Bertrand Nursing And Rehab Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide an appropriate diagnosis for the use of a psychotropic medication (a medication that alters the levels of chemicals in the brain that influence mood, behavior, and perception) for one resident (Resident #38) out of five sampled residents. The facility census was 53.Review of the facility's policy titled, Antipsychotic (a medication that affects the brain activities associated with mental processes and behavior) Medication Use, revised December 2016, showed:Antipsychotic medications may be considered for residents with dementia (a disorder marked by memory loss, personality changes, and impaired reasoning that interferes with daily functioning), but only after medical, physical, functional, psychological, emotional psychiatric, social and environmental causes of behavioral symptoms have been identified and addressed;Antipsychotic medications will be prescribed at the lowest possible dosage for the shortest period of time in our subject to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the safety of a resident by not assessing and evaluating the mobility rail (a rail to assist residents with positioning in bed) for five residents (Resident #3, #8, #16, #45, #51) out of five sampled residents. The facility census was 53. Review of the facility's policy titled, “Assistive Devices and Equipment,” dated January 2020, showed: The facility maintains and supervises the use of assistive devices and equipment for residents; The following factors are addressed to the extent possible to decrease the risk of avoidable accidents associated with devices and equipment: appropriateness for resident condition - the resident is assessed for lower extremity strength, range of motion, balance and cognitive abilities when determining the safest use of devices and equipment. 1. Review of Resident #3's medical record showed: admitted on [DATE]; Diagnoses of hypertension (high blood pressure) and hypokalemia (decreased blood level of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to maintain a medication error rate of less than five percent (%). There were 28 opportunities with four errors made, resulting in an error rate of 10.71% for one resident (Resident #34) out of three sampled residents. The facility's census was 53. The facility did not provide a policy addressing priming of insulin pens. Review of the Fiasp/Novolog (fast-acting insulin injected just below the skin that helps lower mealtime blood sugar spikes) Flex Pen administration instructions, dated September 2021, showed:To prime the pen, turn the dose selector to two units;Keep the needle upwards and press the push button until the dose selector reads zero;Turn the dose selector to select the number of prescribed units to administer the insulin.1. Review of Resident #34's Physician's Order Sheet (POS), dated July 2025, showed:An order for Novolog FlexPen 16 units subcutaneously (injection under the skin) two times a day, dated 02/27/25;An order for Novolog FlexPen per sliding scale for a blood sugar of 51-200 = 0 units,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to follow infection control protocols during wound care for one resident (Resident #7) out of two sampled residents. The facility census was 53. Review of the facility's policy titled, Dressings, Dry/Clean, last revised September 2013, showed:Wash and dry hands thoroughly;Put on clean gloves. Loosen tape and remove soiled dressing;Pull glove over dressing and discard into plastic or biohazard bag;Wash and dry your hand thoroughly;Put on clean gloves;Assess the wound and surrounding skin for edema, redness, drainage, tissue healing progress, and wound stage;Cleanse the wound with ordered cleanser. If using gauze, use clean gauze for each cleansing stroke. Clean from the least contaminated area to the most contaminated area (usually from the center outward);Use dry gauze to pat the wound dry;Apply the ordered dressing and secure with tape or bordered dressing per order;Remove disposable gloves and discard into designated container. Wash and dry your hands thoroughly.Review of the facility's policy titled,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to conduct inspections of all bed frames, mattresses, and side rails as a part of a regular maintenance program for five residents (Resident #3, #8, #16, #45, and #51) out of five sampled residents. The facility census was 53. Review of the facility's policy titled, “Assistive Devices and Equipment,” dated January 2020, showed: The facility maintains and supervises the use of assistive devices and equipment for residents; The policy did not address an inspection of the mobility rail as part of the facility's maintenance program. 1. Review of Resident #3's medical record showed: admitted on [DATE]; Diagnoses of hypertension (high blood pressure) and hypokalemia (decreased blood level of potassium); No maintenance inspection for the mobility rail. Observations on 07/22/25 at 1:21 P.M., at 07/23/25 at 1:20 P.M., and 07/24/25 at 10:20 A.M. showed: - A U-shaped mobility rail in the upright position on the right side of the resident's bed. During…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a safe, clean and comfortable homelike environment. This deficient practice had the potential to affect all residents in the facility. The facility census was 51. Review of the facility's policy titled, Homelike Environment, revised February 2021, showed: - Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use personal belongings to the extent possible; - The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting; - These characteristics include a clean, sanitary and orderly environment; - Staff provide person-centered care that emphasizes the resident's comfort, independence and personal needs and preferences. Observations made on 07/07/24 at 8:40 A.M. , 07/08/24 at 9:44 A.M. and 07/09/24 at 8:22 A.M., showed: - Several areas of peeled paint on the walls behind the recliner near the window in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to implement a care plan with specific interventions to meet individual needs for one resident (Resident #21) out of 13 sampled residents. The facility census was 51. Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, dated December 2016, showed: - A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident; - The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident; - The care planning process will include an assessment of the resident's strengths and needs; - The comprehensive, person-centered care plan will describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. 1. Review of Resident #21's medical record showed: - An…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review the facility failed to obtain orders to change the indwelling catheter (a tube inserted into the urinary bladder to drain urine) every 30 days and failed to ensure documentation of the catheter changes were maintained for one resident (Resident #31) and failed to obtain a physicians order for catheter care to be performed every shift for two residents (Residents #31 and #40) out of two sampled residents. The facility census was 51. Review of the facility's policy, titled, Catheter Care, Urinary, revised September 2014, showed: - Policy did not address frequency catheter care should be completed; - Policy did not address frequency catheter should be changed. 1. Review of Resident #31's medical record showed: - admission date of 04/06/22; - Diagnoses of intervertebral disc degeneration, thoracolumbar region (discs between vertebrae with loss of cushioning), Incontinence without sensory awareness (inability to control the flow of urine from the bladder), Acute Respiratory Failure (when the body is unable to exchange oxygen and carbon…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review the facility failed to ensure an appropriate diagnosis for the use of an anti-psychotic medication for one resident (Resident #32) out of five sampled residents. The facility census was 51. Review of the facility's policy titled, Medication Regimen Review, revised April 2007, showed: - The pharmacist will perform Medication Management Review (MMR) for every resident in the facility on a monthly basis; - The pharmacist will evaluate for appropriate dosage, interactions, and adverse consequences; - Findings and recommendations are reported to the Director of Nursing (DON) and the medical director. 1. Review of Resident #32's Physician Order Sheet (POS), dated February 2024 through July 2024 showed: - Diagnoses included dementia (a condition characterized by progressive loss of memory and thinking, sometimes resulting in personality change, resulting from disease of the brain), anxiety disorder (a mental health disorder characterized by feelings of worry, or fear that can be strong enough to interfere with daily activities, and altered mental status…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to utilize proper technique during incontinent care and urinary catheter (a tube placed in the body to drain and collect urine from the bladder) care when staff did not change gloves or perform hand hygiene before or after care, or in between dirty and clean tasks for one resident (Resident #4) out of 13 sampled residents and two residents (Resident #9 and #31) outside the sample. The facility census was 51. Record review of the facility's Handwashing/Hand Hygiene policy, revised August 2019, showed: - This facility considers hand hygiene the primary means to prevent the spread of infection; - All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors; - Hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub, etc.) shall be readily accessible and convenient for staff use to encourage compliance with hand hygiene policies; - Use an alcohol-based hand rub containing at least 62% alcohol; or,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.