that were present during the
survey as having orders for side/bed rails. Of Of those 13, seven were sampled and
problems were found with six. (Residents #45, #113, #119, #4, #22 and #108). The census

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

PRINTED: 7/11/2019
FORM APPROVED
OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265500

(X2) MULTIPLE CONSTRUCTION
A. BUILDING	___________
B. WING	___________

(X3) DATE SURVEY COMPLETED

06/13/2018

NAME OF PROVIDER OF SUPPLIER

BERNARD CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

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 0700 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some	(continued… from page 4) was 139. 1. Review of Resident #45’s quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/5/18, showed the following: -Sometimes understood; -Usually understands; -Extensive assistance of one person required for bed mobility; -Total dependence of two (+) persons required for transfers; -Bed rails not used. Review of the resident’s physician’s orders [REDACTED]. Review of the resident’s Side Rail Assessment, dated 5/21/18, showed the following: -Recommendation: One left and one right upper 1/4 partial side rail at all times when resident is in bed; -The assessment did not address the risk of entrapment. Observation on 6/13/18 at 8:15 A.M., showed the resident lay in bed with quarter sized right and left metal bed rails up. 2. Review of Resident #113’s Side Rail Assessment, dated 4/18/18, showed the following: -Recommendation: One left and right upper 1/4 partial side rail at all times when resident is in bed; -The assessment did not address the risk of entrapment. Review of the resident’s admission MDS, dated [DATE], showed the following: -Sometimes understands; -Independent for bed mobility; -Limited assistance of one person required for transfers; -Diagnsoes of diabetes mellitus (DM) and [MEDICAL CONDITION]/[MEDICAL CONDITION] (weakness or paralysis of one side of the body); -Bed rails not used. Review of the resident’s POS, dated 5/15/18 through 6/14/18, showed an order for[REDACTED]. Observation on 6/11/18 at 10:10 A.M. and 6/13/18 at 6:18 A.M., showed the resident lay in bed with quarter sized right and left metal bed rails up. 3. Review of Resident #119’s Side Rail Assessment, dated 4/20/18, showed the following: -Recommendation: One left and right upper side rail and one left and right upper and lower full side rail at all times when resident is in bed; -The assessment did not address the risk of entrapment. Review of the resident’s admission MDS, dated [DATE], showed the following: -Understood/understands; -Limited assistance of one person required for bed mobility; -Total dependence of two (+) persons required for transfers; -[DIAGNOSES REDACTED]. -Bed rails used daily. Review of the resident’s POS, dated 5/15/18 through 6/14/18, showed an order for[REDACTED]. Observation on 6/8/18 at 5:39 A.M. showed the resident lay in bed with one right and left quarter sized bed rails up. 4. Review of Resident #4’s Side Rail Assessment, dated 5/15/18, showed the following: -Recommendation: One left and right upper 1/2 side rail at all times when resident is in bed; -The assessment did not address the risk of entrapment. Review of the resident’s significant change in status MDS, dated [DATE], showed the

(X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)

F 0700

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 4)
was 139.
1. Review of Resident #45’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 4/5/18, showed the following:
-Sometimes understood;
-Usually understands;
-Extensive assistance of one person required for bed mobility;
-Total dependence of two (+) persons required for transfers;
-Bed rails not used.
Review of the resident’s physician’s orders [REDACTED].
Review of the resident’s Side Rail Assessment, dated 5/21/18, showed the following:
-Recommendation: One left and one right upper 1/4 partial side rail at all times when
resident is in bed;
-The assessment did not address the risk of entrapment.
Observation on 6/13/18 at 8:15 A.M., showed the resident lay in bed with quarter sized
right and left metal bed rails up.
2. Review of Resident #113’s Side Rail Assessment, dated 4/18/18, showed the following:
-Recommendation: One left and right upper 1/4 partial side rail at all times when resident
is in bed;
-The assessment did not address the risk of entrapment.
Review of the resident’s admission MDS, dated [DATE], showed the following:
-Sometimes understands;
-Independent for bed mobility;
-Limited assistance of one person required for transfers;
-Diagnsoes of diabetes mellitus (DM) and [MEDICAL CONDITION]/[MEDICAL CONDITION] (weakness
or paralysis of one side of the body);
-Bed rails not used.
Review of the resident’s POS, dated 5/15/18 through 6/14/18, showed an order for[REDACTED].
Observation on 6/11/18 at 10:10 A.M. and 6/13/18 at 6:18 A.M., showed the resident lay in
bed with quarter sized right and left metal bed rails up.
3. Review of Resident #119’s Side Rail Assessment, dated 4/20/18, showed the following:
-Recommendation: One left and right upper side rail and one left and right upper and lower
full side rail at all times when resident is in bed;
-The assessment did not address the risk of entrapment.
Review of the resident’s admission MDS, dated [DATE], showed the following:
-Understood/understands;
-Limited assistance of one person required for bed mobility;
-Total dependence of two (+) persons required for transfers;
-[DIAGNOSES REDACTED].
-Bed rails used daily.
Review of the resident’s POS, dated 5/15/18 through 6/14/18, showed an order for[REDACTED].
Observation on 6/8/18 at 5:39 A.M. showed the resident lay in bed with one right and left
quarter sized bed rails up.
4. Review of Resident #4’s Side Rail Assessment, dated 5/15/18, showed the following:
-Recommendation: One left and right upper 1/2 side rail at all times when resident is in
bed;
-The assessment did not address the risk of entrapment.
Review of the resident’s significant change in status MDS, dated [DATE], showed the

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

PRINTED: 7/11/2019
FORM APPROVED
OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265500

(X2) MULTIPLE CONSTRUCTION
A. BUILDING	___________
B. WING	___________

(X3) DATE SURVEY COMPLETED

06/13/2018

NAME OF PROVIDER OF SUPPLIER

BERNARD CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

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 0700 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some	(continued… from page 5) following: -Understood/understands; -Independent for bed mobility; -Limited assistance of one person required for transfers; -Bed rails not used. Review of the resident’s POS, dated 6/7/18 through 6/14/18, showed no order for the use of[REDACTED] Observation on 6/7/18 at 11:01 A.M., 6/11/18 at 10:14 A.M. and 1:09 P.M., showed the resident lay in bed with two quarter sized metal bed rails up. Observation on 6/8/18 at 5:44 A.M., showed the resident lay in bed with one metal quarter sized bed rail up on the exit side of the bed. 5. Review of Resident #22’s POS, dated 5/15/18 through 6/14/18, showed no order for the use of [REDACTED] Review of the resident’s Side Rail Assessment, dated 5/21/18, showed the following: -Recommendation: One left and right 1/4 partial rail at all times when the resident is in bed. Review of the resident’s quarterly MDS, dated [DATE], showed the following: -Understood/understands; -Limited assistance of one person required for bed mobility; -Total dependence of two (+) persons required for transfers; -[DIAGNOSES REDACTED].>-Bed rails used daily. Observation on 6/7/18 at 10:50 A.M., 6/11/18 at 1:14 P.M. and 6/13/18 at 6:14 A.M., showed the resident lay in bed with two metal quarter sized bed rails up. 6. Review of Resident #108’s admission MDS, dated [DATE], showed the following: -Understood/understands; -Extensive assistance of one person required for bed mobility; -Total dependence of two (+) persons required for transfers; -[DIAGNOSES REDACTED]. -Bed rails used daily. Review of Resident #108’s POS, dated 5/15/18 through 6/14/18, showed no order for the use of [REDACTED] Review of the resident’s Side Rail Assessment, dated 5/21/18, showed the following: -Recommendation: One left and right upper 1/2 rail at all times when the resident is in bed. Observation on 6/8/18 at 5:20 A.M. and 6/13/18 at 6:09 A.M., showed the resident lay in bed with two metal 1/2 bed rails up. 7. During an interview on 6/13/18 at 9:23 A.M., the administrator said she was not aware residents that use side rails needed to be assessed for risk of entrapment. The Director of Nurses said she was aware, but their side rail assessments had not been updated yet to address entrapment. Physician orders [REDACTED].
	F 0812 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some	Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review, the facility fail to ensure food and thawed health shakes were dated in the walk in refrigerator and failed to ensure

(X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)

F 0700

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 5)
following:
-Understood/understands;
-Independent for bed mobility;
-Limited assistance of one person required for transfers;
-Bed rails not used.
Review of the resident’s POS, dated 6/7/18 through 6/14/18, showed no order for the use of[REDACTED] Observation on 6/7/18 at 11:01 A.M., 6/11/18 at 10:14 A.M. and 1:09 P.M., showed the
resident lay in bed with two quarter sized metal bed rails up.
Observation on 6/8/18 at 5:44 A.M., showed the resident lay in bed with one metal quarter
sized bed rail up on the exit side of the bed.
5. Review of Resident #22’s POS, dated 5/15/18 through 6/14/18, showed no order for the
use of [REDACTED] Review of the resident’s Side Rail Assessment, dated 5/21/18, showed the following:
-Recommendation: One left and right 1/4 partial rail at all times when the resident is in
bed.
Review of the resident’s quarterly MDS, dated [DATE], showed the following:
-Understood/understands;
-Limited assistance of one person required for bed mobility;
-Total dependence of two (+) persons required for transfers;
-[DIAGNOSES REDACTED].>-Bed rails used daily.
Observation on 6/7/18 at 10:50 A.M., 6/11/18 at 1:14 P.M. and 6/13/18 at 6:14 A.M., showed
the resident lay in bed with two metal quarter sized bed rails up.
6. Review of Resident #108’s admission MDS, dated [DATE], showed the following:
-Understood/understands;
-Extensive assistance of one person required for bed mobility;
-Total dependence of two (+) persons required for transfers;
-[DIAGNOSES REDACTED].
-Bed rails used daily.
Review of Resident #108’s POS, dated 5/15/18 through 6/14/18, showed no order for the use
of [REDACTED] Review of the resident’s Side Rail Assessment, dated 5/21/18, showed the following:
-Recommendation: One left and right upper 1/2 rail at all times when the resident is in
bed.
Observation on 6/8/18 at 5:20 A.M. and 6/13/18 at 6:09 A.M., showed the resident lay in
bed with two metal 1/2 bed rails up.
7. During an interview on 6/13/18 at 9:23 A.M., the administrator said she was not aware
residents that use side rails needed to be assessed for risk of entrapment. The Director
of Nurses said she was aware, but their side rail assessments had not been updated yet to
address entrapment. Physician orders [REDACTED].

F 0812

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Procure food from sources approved or considered satisfactory and store, prepare,
distribute and serve food in accordance with professional standards.

Based on observation, interview and record review, the facility fail to ensure food and
thawed health shakes were dated in the walk in refrigerator and failed to ensure

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

PRINTED: 7/11/2019
FORM APPROVED
OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265500

(X2) MULTIPLE CONSTRUCTION
A. BUILDING	___________
B. WING	___________

(X3) DATE SURVEY COMPLETED

06/13/2018

NAME OF PROVIDER OF SUPPLIER

BERNARD CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

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 0812 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some	(continued… from page 6) unpasteurized eggs were cook thoroughly. This deficient practice had the potential to affect residents who ate at the facility. Observation of the kitchen on 6/8/18 at 8:29 A.M., showed the following: -One small package of slice yellow cheese slices and a large package of white cheese slices in the walk in refrigerator did not have a date; -Approximately 30 various flavors of health shakes did not have a date in the walk in refrigerator. Observation on 6/13/18, of the kitchen showed the following: -7:16 A.M., Cook A cracked approximately 30 eggs and place the on the grill, after approximately three minutes, Cook A flipped the eggs. After approximately another two minutes the eggs were removed and placed in a pan.; -7:20 A.M., observation of one of the eggs showed it to have a runny yellow yolk. Observation of the egg cardboard container showed the eggs were not pasteurized. During an interview at that time, Cook A said he/she did not know if the eggs were pasteurized. During an interview on 6/13/18 at 1:07 P.M., the Dietary Manager (DM) said items in the walk in refrigerator should be wrapped, labeled and dated. The thawed health shakes should have a date of 14 days out from the time they are pulled from the freezer. The DM said the eggs were not pasteurized and should be cooked thoroughly. The DM said undercooked unpasteurized could cause food bourne illness.
	F 0921 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some	Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation, interviews, and record review, the facility failed to ensure the walls, vents, and floor of the main kitchen were maintained in good repair. The census was 139. Observation of the main kitchen on 6/7/18 at 8:29 A.M., 6/8/18 at 5:27 A.M. and 6/13/18 at 7:13 A.M., showed, the wall behind the stove and fryer were covered with brown grease. The wall near the convection oven and the wall near the three vat sink had dirt and grime. The vent above the preparation table was covered with dirt. During an interview on 6/13/18 at 1:07 P.M., the Dietary Manager said the Porter should be cleaning those areas. He did not know why it was not being completed.

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