The resident, who has bilateral knee amputations, told inspectors on December 19th that his wheelchair had been broken for two weeks and was finally being repaired in the basement. But the elevator stopped working the day before, leaving his only means of mobility inaccessible.
"I am upset because my wheelchair is in the basement to get repaired, but the elevator is out of service," the resident said. He told a licensed practical nurse that he was expecting company and Christmas was next week. "I like to come and go and does not like being in bed."
The resident's frustration carried deeper trauma. He had previously spent four months confined to bed due to a wound. "I did not want to do that anymore," he told staff. "If God gives me the strength, I will get up."
His care plan documented the psychological toll of his condition. The resident "complains daily to staff about his wheelchair and other issues" and struggles with "depression and acceptance surrounding his diagnosis, specifically the loss of his legs." He was working to get prosthetics but was "often frustrated about the process."
The facility's Administrator admitted the elevator had become increasingly unreliable. "In the last year, it has broken more times than ever," the Administrator said during the December 19th inspection. The repair company had been called but provided no estimated arrival time.
Director of Nursing explained that wheelchair repairs required basement access. "The company had to use the basement to repair the wheelchair; they could not use the resident's room or hallway," she said. The resident "likes to leave and go around to the store," but his wheelchair remained trapped below.
Staff offered alternative seating, but the resident's physical limitations made standard options unusable. The Director of Nursing said the resident "has no trunk control" and they lacked appropriate equipment with reclining features and safety restraints to properly position him.
The resident's medical record showed he was admitted with high blood pressure, chronic atrial fibrillation, and bilateral below-knee amputations. His care plan required total assistance with daily activities and noted he used an electric wheelchair for all locomotion. Staff were instructed to monitor for complications from immobility, including blood clots, skin breakdown, and contractures.
Inspectors observed the wheelchair's condition two days before it went for repair. The tilted electric chair was missing the support limb for the right thigh, which had broken two weeks earlier. The repair was scheduled for December 18th.
Federal inspectors cited Bernard Care Center for failing to maintain essential equipment in safe working condition. The violation affected the facility's 131 residents, who depended on the elevator for access between floors.
The timing proved particularly cruel. As the resident told staff while requesting his wheelchair: "I am having company and Christmas is next week." His repeated attempts to retrieve his mobility device were met with the reality of a basement repair shop he couldn't reach.
The facility's equipment failures created a cascade of immobility for a resident already struggling with the psychological impact of his amputations. His care plan specifically noted the need to "anticipate and meet the resident's needs" and "explain all procedures to the resident before starting and allow the resident time to adjust to changes."
Instead, the resident found himself facing another extended period of bed confinement during what should have been a time for holiday visitors and the independence his electric wheelchair provided for trips to the store.
The inspection report noted the resident's determination despite the circumstances, quoting his words about summoning divine strength to get up. But with his wheelchair trapped in an inaccessible basement and no suitable alternative equipment available, that strength had nowhere to go.
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.