Bertram Nursing and Rehabilitation

Inspectors wroteBased 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]. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that residents were free from neglect. The facility failed to seek medical attention for Resident #1 who had fallen and complained of pain in her right shoulder.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents had the right to be free from abuse for one (Resident #2) out of three residents reviewed for abuse, in that: The facility failed to prevent a physical altercation between Resident #1 and Resident #2 that led to Resident #2 sustaining a head injury, subdural hematoma (brain bleed), and subsequent death. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 10/04/23 at 12:57 PM. While the IJ was removed on 10/05/23 at 11:40 AM, the facility remained at a level of actual harm at a scope of isolated that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed residents at risk pain, injury, hospitalization, and death.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.