Health inspection·January 28, 2026

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review the facility failed to ensure, in accordance with accepted professional standards and practices, medical records were maintained on each resident that were complete, accurately documented, readily accessible, and systematically organized for 1 of 5 residents (Resident #1) reviewed for resident records. The facility failed to ensure physician orders for Resident #1's X-ray were entered on the porta on 01-16-2026. This failure could place residents at risk for incorrect treatment decisions, evaluation, and treatment plans compromising patient safety due to insufficient information records.Findings Included:Record review of Resident #1's admission record, dated 01-28-2026, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included Dementia (Condition which involves memory loss, affecting thinking, and social abilities which interfere with their daily lives) and, Repeated Falls and Depression (a mood disorder that causes a persistent feeling of sadness and loss of interest).Record review of Resident #1's quarterly MDS assessment, dated 12-17-2025, reflected Resident #1 had a BIMS of 03, which indicated the resident had severe problems with thinking and memory. The document reflected that she used a walker for mobility, and she was independent regarding eating and toileting.Record review of Resident #1 care plan, dated 12-23-2025, reflected the resident had a behavior problem related to dementia. Her behavior was to hoard napkins, food and spoons. Interventions included anticipating and meeting the residents' needs. Interventions which included the activity director would encourage and remind Resident # 1 of current activities.Record review of Resident # 1's Progress Notes dated 01/16/2026 at 8:15 PM reflected. LVN A documented a note as late entry, NP orders received for lidocaine 4% pain patch to back and X-ray left rib area times 3 views. Record review of Resident #1's order summary on 01-28-2026 reflected Chest X-ray order was entered into PCC on 01/18/2026 at 7:30 a.m.During an interview with LVN A on 01/28/2026 at 10:01 a.m., LVN A stated, after I assessed [Resident # 1], I called the doctor to report [Resident # 1's] condition and I received verbal orders from PA that included a chest X-ray and 4% lidocaine patch. She stated she put the orders in PCC under the Doctors' orders tab. LVN A stated it was her responsibility to enter the orders for the X-ray into the portal immediately upon receiving the orders. LVN A stated she forgot to put the orders into the portal and that caused the resident to not get the chest Xray stat. During an interview on 01/28/2026 at 12:02 p.m., reflected, ADON B worked on Sunday, 01/25/2026 at 6:00 a.m. and she reviewed the facility's 24-hour report. She stated on the 24-hour report there was a record of the incident with Resident # 1, and the record included orders for an X-ray of the residents' ribs. ADON B checked the portal and Resident # 1's name was not on the portal for an X-ray order. ADON B then, I ordered the X-ray Stat. ADON B ordered the X-ray before 12:00 p.m. on 01/18/2026 with the expectation that the mobile X-ray service would arrive at the facility within 4-6 hours. ADON B stated, she returned to work on Monday 01/19/2026 at 6:00 a.m. and I found the X-ray team was (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 676117 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/28/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bertram Nursing and Rehabilitation 540 E State Hwy 29 Bertram, TX 78605 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)