Inspection Reports for
Bertrand Nursing And Rehab Center
603 US-62, Bertrand, MO 63823, United States, MO, 63823
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
3.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
40% better than Missouri average
Missouri average: 5.5 deficiencies/year
Deficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
53 residents
Based on a July 2025 inspection.
Occupancy 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
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
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
Report
Jul 10, 2024
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Jul 10, 2024
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Apr 20, 2023
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Apr 20, 2023
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Oct 29, 2020
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Oct 29, 2020
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Aug 31, 2020
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Aug 12, 2020
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May 20, 2020
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Jul 11, 2019
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Jul 11, 2019
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Sep 28, 2018
Report
Sep 28, 2018
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