Inspection Reports for
Bertrand Nursing And Rehab Center
603 US-62, Bertrand, MO 63823, United States, MO, 63823
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
45% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
16
12
8
4
0
Occupancy
Latest occupancy rate
88% occupied
Based on a July 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Routine
Census: 53
Deficiencies: 5
Date: Jul 25, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to psychotropic medication use, accident hazard prevention, medication error rates, infection control, and equipment maintenance in the nursing home.
Findings
The facility was found deficient in providing appropriate diagnoses for psychotropic medication use, assessing and maintaining mobility rails for residents, maintaining medication error rates below 5%, following infection control protocols during wound care, and regularly inspecting bed frames, mattresses, and bed rails. All deficiencies were cited with minimal harm or potential for actual harm and affected a few residents.
Deficiencies (5)
Failed to provide an appropriate diagnosis for the use of a psychotropic medication for one resident.
Failed to assess and evaluate the mobility rail for five residents.
Failed to maintain a medication error rate of less than 5%, with an error rate of 10.71% for one resident.
Failed to follow infection control protocols during wound care for one resident.
Failed to conduct inspections of all bed frames, mattresses, and bed rails as part of a regular maintenance program for five residents.
Report Facts
Facility census: 53
Medication error opportunities: 28
Medication errors: 4
Medication error rate: 10.71
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Named in medication administration and wound care findings |
| LPN B | Licensed Practical Nurse | Named in medication administration and wound care findings |
| LPN D | Licensed Practical Nurse | Interviewed regarding medication administration and wound care practices |
| Certified Medication Technician C | Certified Medication Technician | Interviewed regarding insulin pen priming |
| Director of Nursing | Director of Nursing | Interviewed regarding psychotropic medication diagnosis, medication error expectations, wound care, and mobility rail inspections |
| Therapy Director | Therapy Director | Interviewed regarding lack of documentation for mobility rail assessments |
| Maintenance Assistant | Maintenance Assistant | Interviewed regarding repair and inspection of mobility rails |
| Administrator | Administrator | Interviewed regarding psychotropic medication diagnosis and mobility rail inspections |
Inspection Report
Plan of Correction
Census: 51
Deficiencies: 4
Date: Jul 10, 2024
Visit Reason
The inspection was conducted to assess compliance with federal regulations regarding resident care, environment, and medication management at Bertrand Nursing and Rehab Center. The document includes a plan of correction submitted in response to identified deficiencies.
Findings
The facility was found deficient in maintaining a safe, clean, and homelike environment, developing and implementing comprehensive care plans, managing bowel/bladder incontinence and catheter care, and ensuring proper use of psychotropic medications. Multiple environmental and care-related issues were observed and documented.
Deficiencies (4)
F584 Safe/Clean/Comfortable/Homelike Environment. The facility failed to provide a safe, clean, and comfortable homelike environment, with issues such as peeled paint, unsecured cable plate covers, and problematic self-closing doors affecting resident safety and comfort.
F656 Develop/Implement Comprehensive Care Plan. The facility failed to implement a comprehensive care plan with specific interventions to meet individual resident needs, including dementia care, for one resident out of 13 sampled.
F690 Bowel/Bladder Incontinence, Catheter, UTI. The facility failed to obtain and maintain physician orders for catheter care every shift and to ensure appropriate treatment for residents with incontinence, affecting two sampled residents.
F758 Free from Unnec Psychotropic Meds/PRN Use. The facility failed to ensure appropriate diagnosis and documentation for psychotropic medication use and gradual dose reductions for one resident out of five sampled.
Report Facts
Facility census: 51
Sampled residents: 13
Sampled residents for psychotropic meds: 5
Residents with catheter care issues: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dan D. Chance | Administrator | Named in relation to environmental concerns and plan of correction |
| Director of Nursing | Interviewed regarding care plans, medication administration, and resident conditions | |
| Assistant Director of Nursing | Interviewed regarding catheter care orders and medication administration | |
| Minimum Data Set (MDS) Coordinator | Interviewed regarding care plan completion and dementia diagnosis |
Inspection Report
Life Safety
Census: 51
Deficiencies: 2
Date: Jul 10, 2024
Visit Reason
The inspection was conducted as an Emergency Preparedness Survey focusing on compliance with the 2012 Existing Edition of the Life Safety Code and related fire safety regulations.
Findings
The facility failed to maintain fire dampers in working order, which could potentially affect all residents and staff. The fire alarm system testing and maintenance requirements were not met as evidenced by the malfunctioning smoke dampers.
Deficiencies (2)
K345 Fire Alarm System - Testing and Maintenance: The facility failed to maintain fire dampers in working order, which could cause smoke to travel improperly during an alarm. Records of system acceptance, maintenance, and testing were not readily available.
A2019 Fire Alarm System-Test/Maintain: The facility did not complete fire alarm system testing and maintenance in accordance with NFPA 72, 1999 edition. This regulation was not met as evidenced by the K345 deficiency.
Report Facts
Facility census: 51
Inspection Report
Routine
Census: 51
Deficiencies: 4
Date: Jul 10, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident safety, care planning, catheter care, medication management, and environmental conditions in the nursing facility.
Findings
The facility was found deficient in maintaining a safe, clean, and homelike environment; implementing comprehensive care plans addressing resident needs; ensuring proper catheter care orders and documentation; and providing appropriate diagnosis documentation for psychotropic medication use. Several environmental hazards and care plan deficiencies were noted, along with inadequate catheter care orders and missing indications for antipsychotic medication.
Deficiencies (4)
Failed to provide a safe, clean, and comfortable homelike environment with multiple areas of peeled paint, exposed sheetrock, unsecured cable plate cover, and protruding nails in resident rooms.
Failed to implement a care plan with specific interventions related to dementia for one resident.
Failed to obtain orders for catheter care every shift and catheter changes every 30 days, and failed to document catheter care for two residents.
Failed to ensure an appropriate diagnosis or indication for the use of an antipsychotic medication for one resident.
Report Facts
Facility census: 51
Deficiencies cited: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Provided interviews regarding door safety, care planning, catheter care expectations, and psychotropic medication diagnosis |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Interviewed regarding catheter care orders and documentation |
| Maintenance Supervisor | Maintenance Supervisor | Interviewed about repair log and environmental concerns reporting |
| Administrator | Administrator | Interviewed about environmental concerns reporting and door safety in new wing |
| Minimum Data Set Coordinator | MDS Coordinator | Interviewed regarding care plan completion and dementia diagnosis inclusion |
Inspection Report
Annual Inspection
Census: 51
Deficiencies: 2
Date: Apr 20, 2023
Visit Reason
Annual inspection survey conducted to evaluate infection prevention and control practices at Bertrand Nursing and Rehab Center.
Findings
The facility failed to utilize proper technique during incontinent care and urinary catheter care, including failure to change gloves and perform hand hygiene between tasks for multiple residents. Observations and record reviews showed noncompliance with hand hygiene and catheter care policies.
Deficiencies (2)
F880 Infection Prevention & Control: The facility failed to utilize proper technique during incontinent care and urinary catheter care, including failure to change gloves and perform hand hygiene between tasks for multiple residents. Observations showed staff did not sanitize hands before leaving rooms or between resident care activities.
A4086 Infection Control/Communicable Disease: The facility failed to meet infection control regulations as evidenced by deficiencies cited under F880.
Report Facts
Resident census: 51
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dan D. Chance | Administrator | Signed the Statement of Deficiencies and Plan of Correction |
| CNA A | Observed failing to perform hand hygiene and glove changes during resident care | |
| CNA B | Observed failing to perform hand hygiene and glove changes during resident care |
Inspection Report
Life Safety
Census: 51
Deficiencies: 2
Date: Apr 20, 2023
Visit Reason
The inspection was conducted as an Emergency Preparedness and Life Safety Code survey to assess compliance with the 2012 Existing Edition of the Life Safety Code of the National Fire Protection Association (NFPA) and related regulations.
Findings
The facility failed to meet the applicable provisions of the Life Safety Code related to electrical equipment, specifically the use of temporary wiring and power strips in patient care areas. Observations showed unsafe use of power strips and extension cords, potentially affecting all residents and staff.
Deficiencies (2)
K920 Electrical Equipment - Power Cords and Extension Cords: The facility failed to restrict the use of temporary wiring, including power strips piggybacked together and improper use of adapters, in violation of NFPA standards. This posed a potential hazard to residents and staff.
A3037 Extension Cords/Duplex Receptacles: Extension cords were not UL-approved or compliant with electrical appliance standards and were improperly placed, violating 19 CSR 30-85.032(37).
Report Facts
Facility census: 51
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Don O. Chance | Administrator | Interviewed regarding correction of electrical cord issues and signed plan of correction |
Inspection Report
Complaint Investigation
Census: 51
Deficiencies: 1
Date: Apr 20, 2023
Visit Reason
The inspection was conducted due to concerns about improper infection prevention and control practices, specifically related to hand hygiene and catheter care techniques by staff during resident care.
Complaint Details
The complaint investigation found that staff did not follow proper hand hygiene and glove use protocols during care of residents #4, #9, and #31, including failure to sanitize hands before and after care, reuse of soiled gloves, and improper handling of urinary drainage bags. Interviews with staff and administration confirmed expectations for hand hygiene and catheter care were not met.
Findings
The facility failed to utilize proper technique during incontinent care and urinary catheter care, with staff not performing hand hygiene before or after care or between dirty and clean tasks for multiple residents. Observations and record reviews confirmed noncompliance with facility policies on hand hygiene, glove use, peri care, and catheter care.
Deficiencies (1)
Failure to perform hand hygiene before donning gloves and between dirty and clean tasks during incontinent and catheter care.
Report Facts
Residents affected: 3
Census: 51
Sampled residents: 13
Inspection Report
Complaint Investigation
Census: 44
Deficiencies: 2
Date: Oct 29, 2020
Visit Reason
The inspection was conducted to investigate complaints regarding the facility's failure to provide sufficient preparation and orientation to residents prior to transfer or discharge.
Complaint Details
The visit was complaint-related, triggered by concerns about inadequate preparation and orientation for resident transfers. The complaint was substantiated as the facility failed to document required transfer preparation for multiple residents.
Findings
The facility failed to document preparation and orientation for transfer for four residents. Medical records and progress notes lacked evidence that residents were prepped and oriented for transfer out of the facility.
Deficiencies (2)
F 624: The facility failed to provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge. Medical records for four residents did not show documentation of preparation and orientation for transfer.
A4074: Each resident shall receive personal attention and nursing care in accordance with his/her condition. This regulation was not met as evidenced by the failure described in F624.
Report Facts
Residents lacking transfer documentation: 4
Facility census: 44
Inspection Report
Life Safety
Census: 34
Capacity: 60
Deficiencies: 2
Date: Oct 27, 2020
Visit Reason
The inspection was conducted to evaluate compliance with the 2012 Existing Edition of the Life Safety Code of the National Fire Protection Association (NFPA) and related regulations.
Findings
The facility failed to ensure all hazardous area doors within an exit passageway were self-closing and kept in the closed position, affecting resident and staff safety. The facility also did not meet the smoke section wall/door fire rating requirements.
Deficiencies (2)
K223: Doors with Self-Closing Devices. The facility failed to ensure all hazardous area doors within an exit passageway were self-closing and kept closed, affecting residents and staff egress safety.
A2054: Smoke Section Walls/Doors. The facility did not meet the requirement for one-hour fire-rated walls separating smoke sections, as doors were not self-closing or automatic-closing as required.
Report Facts
Facility capacity: 60
Resident census: 34
Inspection Report
Routine
Deficiencies: 0
Date: Aug 31, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness survey and a COVID-19 Focused Infection Control Survey were conducted to assess compliance with relevant regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended infection control practices for COVID-19.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Aug 12, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess the facility's compliance with related regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Routine
Deficiencies: 0
Date: May 20, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey and a COVID-19 Focused Emergency Preparedness survey were conducted on 05/20/2020 to assess the facility's compliance with CMS and CDC recommended practices and relevant regulations.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices for COVID-19 infection control and with 42 CFR 483.73 related to emergency preparedness.
Inspection Report
Complaint Investigation
Census: 47
Deficiencies: 8
Date: Jul 11, 2019
Visit Reason
The inspection was conducted to investigate complaints regarding the facility's failure to recognize significant changes in residents' conditions, implement comprehensive care plans, maintain accurate medication records, and ensure sanitary food preparation.
Complaint Details
The complaint investigation found multiple substantiated deficiencies related to failure to recognize significant resident changes, inadequate care planning, medication management issues, and food safety violations.
Findings
The facility failed to recognize significant changes in residents' conditions, did not implement individualized comprehensive care plans for high-risk residents, and failed to maintain accurate and complete medication records. Additionally, the kitchen was found to be unsanitary with multiple food safety violations.
Deficiencies (8)
F637: The facility failed to recognize significant changes in residents' physical or mental conditions within required timeframes for three sampled residents. The MDS significant change assessments were not completed timely.
F656: The facility failed to develop and implement a comprehensive, person-centered care plan for a resident at high risk for pressure sores, omitting required care interventions and assessments.
F755: The facility failed to provide routine and emergency drugs and biologics properly, including failure to do accurate reconciliation and account for all controlled medications. Multiple narcotic count verification sheet signatures were missing.
F761: The facility failed to label drugs and biologics properly and maintain secure storage with accurate dating of multi-dose vials. Multi-dose vials were open and undated, and some had been kept beyond recommended timeframes.
F812: The facility failed to maintain kitchen equipment and food storage in a clean, sanitary manner, resulting in potential for cross-contamination and foodborne illness. Numerous food items were undated or improperly stored, and kitchen surfaces were dirty.
A4061: Medication labeling did not comply with professional standards and federal regulations, including missing expiration dates and proper labeling on prescription medications.
A4070: The facility failed to establish a system of records for receipt and disposition of controlled drugs to enable accurate reconciliation and ensure drug records were in order.
A4074: The facility failed to provide personal attention and nursing care consistent with acceptable nursing practice, and failed to clean nonfood contact surfaces as needed.
Report Facts
Facility census: 47
Sampled residents: 12
Opportunities for narcotic count signature: 93
Missed signatures: 17
Missed signatures: 16
Inspection Report
Life Safety
Census: 47
Deficiencies: 6
Date: Jul 11, 2019
Visit Reason
The inspection was conducted to assess compliance with the 2012 Existing Edition of the Life Safety Code of the National Fire Protection Association (NFPA) and related regulations.
Findings
The facility failed to maintain properly working exit doors, HVAC ventilation for gas-fired appliances, and safe use of power cords and extension cords. These deficiencies potentially affected all residents and staff.
Deficiencies (6)
K222 Egress Doors: The facility failed to maintain properly working exit doors, including a service hall exit door that did not open when tested, potentially affecting all residents and staff.
K521 HVAC: The facility failed to maintain required HVAC ventilation for gas-fired appliances, including exhaust fans mounted too high, potentially affecting all residents and staff.
K920 Electrical Equipment - Power Cords and Extension Cords: The facility failed to maintain the facility free of extension cords and power strip use in patient care areas, with observed violations including power strips in therapy and break rooms, potentially affecting all residents and staff.
A2037 Exit Requirements: The facility did not meet exit requirements for having at least two unobstructed exits remote from each other, including an exit leading to a lobby without proper fire-rated separation.
A1096 Heating System: The facility failed to furnish and install heating, steam, boilers, and ventilation systems to meet all local and state codes and NFPA regulations.
A1125 Electrical System: The facility's electrical system did not comply with the National Electrical Code and Life Safety Code requirements.
Report Facts
Facility census: 47
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Chance | Administrator | Signed the inspection report and plan of correction |
| Maintenance Supervisor | Interviewed regarding exit door and HVAC ventilation deficiencies |
Inspection Report
Complaint Investigation
Census: 47
Deficiencies: 5
Date: Sep 28, 2018
Visit Reason
The inspection was conducted due to a complaint investigation regarding Medicaid/Medicare coverage, accuracy of assessments, comprehensive care plans, drug labeling and storage, and infection control practices at Bertrand Nursing and Rehab Center.
Complaint Details
The visit was complaint-related, focusing on Medicaid/Medicare coverage notices, assessment accuracy, care planning, drug storage, and infection control. Specific substantiation status is not stated.
Findings
The facility failed to issue a Notice of Medicare Non-Coverage when benefits were not exhausted, did not document accurate Minimum Data Set assessments, failed to implement individualized comprehensive care plans, did not label and store drugs according to professional standards, and failed to maintain infection control practices including proper cleaning of glucometers.
Deficiencies (5)
F582 Medicaid/Medicare Coverage/Liability Notice: The facility failed to issue a Notice of Medicare Non-Coverage when benefits were not exhausted and the resident remained in the facility. The facility census was 47.
F641 Accuracy of Assessments: The facility failed to document a complete and accurate Minimum Data Set assessment for one resident out of 14 sampled residents. The facility census was 47.
F656 Develop/Implement Comprehensive Care Plan: The facility failed to implement an individualized comprehensive care plan for one resident out of 14 sampled residents. The facility census was 47.
F761 Label/Store Drugs and Biologicals: The facility failed to label and store drugs in accordance with accepted professional standards. The narcotic storage box was unsecured and the facility census was 47.
F880 Infection Prevention & Control: The facility failed to maintain infection control practices to prevent transmission of infections, including failure to clean glucometers properly during blood sugar screenings for three residents. The facility census was 47.
Report Facts
Facility census: 47
Sampled residents for assessment: 14
Sampled residents for care plan: 14
Residents with blood sugar screening issues: 3
Inspection Report
Plan of Correction
Census: 47
Deficiencies: 5
Date: Sep 28, 2018
Visit Reason
The inspection was conducted to assess compliance with the 2012 Existing Edition of the Life Safety Code of the National Fire Protection Association (NFPA) and related fire safety regulations.
Findings
The facility failed to maintain exit discharges free of obstructions, maintain the kitchen range hood to NFPA standards, maintain the sprinkler system, maintain portable fire extinguishers, and properly store oxygen tanks. These deficiencies potentially affected all residents, staff, and occupants.
Deficiencies (5)
K271 Discharge from Exits: The facility failed to maintain exit discharges free of obstructions, including blocked exit doors near the kitchen by serving carts.
K324 Cooking Facilities: The facility failed to maintain the kitchen range hood to NFPA standards, with filters laden with grease.
K353 Sprinkler System - Maintenance and Testing: The facility failed to maintain the sprinkler system clean and free of debris, with three sprinkler heads covered in dust and debris.
K355 Portable Fire Extinguishers: The facility failed to maintain required monthly checks on fire extinguishing systems, including the Ansul kitchen hood suppression system.
K923 Gas Equipment - Cylinder and Container Storage: The facility failed to properly maintain separation of full and empty oxygen tanks and secure tanks properly in storage.
Report Facts
Facility census: 47
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