He had fallen at least once before his admission.
Nursing Home News — Page 12
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When inspectors arrived on November 24, 2025, they found the entire 100-hall had been without hot water since before summer.
The answer at Bernard Care Center, a 126-bed facility on West Pine Boulevard, was not much.
That gap matters because catheter care, done wrong, is one of the more direct routes to infection for nursing home residents.
The findings came from a complaint inspection conducted December 1, 2025.
Inspectors cited the facility for failing to protect a resident from fall hazards, a deficiency rated at the level of actual harm.
The facility had a Skin and Wound Management policy, last reviewed in December 2024.
The inspection at Winning Wheels, a nursing facility at 701 East 3rd Street in Prophetstown, was triggered by a complaint and completed on December 21, 2025.
Inspectors who visited the facility at 7940 Topanga Canyon Blvd.
V13 told inspectors she knew the requirement.
One resident, identified in the inspection report as R5, said she used to shower every other day.
The facility's own policy requires hot food to be held above 135 degrees.