Bernard Care Center

In the surveyor’s words

From the most serious findings on record at Bernard Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Aug 31, 2026

  Based on observation, interview and record review, the facility failed to provide protection from sexual abuse to one resident (Resident #2), by Resident #1, who had a documented history of sexual preoccupation and sexually inappropriate behaviors. Resident #1 was observed standing over Resident #2, who had documented developmental disabilities and moderate cognitive impairment, while pulling up his/her pants. On [DATE] at 9 A.M., Social Services said the resident reported he/she had been asleep and stated upon waking, Resident #1 was positioned over Resident #2 while touching himself/herself. Resident #2 reported Resident #1 ejaculated into Resident #1's mouth, causing him/her to cough, and stated that he/she attempted to push Resident #1 away. […]

• Immediate jeopardy, isolatedF689Feb 23, 2023

  Based on interview and record review, the facility failed to provide protective oversight for one of three sampled residents with a history of substance abuse and seizures. The facility was aware this resident had left on an LOA several times and returned after drinking. The facility had not developed and evaluated interventions on the resident's care plan and documented education with the resident. The resident signed out of the facility for a leave of absence (LOA) on 12/9/22. The resident told staff he/she would return that evening. The resident did not return until 12/11/22 and missed 4 doses of seizure medication. When the resident returned, and was potentially intoxicated, he/she went to bed. […]

• Actual harm, isolatedF740Aug 31, 2026

  Based on observation, interview and record review, the facility failed to provide the necessary behavioral services as recommended by the admission Preadmission Screening and Resident Review (PASRR, a federally required screening process used to check if a person applying to or living in a Medicaid-certified nursing facility has a serious mental illness, intellectual disability, or developmental disability) assessment for one resident and follow the behavior modification plan for Resident #1, who had a documented history of sexual preoccupation and sexually inappropriate behaviors. Resident #1 was observed standing over a sleeping resident with documented developmental disabilities and moderate cognitive impairment (Resident #2) and begged and pleaded for oral sex. […]

• No harm, potential for more than minimal, widespreadF578Aug 26, 2022

  Based on observation, interview and record review, the facility failed implement written policies and procedures regarding the residents' right to formulate an advance directive when staff failed to follow policies and procedures regarding accurate documenting of residents code status, for 13 of 27 sampled residents (Residents #120, #29, #76, #66, #9, #69, #65, #534, #63, #484, #81, #16, and #103). The census was 135. Review of the facility's Code Status/emergency Procedures/Medical Emergencies policy, revised on [DATE], showed: -Purpose: To outline procedures to be followed during a medical emergency, to establish guidelines for the initiation of cardiopulmonary resuscitation (CPR), and notification of emergency medical services (EMS), attending physician, administrator, Director of… […]

• No harm, potential for more than minimal, widespreadF806Aug 26, 2022

  Based on observation, interview and record review, the facility failed to provide alternate meals to residents. The facility did not have a documented alternate meal plan for six out of 27 sampled residents (Residents #16, #55, #65, #91, #74, and #103). The facility census was 135. 1. Review of the facility's resident council minutes, dated 6/23/22, showed: -Dietary: They have gotten worse. Can they have a choice between a sandwich or salad for substitutes; -Department heads in attendance included Food Services Director. During a resident council interview on 8/23/22 at 10:30 A.M., seven of seven residents in attendance who represent the resident population said if they do not like what is served during a meal, they are given a sandwich. 2. […]