Above average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Envive Of Berne during CMS and state inspections, most recent first.
Therapeutic puree diets were not prepared using required recipes or texture-testing methods. A dietary staff member stated there was no puree recipe book and that consistency was judged by eye, while the DON/Dietary Manager said there was no testing method for puree diets despite a recipe book being available. Six residents with dysphagia or puree diet orders were affected, including residents ordered pureed textures with nectar/mildly thick or thin liquids, and one resident who requested pureed food.
Failure to Sanitize and Maintain Ice Machine: The facility failed to ensure the ice machine was cleaned and sanitized per policy. The DON observed black and orange substances on the rubber surface inside the main dining room ice machine, which was the only ice machine in the building and supplied ice to 28 of 42 residents. The Dietary Manager said dietary staff did not clean it, and the Maintenance Director said he did not clean the area where the ice sat and only cleaned the machine once a year.
Tube Feeding Not Maintained as Ordered: A resident with a G-tube, NPO status, and an order for continuous Jevity 1.2 with hourly water flushes was observed multiple times alone in his room with the enteral pump turned off. Staff gave inconsistent explanations, including uncertainty about why the pump was off, a prior activity hold order, and a shower-related disconnect, while the DON said there was a communication breakdown about when the resident returned to his room.
The facility's kitchen had multiple sanitation and maintenance deficiencies, including debris in grease traps, a leaking pipe in the freezer, and weak sanitation solutions. The oven door was not fully functional, and the freezer lacked a thermometer. Staff were guessing temperatures, and cleaning logs were incomplete. Handwashing practices did not meet required standards, and a work order for the oven door had been pending since August.
Therapeutic Puree Diets Not Prepared Using Required Recipes
Penalty
Summary
The facility failed to ensure recipes were followed for therapeutic diets, specifically puree diets, for six residents. During an observation of puree preparation, a staff member stated there was no recipe book for purees and that she was told to just add water and bread. She said she would eyeball the consistency by opening the lid to see how thick or thin it was, did not know how the nutritional value was maintained, and did not know the fork or spoon method for testing appropriate puree thickness. The Dietary Manager stated there was no testing method for puree diets, although there was a recipe book and cooks typically knew what to add. Record review showed the affected residents had physician-ordered puree diets related to dysphagia or swallowing disorders. Resident 2 had dysphagia, oropharyngeal phase, and an order for a controlled carbohydrate diet with pureed texture and nectar/mildly thick consistency. Resident 5 had dysphagia, oropharyngeal phase, and an order for a large portion pureed diet with nectar/mildly thick consistency and pudding as desired. Resident 7 requested food be pureed for a regular mechanical soft diet. Resident 8 had an order for a regular diet with pureed texture. Resident 12 had an order for a controlled carbohydrate diet with pureed texture. Resident 33 had an order for a regular diet with pureed texture and nectar/mildly thick consistency. A facility recipe for pureed beef patty stated to use a food processor, blend until smooth, and test texture with a fork drip test and spoon tilt, with added liquids or thickener as needed.
Failure to Sanitize and Maintain Ice Machine
Penalty
Summary
The facility failed to ensure the ice machine was sanitized and maintained in accordance with its infection control policy. During observation of the ice machine in the main dining room, the Director of Nursing opened the lid and black and orange substances were seen on the rubber surface, with ice cubes located below. The DON stated this was the only ice machine in the building and indicated it would be shut down. The facility reported that 28 of 42 residents received ice from this machine. Interviews and record review showed the Dietary Manager stated dietary staff did not clean or have anything to do with the ice machine, and the Maintenance Director stated he did not internally clean it, only thawed and cleaned the inner workings and water reservoir, not the area where the ice sits. He also stated the machine was cleaned once a year. The facility policy titled Infection Control: cleaning ice machine and scoop, dated 1/23, stated the ice machine and equipment would be cleaned on a regular basis, including washing the interior thoroughly, sanitizing, and air-drying, with maintenance responsible for cleaning and maintaining the interior.
Tube Feeding Not Maintained as Ordered
Penalty
Summary
The facility failed to follow physician orders for tube feeding for one resident with a G-tube. Resident 43 had diagnoses including other specified disorder of brain, unspecified convulsions, disturbances of salivary secretion, dysphagia oropharyngeal phase, and progressive multifocal leukoencephalopathy. The resident’s orders included NPO status and continuous Jevity 1.2 tube feeding via G-tube at 65 mL/hr with 30 mL water flushes hourly, with permission to stop the feeding for activities, therapy, showers, and similar events. The care plan identified the resident as dependent on tube feeding and water flushes and directed staff to follow the current feeding orders. During observations, the resident was found alone in his room with the enteral feeding pump turned off on multiple occasions. On one occasion, an LPN stated she was unsure why the pump was off and noted the resident was not participating in an activity, while the resident’s RN later stated the pump had been on and the resident had been receiving continuous tube feeding all day, though the pump was off at the time of the observation. On another occasion, an RN stated the feeding had been turned off and disconnected for a shower but was unsure how long the resident had been back in his room. The DON was unable to provide a reason for the pump being off and stated there was a communication breakdown regarding notifying nursing when the resident returned from activities or a shower.
Sanitation and Maintenance Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, affecting the food preparation for 38 of 39 residents. During an observation, it was noted that the grease traps under the burners contained burnt food debris and the oven door did not close fully. The walk-in cooler had various debris under the racks, and a pipe in the walk-in freezer was leaking, with a container placed to catch the liquid. The freezer lacked a thermometer, and staff were guessing the temperature. Sanitation solution in the kitchen was found to be weak, and the dietary aide was unable to determine the correct concentration for the solution. Interviews revealed that the Dietary Manager was not present, and a work order for the oven door had been pending since August. The cleaning logs for the kitchen were incomplete, and the handwashing practices of the Dietary Manager did not meet the required 20-second minimum. The Maintenance Director confirmed the pipe in the freezer was cracked and temporarily fixed with heat tape. Policies provided by the Administrator indicated that cleaning and sanitizing solutions should be maintained at proper concentrations, and a comprehensive cleaning schedule should be followed, which was not adhered to.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Berne
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Swiss Village | 0.6 mi | ★★★★★ | 8 | 0 |
| Adams Woodcrest | 12 mi | ★★★★★ | 2 | 0 |
| Christian Care Retirement Community | 12.4 mi | ★★★★★ | 7 | 0 |
| Persimmon Ridge Rehabilitation Centre | 14.9 mi | ★★★★★ | 0 | 0 |
| River Terrace Health Care Center | 14.9 mi | ★★★★★ | 30 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.