Above average — CMS composite of the measures below.
The next survey window likely opens 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 Bertram Nursing And Rehabilitation during CMS and state inspections, most recent first.
A resident with dementia, repeated falls, and new rib pain had a stat X-ray and lidocaine patch verbally ordered by an NP after an LVN’s assessment. The LVN documented the orders in a progress note but failed to enter the X-ray order into the electronic portal as required, resulting in no timely stat X-ray request being visible in the system. Later review of the 24-hour report by the ADON revealed the incident and intended X-ray, but no corresponding portal order, demonstrating that the resident’s medical record was not complete or accurately maintained in line with facility policy and accepted standards.
Surveyors found multiple food safety and sanitation failures in the kitchen, including unlabeled raw chicken thawing in a walk‑in refrigerator, a reach‑in refrigerator with a dried yellow spill on the bottom, and severely dented canned goods stored with regular stock instead of in a designated dented‑can area. Spoiled sweet potatoes with mold‑like growth and gnats were found in dry storage, and numerous bags of hot dog buns were either past their best‑by date or had no date at all, with some stale bread left on the rack next to fresh bread. Opened large bags of chips lacked open or use‑by dates. A cook with a beard was observed preparing and plating food while wearing a hairnet but no beard guard, despite facility expectations and policies requiring hair and beard restraints. Interviews with dietary staff, the dietary manager, the dietitian, and the administrator confirmed that these practices did not meet the facility’s own policies for labeling, dating, storage, equipment sanitation, and use of hair restraints, as well as FDA Food Code requirements for date marking and protection from cross‑contamination.
Staff failed to follow infection control practices during peri-care and wound-related precautions for multiple residents. CNAs provided perineal care to several incontinent residents without performing hand hygiene between glove changes, without changing gloves between front and back peri-areas, and in some cases continued to touch environmental surfaces and assist with transfers while wearing contaminated gloves, despite having received training on proper hand hygiene and glove use. For a resident with a surgical wound on EBP, there was no precaution signage on the door and no PPE available near the room, even though the care plan and orders required gown and glove use during wound care and facility policy and in-service materials specified that EBP rooms must have posted signs and readily accessible PPE.
The facility failed to ensure resident privacy by not adhering to the protocol of knocking on residents' doors before entering. Staff members, including CNAs and an RN, entered rooms without knocking, despite being trained on resident rights. Residents expressed discomfort and a preference for staff to knock, highlighting a deficiency in maintaining personal privacy.
The facility failed to maintain food safety and hygiene standards, with staff not adhering to personal hygiene protocols, improper food storage, and inadequate cleanliness in the kitchen and nourishment room. Observations revealed open, undated food items, improper hand hygiene by staff, and inconsistencies in policy implementation, potentially risking residents' health.
A resident with paraplegia and a history of falls was found with their bed not in the low position, contrary to the facility's fall prevention policy. Despite the presence of a fall mat, the bed was only lowered after a nurse intervened. Staff interviews confirmed the expectation for beds to be kept low for residents on fall precautions, as outlined in the facility's policy.
A resident with severe cognitive impairment and osteoarthritis did not receive her scheduled Lidocaine patch for pain management on time, as per the facility's policy. The delay in medication administration was due to a medication aide running late, which was not communicated to the nursing staff, resulting in the resident experiencing prolonged pain.
A resident with a recent shoulder surgery and history of falls experienced multiple falls in the facility, complaining of shoulder pain afterward. Despite her complaints and a care plan indicating fall risk and need for monitoring, the facility did not provide timely medical attention. Staff interviews revealed inconsistencies in handling the situation, and the resident's pain was only addressed after a follow-up appointment revealed a shoulder separation.
Failure to Timely Enter Stat X-Ray Order Resulting in Incomplete Medical Record
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete, accurately documented, and systematically organized medical records for a resident, specifically related to physician orders for a diagnostic X-ray. The resident was an elderly female with dementia, repeated falls, and depression, who used a walker and was independent with eating and toileting but had severe cognitive impairment as indicated by a BIMS score of 3. Her care plan noted dementia-related hoarding behaviors. On a Friday, an NP received a call from an LVN reporting the resident’s rib pain and gave verbal orders for a stat chest/rib X-ray and a 4% lidocaine patch. The LVN documented the NP’s orders as a late entry in the progress notes, indicating orders for a lidocaine patch and an X-ray of the left rib area, but failed to enter the X-ray order into the electronic portal as required. Record review showed that the X-ray order did not appear in the order summary until two days later, when it was entered into the system. The LVN acknowledged in interview that it was her responsibility to enter the X-ray order into the portal immediately and admitted she forgot to do so, which resulted in the resident not receiving the stat X-ray as ordered. The ADON, who worked the following Sunday and reviewed the 24-hour report, saw documentation of the incident and the X-ray order but found no corresponding order in the portal for the resident. This discrepancy between the clinical documentation and the absence of a timely portal entry demonstrated that the resident’s medical record was not complete or accurately maintained in accordance with facility policy and accepted professional standards. Further interviews clarified expectations and timelines for stat X-rays and documentation. The ADON stated she subsequently ordered the X-ray stat via the portal, and the mobile X-ray service arrived but initially could not complete the study due to equipment malfunction, with the X-ray ultimately performed the next day and the report later showing a hairline fracture of the left 5th rib. The infection control RN stated that stat X-rays were expected to be completed within four hours and that if a stat X-ray could not be done, staff were to assess pain and consider contacting the physician about hospital transfer. The NP stated that she expected a stat X-ray to be completed within 6–12 hours and that she was not notified that the X-ray was not done as ordered. The DON confirmed that staff were expected to submit X-ray orders into the portal immediately and that facility policy required a current, chronological list of orders in each resident’s clinical record, underscoring that the missing and delayed X-ray order entry constituted a failure to maintain the resident’s medical record in accordance with policy.
Food Storage, Sanitation, and Hair Restraint Failures in Dietary Services
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to improper storage, labeling, dating, sanitation, and handling of food items in the kitchen. During an initial kitchen tour, surveyors observed a pan of raw chicken in the walk‑in refrigerator covered with plastic wrap but lacking any label or dates indicating when it was pulled to thaw or when it should be used. In the same tour, a reach‑in refrigerator contained a dried, crusted yellow substance covering the entire bottom, indicating it had not been cleaned as expected. In the canned food storage room, multiple cans of pineapple chunks and chocolate pudding had severe dents near the lip and sides, including one can with a finger‑deep dent and sharp points, and these cans were stored with regular stock rather than in a separate dented‑can area. In dry storage, a box of sweet potatoes marked with a date that represented the received date contained spoiled product with large black areas, white fuzzy patches, and gnats throughout the potatoes. On the bread and miscellaneous items rack, surveyors found multiple 12‑count bags of hot dog buns with a best‑by date that had already passed, as well as additional bags with no visible date at all. Four large opened bags of chips, including one in a clear zip‑seal bag, had no open date or use‑by date. A cook stated that the bread rack was supposed to be checked every three days for expired items and that all items on the rack and in the refrigerator should be labeled with item identification and dates, but acknowledged that the rack likely had not been checked since several days prior and began discarding some of the obviously stale buns during the observation. The cook also stated that dented cans were supposed to be set aside and not kept with usable cans, and that the reach‑in refrigerator was expected to be cleaned weekly, but she could not identify the yellow substance in the bottom of the unit. Surveyors also observed failures in personal protective practices and ongoing food quality control. A cook with a quarter‑inch beard was seen preparing desserts and assisting with plating meal trays while wearing a hairnet but no beard guard. He later stated that the expectation was for dietary staff to always wear hairnets and beard guards in the kitchen, and that hairnets and beard guards were normally stocked on a kitchen window shelf but were not readily available at the time, which he said contributed to him forgetting to put one on. The dietary manager confirmed his expectation that dented cans be removed from regular stock and placed in a designated area for return, but the cart he used for dented cans had no clear identification. He also stated that items in refrigerators should be marked with open or pulled dates and use‑by dates, and that sanitation of kitchen equipment and refrigerators was to occur daily and every shift. On a follow‑up observation, surveyors found that several bags of hot dog buns with a best‑by date that had already passed remained on the bread rack next to fresh bread, and the buns were hard and stale. When questioned, the dietary manager reported being told that a best‑by date was different from an expiration date and that it was up to the facility when to discard such items, and he left the stale bread on the rack. The facility dietitian later stated that bread should not be kept much longer than about a week past its best‑by date, that she would not want residents to receive stale bread, and that staff should pay attention to color, texture, and smell and discard items that feel stale or show spoilage. The dietitian and the administrator both stated expectations that food items be labeled and dated with received, opened, and use‑by dates, that frozen items pulled to thaw be dated, that dented cans be separated and returned, that refrigerators and equipment be cleaned daily and as messes occur, and that dietary staff always wear hairnets and beard guards. Facility policies and FDA Food Code excerpts reviewed by surveyors required opened foods to be labeled and dated, dented cans to be stored separately and not used, perishable foods to be used within specified time frames, frozen items thawed under refrigeration and dated, and dietary staff to wear hair restraints, all of which contrasted with the observed practices in the kitchen.
Failure to Follow Hand Hygiene and Enhanced Barrier Precautions During Resident Care
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program, specifically related to hand hygiene during peri-care and implementation of Enhanced Barrier Precautions (EBP) for a resident with a surgical wound. For one male resident with parkinsonism, bone density disorder, chronic atrial fibrillation, depression, bladder and bowel incontinence, and risk for UTIs, a CNA provided peri-care without sanitizing her hands between glove changes and without changing gloves between cleaning the front and back perineal areas. The CNA also repeatedly touched the package of wipes with contaminated gloves before changing them. The CNA later stated she had received monthly training on hand hygiene and peri-care, knew she should sanitize her hands every time she changed gloves and between front and back peri-care, and acknowledged she forgot to do so. For a female resident with Alzheimer’s disease, major depressive disorder, type 2 diabetes, muscle weakness, bladder and bowel incontinence, and a care plan requiring staff to provide peri-care after each incontinent episode, a CNA performed peri-care without sanitizing her hands or changing gloves between cleaning the front and back perineal areas. After completing peri-care, the CNA did not remove the contaminated gloves and proceeded to assist the resident back into her wheelchair, then pushed the wheelchair into the hallway while touching the doorknob with the same contaminated gloves. In an interview, this CNA reported she had been trained on hand hygiene and peri-care the prior week and stated she should remove gloves after completing peri-care and wash hands before touching anything else in the resident’s environment, and that not cleaning hands and not changing gloves would spread infection to other residents. For another female resident with dementia, muscle weakness, Down syndrome, and a care plan requiring peri-care and application of barrier creams after every incontinent episode, two CNAs provided peri-care and changed gloves without performing hand hygiene. One CNA did not remove gloves before reaching for the side table, opening a drawer, and taking out barrier cream, then applied the cream to the resident’s skin while still wearing the same gloves. Both CNAs stated they had been trained on hand hygiene and were supposed to wash their hands between glove changes, avoid touching furniture with contaminated gloves, and change gloves and perform hand hygiene between front and back peri-care areas and when gloves became soiled. One CNA stated she forgot to change gloves and perform hand hygiene because she was nervous. The facility also failed to implement EBP for a male resident with dementia, anemia, hypertension, emphysema, and a surgical wound to the back. His care plan and active orders documented that he had a surgical site and required wound care with non-surgical dressings, and that he was on EBP with gloves and gown to be applied when wound care was performed. However, observation of his room showed no EBP signage on the door and no PPE available near the room, despite wound care having been provided the day before the survey. The facility’s infection control policy and EBP in-service materials required that hand hygiene be performed before and after direct resident contact, after removing gloves, and during personal care, and that EBP rooms have a sign posted outside the room indicating when to wear gowns and gloves, with gowns and gloves available outside the room. In interviews, the DON and ADON confirmed that the resident was supposed to be on EBP, that his room should have been marked with a sign, and that PPE should be available, but the DON stated she did not know what happened to the sign or the PPE box that had been outside the door.
Failure to Ensure Resident Privacy by Not Knocking Before Entering Rooms
Penalty
Summary
The facility failed to ensure the personal privacy of residents by not adhering to the protocol of knocking on residents' doors before entering their rooms. This deficiency was observed in the cases of four residents, who were part of a group of seven reviewed for personal privacy. Staff members, including CNAs and an RN, entered the rooms of these residents without knocking, which is against the facility's policy and training on resident rights. The Director of Nursing (DON) and the Administrator (ADM) confirmed that staff were trained to knock and wait for a response before entering, but this practice was not consistently followed. The residents involved had various medical conditions, including metabolic encephalopathy, brain tumor, dementia, and chronic kidney disease, among others. Their cognitive abilities varied, with BIMS scores indicating different levels of understanding and communication ability. Despite these differences, the common issue was the lack of privacy due to staff entering their rooms without knocking, which was confirmed through interviews with the residents. Some residents expressed that they would prefer staff to knock, as it startled them or made them feel uncomfortable when staff entered unannounced. Interviews with staff members revealed that they were aware of the requirement to knock before entering a resident's room, yet this practice was not consistently followed. The staff acknowledged that failing to knock could make residents feel like their privacy was being invaded. Despite being trained on resident rights, the staff did not consistently apply this knowledge in practice, leading to the deficiency in maintaining residents' personal privacy. The facility's Resident Rights Policy, which includes the right to personal privacy, was not provided to the surveyor upon request, further highlighting the deficiency in policy adherence.
Food Safety and Hygiene Deficiencies in Facility
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed in both the kitchen and nourishment room. Dietary Staff F was noted to be non-compliant with personal hygiene protocols, as he did not wear a beard guard to cover his facial hair and his hairnet did not fully cover his hair. Additionally, the kitchen refrigerator contained multiple items that were open, undated, and improperly stored, including a bottle of Hershey's syrup, sweet chili sauce, bread and butter pickles, and vanilla ice cream. Shelf-stable spices were also missing dates, and bags of taquitos and chicken nuggets were improperly closed and exposed to air. In the nourishment room, food items were found unlabeled and undated, with cupcakes left uncovered on the counter. The ice chest was improperly maintained, with the scoop left inside and a brown substance present in the cracks. Coffee creamer was stored beneath cleaning chemicals, and several shelf-stable items were open and undated. Dietary Staff E was observed not following proper hand hygiene protocols, failing to wash hands between tasks and not referencing recipes while preparing pureed foods. Interviews with dietary staff and management revealed inconsistencies in the understanding and implementation of food safety policies. Staff acknowledged the importance of proper labeling, dating, and storage of food items, as well as the necessity of maintaining cleanliness in food preparation areas. However, there was a lack of adherence to these protocols, as evidenced by the observations made during the survey. The dietary manager and administrator expressed expectations for compliance with hygiene and food safety standards, but the observed practices did not align with these expectations, potentially putting residents at risk for health complications and foodborne illnesses.
Failure to Maintain Bed in Low Position for Fall Prevention
Penalty
Summary
The facility failed to ensure that a resident's bed was maintained in the lowest position as per the facility's fall prevention policy. This deficiency was identified during an observation and interview, where it was noted that the bed of a resident with a history of falls and paraplegia was not in the low position. The resident, who had intact cognitive status, was at risk for falls due to his paraplegic condition. A fall mat was present on the floor, but the bed was not lowered until a registered nurse intervened. Interviews with the nursing staff and the Director of Nursing (DON) confirmed that the expectation was for beds to be kept in the low position for residents on fall precautions. The facility's policy, revised in 2016, clearly stated that beds should be kept in the low position as part of preventive strategies to reduce fall risk. The Administrator also acknowledged that the facility's policy should be followed, although he refrained from speculating on potential risks. This oversight in maintaining the bed in the correct position could place residents at risk of falls and related injuries.
Failure to Administer Timely Pain Management
Penalty
Summary
The facility failed to provide timely pain management for a resident, identified as Resident #18, who required such services. Resident #18, an elderly female with severe cognitive impairment, was admitted with diagnoses of pain in the right shoulder and primary generalized osteoarthritis. Her care plan included the administration of a Lidocaine 5% patch daily at 6:00 AM to manage her pain. However, on the morning of August 27, 2024, the resident did not receive her scheduled pain patch within the designated time frame, which was between 6:00 AM and 10:00 AM, as per the facility's liberalized medication policy. Interviews with facility staff revealed that the medication aide responsible for administering the patch was delayed in her medication pass, resulting in the resident experiencing prolonged pain. The CNA/MA acknowledged the delay and the potential risk of increased pain for the resident. The RN and DON both expressed that medications should be administered on time, and the delay was not communicated to the nursing staff. The facility's policy stated that medications should be given at the specified time if ordered by a physician, which was not adhered to in this instance, leading to the deficiency.
Neglect in Addressing Resident's Post-Fall Pain
Penalty
Summary
The facility failed to ensure that a resident was free from neglect, as evidenced by the lack of timely medical attention following multiple falls. The resident, who had a history of falls and a recent right shoulder replacement surgery, experienced several falls within the facility. Despite complaints of pain in her right shoulder after one of these falls, the facility did not send her for immediate medical evaluation. The resident's care plan indicated she was at risk for falls and required monitoring for signs of infection and pain, particularly due to her recent surgery and brittle bone condition. The resident's medical history included degenerative joint disease, schizophrenia, bipolar disorder, and chronic pain syndrome, among other conditions. She had undergone a right reverse shoulder arthroplasty and was at risk for spontaneous fractures. After the falls, the resident complained of pain, but the facility's response was inadequate. Although x-rays were conducted for knee and wrist pain, the shoulder pain was not addressed until a follow-up appointment with her surgeon, where a shoulder separation was discovered. Interviews with facility staff revealed inconsistencies in the handling of the resident's falls and pain complaints. Some staff members believed the resident had refused hospital care, while others acknowledged the potential for missed injuries. The facility's Director of Nursing (DON) and other staff members noted that the resident's falls might have been exacerbated by a new medication, Klonopin, which was later discontinued. Despite the resident's high cognitive function and ability to communicate pain, the facility did not adequately address her complaints, leading to a delay in necessary medical intervention.
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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 Bertram
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avir At Burnet | 10.3 mi | ★★★★★ | 5 | 0 |
| Granite Mesa Health Center | 16.9 mi | ★★★★★ | 9 | 0 |
| New Hope Manor | 19.4 mi | ★★★★★ | 9 | 0 |
| The Springs Healthcare And Rehabilitation | 20.9 mi | ★★★★★ | 9 | 0 |
| Cedar Pointe Health And Wellness Center | 21.1 mi | ★★★★★ | 6 | 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.