Above average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Bertrand Nursing And Rehab Center during CMS and state inspections, most recent first.
Inappropriate Diagnosis for Antipsychotic Use: A resident with dementia, Alzheimer's disease, and major depressive disorder had an order for olanzapine, but the record contained no appropriate diagnosis, no targeted behaviors, and no documentation of behaviors supporting the antipsychotic use. The DON and Administrator stated an appropriate diagnosis should be present, while the outside psychiatric physician did not provide one; the resident was non-verbal, had a private sitter, and had recently been discharged from hospice.
Failure to Assess Mobility Rail Use: The facility did not document assessments for the use of U-shaped mobility rails for five residents. Records showed diagnoses including stroke, hemiplegia, lumbar vertebra fracture, HTN, DM, anxiety, and depression, while observations found the rails upright on the beds and residents reported using them for getting up, turning in bed, and transfers. The Administrator said rail checks were only visually done during rounds and not documented, and the Therapy Director confirmed no assessments were documented to determine whether residents needed or could safely use the rails.
Medication error rate exceeded 5% after an LPN failed to prime a resident’s Novolog FlexPen before administering insulin on two observed occasions. The resident had orders for scheduled Novolog and sliding-scale Novolog, and the facility had no policy addressing insulin pen priming. Interviews showed staff described priming by wasting two units before giving the ordered dose, and the DON said she expected insulin pen needles to be primed with at least two units.
Failure to Follow Infection Control During Wound Care: An LPN, another LPN, and the DON entered a resident's room without hand hygiene and performed wound care without changing gloves or washing hands between contaminated and clean tasks. One LPN cleaned multiple wounds without glove changes, touched a clean dressing with bare hands, and later applied dressings to the LLE with bare hands, contrary to facility wound care and glove-use policies.
Failure to inspect mobility rails and bed equipment for safety. Five residents had U-shaped mobility rails in use on their beds, but no maintenance inspection was documented for any of them. The Administrator said he visually checked the rails during daily rounds but did not document the inspections, and the Maintenance Assistant said he only repaired or added/removed rails when asked and did not inspect the rails on residents’ beds.
The facility failed to maintain a safe, clean, and homelike environment, with issues such as peeled paint, exposed sheetrock, and unsecured cable covers in resident rooms. Additionally, self-closing doors in a newer wing posed accessibility challenges for residents with mobility aids, leading to difficulties in opening doors independently. Despite a repair log system, there was a lack of documentation and effective communication among staff to address these concerns.
A facility failed to implement a care plan with specific interventions for a resident diagnosed with dementia. The care plan did not address dementia-related needs, despite expectations from the MDS Coordinator and DON. This deficiency was identified during a review of the resident's medical record.
The facility failed to document and obtain physician orders for catheter care and changes for two residents. One resident, with multiple health issues including urinary retention, had no documented orders for catheter care or change frequency, and no care was recorded in the Treatment Administration Record. Another resident, with chronic conditions, also lacked documented catheter care orders, and the Medication Administration Record showed treatment for a UTI without corresponding catheter care documentation. Interviews with nursing staff confirmed the absence of expected orders and documentation.
A resident was prescribed olanzapine, an anti-psychotic medication, without a documented diagnosis or indication for its use. Despite attempts at gradual dose reduction and a psychiatric referral, the facility failed to provide appropriate documentation. The DON cited dementia as the reason for the medication, noting behaviors not typical for dementia, and relied on psychiatric and medical director documentation.
Inappropriate Diagnosis for Antipsychotic Use
Penalty
Summary
The facility failed to provide an appropriate diagnosis for the use of a psychotropic medication for one resident. Resident #38 had an order for olanzapine 2.5 mg by mouth at bedtime, dated 11/15/24, with diagnoses listed as unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, along with Alzheimer's disease and major depressive disorder. The record contained no documentation of an appropriate diagnosis for olanzapine, no identified targeted behaviors, no documentation of any behaviors, and no pharmacist recommendations supporting an appropriate diagnosis for the medication. The resident had been admitted to hospice on 11/15/24 and discharged from hospice on 05/14/25. The medical record and care plan described the resident as non-verbal, rarely or never understood, with impaired cognitive function related to Alzheimer's disease, needing extensive assistance with ADLs, and generally staying in the room throughout the day. Observations showed the resident lying in bed with eyes closed with a private sitter present, and at another time sitting in a wheelchair, non-verbal, also with a private sitter present. The DON stated that if a resident had a physician's order for an antipsychotic medication, it should have an appropriate diagnosis. She reported that the resident's spouse, who was the POA, did not want the resident taken off the psychotropic medication and had taken the resident to an outside psychiatric physician, but the facility had not received psychiatric progress notes. The Administrator stated that an appropriate diagnosis should be present for an antipsychotic order and said he spoke with the psychiatric physician about CMS guidelines, but the physician did not and would not provide an appropriate diagnosis. The Pharmacist stated that based on the low dosage, the diagnosis was appropriate for the resident to receive the medication.
Failure to Assess Mobility Rail Use
Penalty
Summary
The facility failed to ensure the safety of a resident by not assessing and evaluating the use of mobility rails for five sampled residents. The facility policy titled, "Assistive Devices and Equipment," dated January 2020, stated that the facility maintains and supervises the use of assistive devices and equipment and that residents are to be assessed for lower extremity strength, range of motion, balance, and cognitive abilities when determining the safest use of devices and equipment. However, no assessment for the use of the mobility rail was found in the records of Resident #3, Resident #8, Resident #16, Resident #45, or Resident #51. Observations showed U-shaped mobility rails in the upright position on the residents' beds, including rails on one or both sides of the bed depending on the resident. Resident #3 said the mobility bar was used for getting up on the side of the bed; Resident #16 said the mobility rail was used for getting up on the side of the bed and turning side to side; Resident #45 said the mobility rail was used to turn in bed and with transfers out of bed; and Resident #51 said the mobility rails were used for getting up on the side of the bed and turning side to side while in bed. The Administrator said he visually inspected the rails during daily rounds but did not document the inspections. The Therapy Director said the facility did not document any assessments to determine if a resident needed or was able to use a mobility rail, and the Maintenance Assistant said he/she repaired or added/removed rails when asked but did not inspect the rails on residents' beds.
Medication Error Rate Exceeded Due to Improper Insulin Pen Administration
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, with 4 errors in 28 opportunities for an error rate of 10.71% for one resident. The deficiency involved Resident #34, whose physician orders included Novolog FlexPen 16 units subcutaneously twice daily and Novolog FlexPen per sliding scale before meals. The facility also did not provide a policy addressing priming of insulin pens. During observation of medication administration, an LPN administered Novolog by FlexPen on two occasions and failed to prime the pen per the manufacturer's instructions before giving the insulin. The manufacturer instructions reviewed by surveyors stated the pen should be primed by turning the dose selector to two units, keeping the needle upward, and pressing the push button until the dose selector reads zero before selecting the prescribed dose. During interviews, a CMT and an LPN stated they primed the insulin pen by wasting two units before dialing up the ordered dose, and the DON stated she expected staff to prime the insulin pen needle with at least two units before administering insulin.
Failure to Follow Infection Control During Wound Care
Penalty
Summary
The facility failed to follow infection control protocols during wound care for one resident with diagnoses of Alzheimer's disease, cerebral infarction, mood disorder, dysphagia, and anxiety. The resident had physician orders for daily care of open areas on the left lower extremity with wound cleanser, Multidex powder, Telfa, Kerlix, and tape, as well as orders to clean shears on the left hip, right hip, and right knee with wound cleanser and cover with bordered gauze. The facility's policies required hand hygiene, clean gloves, and changing gloves and washing hands between contaminated and clean steps during dressing changes. During observation of the wound care, an LPN, another LPN, and the DON entered the resident's room without performing hand hygiene and put on gloves. One LPN cleaned multiple wounds on the right hip, right knee, and left hip without changing gloves or performing hand hygiene between wounds, then removed gloves and touched a clean dressing with bare hands. The same LPN later cleaned the left lower extremity, removed gloves, and applied Telfa dressings, gauze, and tape with bare hands. The staff members then exited the room without performing hand hygiene.
Failure to Inspect Mobility Rails and Bed Equipment
Penalty
Summary
The facility failed to conduct inspections of all bed frames, mattresses, and side rails as part of a regular maintenance program for five sampled residents: Resident #3, #8, #16, #45, and #51. The facility census was 53. Review of the facility policy titled, “Assistive Devices and Equipment,” dated January 2020, showed that the facility maintains and supervises the use of assistive devices and equipment for residents, but the policy did not address inspection of the mobility rail as part of the maintenance program. For each of the five residents, the medical record showed no maintenance inspection for the mobility rail, while observations on multiple dates showed U-shaped mobility rails in the upright position attached to the residents’ beds. Resident #3 had diagnoses of HTN and hypokalemia and said the rail was used to get up on the side of the bed. Resident #8 had diagnoses of cerebral infarction, major depressive disorder, and anxiety, and had a U-shaped mobility rail on the left side of the bed. Resident #16 had diagnoses of left side hemiplegia, HTN, and type II DM and said the rail was used to get up on the side of the bed and turn side to side. Resident #45 had diagnoses of a burst fracture of the lumbar vertebra, MI, and chronic respiratory failure and said the rail was used to turn in bed and with transfers out of bed. Resident #51 had diagnoses of HTN, anxiety, and depression and used U-shaped mobility rails on both sides of the bed to get up and turn side to side. The Administrator stated he visually inspected the rails during daily rounds but did not document the inspections, and the Maintenance Assistant stated he repaired or added/removed mobility bars when asked but did not inspect the rails on residents’ beds.
Deficiencies in Environmental Safety and Accessibility
Penalty
Summary
The facility failed to provide a safe, clean, and comfortable homelike environment, as evidenced by several observations of physical deficiencies in resident rooms. These included peeled paint, exposed sheetrock, unsecured cable plate covers, and nails sticking out of walls. Despite having a repair log system in place, there was no documentation of these issues being addressed, indicating a lapse in maintenance and communication among staff. Additionally, the facility's newer wing had self-closing devices on resident room doors, which were observed to close quickly, posing a challenge for residents, particularly those with mobility aids like walkers or wheelchairs. Several residents reported difficulty in opening these doors independently, leading to situations where doors closed on residents or required them to prop doors open with objects like trash cans. This issue was acknowledged by the Director of Nursing and the Administrator, who noted that only residents deemed capable were placed in these rooms, although this was not always effective. Interviews with staff, including housekeepers and the maintenance supervisor, revealed a reliance on verbal communication for reporting environmental concerns, which was not consistently followed by written documentation. The Administrator and Director of Nursing were aware of the door issues but believed the self-closing devices were required by the Life Safety Code, and they attempted to place only suitable residents in these rooms. However, the observations and resident feedback indicated that the measures in place were insufficient to ensure a safe and accessible environment for all residents.
Failure to Implement Dementia-Specific Care Plan
Penalty
Summary
The facility failed to implement a comprehensive, person-centered care plan with specific interventions to meet the needs of a resident diagnosed with dementia. The care plan, dated June 26, 2024, did not address specific interventions related to the resident's dementia diagnosis. Interviews with the Minimum Data Set (MDS) Coordinator and the Director of Nursing (DON) revealed that both expected the dementia diagnosis to be included in the resident's care plan, indicating a lapse in the care planning process. This deficiency was identified during a review of the medical record of a resident admitted on an unspecified date, who was part of a sample of 13 residents in a facility with a census of 51.
Deficiency in Catheter Care Documentation and Orders
Penalty
Summary
The facility failed to obtain and document physician orders for the management of indwelling catheters for two residents. Resident #31, who was admitted with diagnoses including intervertebral disc degeneration, incontinence, acute respiratory failure, COPD, and urinary retention, had a foley catheter placed via a telephone order. However, there were no documented orders for catheter care every shift, catheter change frequency, or catheter size in the resident's Physician's Order Sheet (POS) for June and July 2024. Additionally, the Treatment Administration Record (TAR) for the same period showed no documentation of catheter care being performed. Similarly, Resident #40, admitted with diagnoses of COPD, chronic respiratory failure, urinary retention, and chronic kidney disease, also lacked documented orders for catheter care. The resident's POS for July 2024 did not include orders for catheter care, and the TAR for May 2024 showed a blank space on the date the catheter was ordered to be changed. Furthermore, the Medication Administration Record (MAR) for June 2024 indicated an order for a urinalysis and an antibiotic for a urinary tract infection, but there was no documentation of catheter care. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) confirmed that orders for catheter care and changes were expected but not documented, indicating a lapse in the facility's adherence to its catheter care policy.
Inappropriate Use of Anti-Psychotic Medication Without Diagnosis
Penalty
Summary
The facility failed to ensure an appropriate diagnosis for the use of an anti-psychotic medication for a resident. The resident, who was part of a sample of five, was prescribed olanzapine, an anti-psychotic medication, without a documented diagnosis or indication for its use. The resident's physician order sheet listed diagnoses of dementia, anxiety disorder, and altered mental status, but did not specify a reason for the olanzapine prescription. The medication was started in October 2022, and a gradual dose reduction was attempted in April 2024 but was denied due to potential mood destabilization. A psychiatric referral was made, yet there was still no documentation of a diagnosis or indication for the medication. During an interview, the Director of Nursing (DON) stated that the diagnosis for the olanzapine was dementia, citing the resident's behaviors such as asking for money, asking to drive, and seeing things that are not there. The DON acknowledged that these behaviors are not typical for dementia and relied on the documentation from the psychiatric physician and medical directors. This lack of appropriate documentation and diagnosis for the anti-psychotic medication use constitutes a deficiency in the facility's medication management practices.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Bertrand
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Delta South Nursing & Rehabilitation | 6.6 mi | ★★★★★ | 8 | 0 |
| Sikeston Convalescent Center | 6.9 mi | ★★★★★ | 9 | 0 |
| Daybreak Nursing Center | 7.9 mi | ★★★★★ | 8 | 0 |
| Clearview Nursing Center | 8 mi | ★★★★★ | 14 | 0 |
| Annie's Garden Skilled Nursing | 8 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.