Inspection Reports for Bertrand Nursing and Rehab Center
603 WEST HIGHWAY 62, MO, 63823-9738
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/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
53 residents
Based on a July 2025 inspection.
Census over time
Inspection Report
Annual Inspection
Census: 53
Deficiencies: 5
Date: Jul 25, 2025
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements related to medication use, resident safety, infection control, and maintenance of assistive devices.
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.
Deficiencies (5)
Failed to provide an appropriate diagnosis for the use of psychotropic medication for one resident.
Failed to assess and evaluate the mobility rail for five residents.
Failed to maintain medication error rates below 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 regular maintenance inspections of bed frames, mattresses, and bed rails 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 medication administration, wound care, and mobility rail inspections |
| Therapy Director | Therapy Director | Interviewed regarding 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 dementia, ensuring appropriate catheter care orders and documentation, and providing appropriate diagnosis documentation for psychotropic medication use. Several environmental concerns and resident care issues were observed and documented.
Deficiencies (4)
Failed to provide a safe, clean, comfortable and homelike environment with issues such as peeled paint, exposed sheetrock, unsecured cable plate covers, 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 change frequency, and failed to document catheter changes for two residents.
Failed to ensure an appropriate diagnosis or indication for the use of an anti-psychotic medication for one resident.
Report Facts
Facility census: 51
Dates of observations: Observations made on 07/07/24, 07/08/24, and 07/09/24
Admission date: Mar 17, 2021
Admission date: Apr 6, 2022
Admission date: Feb 2, 2023
Medication start date: Oct 10, 2022
GDR attempt date: Apr 12, 2024
GDR denial date: Apr 15, 2024
Psychiatric referral date: Apr 18, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Housekeeper A | Interviewed regarding environmental concerns and reporting | |
| Housekeeper B | Interviewed regarding environmental concerns and reporting | |
| Maintenance Supervisor | Interviewed regarding repair log and environmental concerns | |
| Administrator | Interviewed regarding environmental concerns and door safety | |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding door safety, care plans, catheter care, and psychotropic medication diagnosis |
| Minimum Data Set Coordinator | Interviewed regarding care plan completion | |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Interviewed regarding catheter care orders and documentation |
Inspection Report
Routine
Census: 51
Deficiencies: 1
Date: Apr 20, 2023
Visit Reason
The inspection was conducted to evaluate the facility's infection prevention and control practices, specifically focusing on proper technique during incontinent care and urinary catheter care.
Findings
The facility failed to utilize proper hand hygiene and glove use techniques during incontinent and catheter care for several residents, including failure to change gloves or perform hand hygiene before, after, and between care tasks. Observations showed multiple instances of staff not performing hand hygiene or changing gloves appropriately, improper handling of urinary drainage bags, and improper peri care techniques.
Deficiencies (1)
Failure to utilize proper technique during incontinent care and urinary catheter care, including not changing gloves or performing hand hygiene before or after care or between dirty and clean tasks.
Report Facts
Residents sampled: 13
Residents affected: 3
Facility census: 51
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