Bertram Nursing And Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review the facility failed to ensure, in accordance with accepted professional standards and practices, medical records were maintained on each resident that were complete, accurately documented, readily accessible, and systematically organized for 1 of 5 residents (Resident #1) reviewed for resident records. The facility failed to ensure physician orders for Resident #1's X-ray were entered on the porta on 01-16-2026. This failure could place residents at risk for incorrect treatment decisions, evaluation, and treatment plans compromising patient safety due to insufficient information records.Findings Included:Record review of Resident #1's admission record, dated 01-28-2026, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included Dementia (Condition which involves memory loss, affecting thinking, and social abilities which interfere with their daily lives) and, Repeated Falls and Depression (a mood disorder that causes a…

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 store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure stored foods in 1 of 1 walk in refrigerator (raw chicken) and 1 of 1 bread/misc . items tray rack (4 large, opened chip bags) were labeled and dated. 2. The facility failed to ensure 1 of 1 reach-in refrigerator was maintained in sanitary condition. 3. The facility failed to ensure dented cans were removed and kept separately in a designated area. 4. The facility failed to ensure dietary staff used a beard guard when preparing and plating resident foods. 5. The facility failed to ensure expired items were removed from storage and discarded. These failures could place residents at risk for food borne illness and cross-contamination.The findings include: During an initial tour on 09/23/25 beginning at 09:03 AM of the one and only kitchen revealed:- 1 of 1 walk-in refrigerator contained a stainless steel straight-sided steam…

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 observations, interviews and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 4 of 7 residents (Resident #7, Resident #23, Resident #18, and Resident 11) reviewed for infection control. 1. The facility failed to follow hand hygiene procedure during direct care for Resident #7, Resident #18, and Resident #23.2. The facility failed to post a sign on Resident #11's door to inform nursing staff about Enhanced Barrier Precautions with readily available personal protective supplies before wound care provided. These failures could place residents at risk for infection transmission, sepsis, and hospitalization.Findings include:1.Record review of Resident #18's face sheet, dated 09/24/2025, reflected an [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included…

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 observations, interviews, and record review the facility failed to ensure resident rights for personal privacy for 4 of 7 residents (Resident #19, Resident #35, Resident #45, and Resident #41) reviewed for personal privacy. The facility failed to knock on Resident #19, #35, #45 and #41's room when going into the residents' rooms. This failure could affect all residents right to privacy in the facility and cause the resident to feel like their privacy was being invaded or the facility was not their home. Findings included: Review of Resident #19's Face Sheet dated 08/29/2024 revealed he was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #19's diagnoses included metabolic encephalopathy (change to how the brain works ), enterococcus (difficult to treat infection), anemia (not enough healthy red blood cells), thrombocytopenia (abnormally low level of platelets), hypoglycemia (low blood sugar), protein-calorie malnutrition, vitamin D deficiency, hypo-osmolality and hyponatremia…

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, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one of one kitchen and one of one nourishment room reviewed for sanitation. 1. The facility failed to ensure Dietary Staff F wore a beard restraint and hair restraint properly while in the kitchen. 2. The facility failed to properly store closed and dated food in the refrigerator. 3. The facility failed to ensure the Nourishment Room was properly cleaned, ice was stored properly, and items were correctly labeled and dated. 4. The facility failed to ensure Dietary [NAME] E properly sanitized her hands between tasks. 5. The facility failed to ensure Dietary [NAME] E referenced recipes while preparing foods. These failures could place residents who were served from the kitchen at risk for health complications and foodborne illnesses, and decreased quality of life. Findings included: Observation in the kitchen on 08/27/24 between 09:32 AM -10:15 AM revealed dietary staff F was standing by the…

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 each resident received adequate supervision and assistance devices to prevent accidents for 1 of 5 residents (Resident #33) reviewed for bed positioning. The facility failed to ensure Resident #33's bed was in the lowest position for fall prevention per facility policy and procedure. This failure could place residents at risk of falls, injuries, pain, and hospitalization. Findings included: Record review of an undated Face Sheet for Resident #33 reflected he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of Paraplegia (paralysis that affects the legs but not arms), and lack of coordination. Record review of the Quarterly MDS dated [DATE] for Resident #33 reflected he had a BIMS score of 15 indicating intact cognitive status. Record review of the Care Plan for Resident #33 dated 11/30/2023 and revised on 03/06/2024 reflected he was at risk for falls related to paraplegic status. An actual fall was noted.…

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 that pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 1 resident (Resident #18) reviewed for pain management. The facility failed to ensure Resident #18 received her 06:00 -10:00 AM daily scheduled Lidocaine Patch 5% for pain on 08/27/2024. This failure placed the resident at risk of increased pain and decreased quality of life. Findings included: Review of the undated Face Sheet for Resident #18 reflected she was an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of pain in right shoulder and pain in unspecified joint. Review of the Quarterly MDS assessment dated [DATE] for Resident #18 reflected a BIMS score of 4, indicating severe cognitive impairment. Section I - Active Diagnoses reflected Resident #18 had pain 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 2 of 4 residents (Residents #1 and 2) reviewed for skin integrity. Protective sleeves were ordered for Residents #1 and #2 after they each sustained skin tears but not applied. This failure placed residents at risk of further skin injury. Findings included: Review of the undated face sheet for Resident #1 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnosis dementia, rash and other non-specific skin eruption, anxiety disorder, and impulse disorder. Review of the quarterly MDS assessment for Resident #1 dated 08/24/23 reflected she could not participate in the assessment. It also reflected she required the extensive assistance of two + people for the activity of dressing. Review of the care plan for Resident #1 dated 06/05/23…

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 develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for six of six residents (Residents #28, 15, 6, 11, 42, and 25) reviewed for comprehensive care plans. The facility failed to include activities and activity preferences in the care plans for Residents #28, 15, 6, 11, 42, and 25. This failure placed residents at risk of boredom, depression, and not attaining/maintaining the highest practicable psychosocial well-being. Findings included: Review of the undated face sheet for Resident #28 reflected an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Alzheimer's disease and major depressive disorder. Review of the annual MDS assessment for Resident #28 dated 10/13/22 reflected a BIMS score of 14 indicating intact…

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 maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one of 24 residents (Resident #25) reviewed for infection control. Specifically, the facility failed to ensure staff were following hand hygiene procedures when involved in direct resident contact providing peri-care for Resident #25; specifically, hand hygiene with glove change was not conducted when performing peri-care when going from dirty to clean. This failure could place all residents at risk of developing communicable diseases and infections. The findings included: Review of Resident #25's Quarterly MDS dated [DATE] revealed a diagnosis of Diabetes Mellitus Type 2, End Stage Renal Disease, and Hemodialysis. Observation conducted on 07/06/23 at 09:16 AM of mechcanical lift transfer and peri-care for Resident #25. CNA C…

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 and interview, the facility failed to ensure all mechanical, electrical, and patient care equipment was in safe operating condition for one of eight residents (Resident #38) reviewed for safe operating patient care equipment. Resident #38's electric bed remote was not maintained in safe operating condition according to manufacturer's recommendations, and more specifically Resident #38's electric bed remote cord had cracked casing and exposed wiring. This failure could put all residents in the facility at risk of injury or electric shock. The findings included: Interview conducted on 07/05/23 at 10:52 AM with Resident #38 revealed she was receiving good care in the facility. Resident #38 stated she was concerned about her bed remote cord exposed wire. Observation conducted on 07/05/23 at 10:55 AM revealed Resident #38 sitting up in wheelchair in her room near her electric bed. The electric bed remote was on the floor between bed and window, and the casing on the cord was cracked with wiring exposed. Resident #38 stated she was unsure…

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.