Bertram Nursing and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Bertram Nursing and Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Oct 5, 2023

  Based 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. […]

• Actual harm, isolatedF600May 6, 2024

  Based 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. Findings include: Record review of Resident #1's face sheet dated April 18, 2024, revealed Resident #1 was a [AGE] year-old female admitted to the facility on [DATE]. Resident #1's diagnoses included primary degenerative joint disease, constipation, protein-calorie malnutrition, muscle weakness, schizophrenia, bipolar disorder, major depressive disorder, anxiety disorder, chronic pain syndrome, glaucoma, high blood pressure, congestive heart failure, chronic lung disease, gastro-esophageal reflux disease, age related osteoporosis without current… […]

• No harm, potential for more than minimal, widespreadF812Nov 26, 2025

  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. […]

• No harm, potential for more than minimal, patternF880Nov 26, 2025

  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. […]

• No harm, potential for more than minimal, patternF583Aug 29, 2024

  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]. […]