Bertrand Nursing and Rehab Center

In the surveyor’s words

From the most serious findings on record at Bertrand Nursing and Rehab Center, in the surveyor’s own words.

• No harm, potential for more than minimal, isolatedF605Jul 25, 2025

  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… […]

• No harm, potential for more than minimal, isolatedF689Jul 25, 2025

  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… […]

• No harm, potential for more than minimal, isolatedF759Jul 25, 2025

  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… […]

• No harm, potential for more than minimal, isolatedF880Jul 25, 2025

  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. […]

• No harm, potential for more than minimal, isolatedF909Jul 25, 2025

  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. […]