Provider Name: BERTRAM NURSING AND REHABILITATION
Address: 540 E STATE HWY 29, BERTRAM, TX 78605
Phone: (512) 355-2116
County: Burnet (222)
Ownership Type: For profit - Corporation
Certified Beds: 74
Average Residents Per Day: 45.7 ()
Provider Type: Medicare and Medicaid, Resides in Hospital: No
Legal Business Name: WEST WHARTON COUNTY HOSPITAL DISTRICT
First Approved Date: November 1, 2006
Affiliated Entity: CREATIVE SOLUTIONS IN HEALTHCARE (169)
Retirement Community: N, Special Focus Status:
Ownership Change in Last 12 Months: N
Resident Family Council: Resident
Sprinkler System Status: Yes
Overall Rating: 2 ()
Health Inspection Rating: 2 ()
QM Rating: 3 ()
Long Stay QM Rating: 5 ()
Short Stay QM Rating: 2 ()
Staffing Rating: 3 ()
Staffing Report Note:
PT Staffing Note:
Nurse Aide Staff Hours Per Day, per resident: 2.25850, LPN Staff Hours Per Day: 0.5491, RN Staff Hours Per Day: 0.5623, Licensed Staff Hours Per Day: 1.1114
Total Nurse Staff Hours Per Day, per resident: 3.36999
Weekend Nurse Staff Hours: 2.83266, Weekend RN Staff Hours: 0.3756
PT Staff Hours Per Day, per resident: 0.1279
Nurse Staff Turnover: 59.2, Nurse Turnover Note:
RN Turnover: 0.0, RN Turnover Note:
Admin Left Number: 1, Admin Turnover Note:
Case Mix Nurse Aide Hours Per Day, per resident: 1.9538, Case Mix LPN Hours Per Day: 0.7820, Case Mix RN Hours Per Day: 0.4166
Adjusted Nurse Aide Hours Per Day, per resident: 2.35491, Adjusted LPN Hours Per Day: 0.5182, Adjusted RN Hours Per Day: 0.5085
Total Adjusted Nurse Hours Per Day, per resident: 3.36944
Adjusted Weekend Nurse Hours Per Day, per resident: 2.83220
Health Survey Dates and Scores: Cycle 1: 2022-05-04 (Score: 111), Cycle 2: 2020-01-15 (Score: 16), Cycle 3: 2019-01-23 (Score: 20)
Total Weighted Health Score: 64.167
Reported Incidents: 1, Substantiated Complaints: 2
Infection Control Citations: 1
Fines and Penalties: Number of Fines: 5, Total Fines in Dollars: 32534.02, Payment Denials Number: 0, Total Penalties Number: 5
Location and GPS: 540 E STATE HWY 29,BERTRAM,TX,78605 (30.7461, -98.060)
Process Date: 2024-03-01
Each record details specific health deficiencies found during inspections, categorized by type, severity, and whether they were corrected. Below are the severity levels and their implications:
Type: Health, Deficiency: Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-11-03
Type: Health, Deficiency: Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Severity: J - Level 4: Immediate jeopardy to resident health or safety. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-10-06
Type: Health, Deficiency: Allow residents to self-administer drugs if determined clinically appropriate.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-05-20
Type: Health, Deficiency: Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-05-20
Type: Health, Deficiency: Provide safe and appropriate respiratory care for a resident when needed.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-05-20
Type: Health, Deficiency: Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-05-20
Type: Health, Deficiency: Provide and implement an infection prevention and control program.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-05-20
Type: Health, Deficiency: Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-05-20
Type: Health, Deficiency: Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-10-14
Type: Health, Deficiency: Reasonably accommodate the needs and preferences of each resident.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-05-25
Type: Health, Deficiency: Provide and implement an infection prevention and control program.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2020-02-07
Type: Health, Deficiency: Provide and implement an infection prevention and control program.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-10-07
Type: Health, Deficiency: Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-02-14
Type: Health, Deficiency: Put firmly secured handrails on each side of hallways.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-02-14
Each record details specific fire safety deficiencies found during inspections, categorized by type, severity, and whether they were corrected. Below are the severity levels and their implications: