Average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Bermuda Commons Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Expired nutritional supplement drinks were found available for use in two nourishment rooms, with 17 expired cartons in one room and 121 in another. Staff interviews revealed confusion over responsibility for removing expired items, and both the Dietary Manager and Central Supply staff were unsure why the expired drinks had not been discarded.
The facility did not document that education on the benefits and potential side effects of flu and pneumonia vaccines was provided to residents before vaccine administration. For four residents, immunization records showed either no documentation or an indication that education was not given, despite facility expectations that nurses provide and record this information prior to vaccination.
Staff failed to document that education on the benefits and potential side effects of the COVID-19 vaccine was provided to several residents before vaccine administration. Immunization records showed that education was either marked as not provided or left undocumented, despite facility expectations that nurses would both educate and document prior to giving the vaccine.
Residents repeatedly raised concerns about excessive nighttime noise during Resident Council meetings, but the facility failed to provide timely or documented follow-up or communicate resolution efforts. Leadership relied on verbal communication and only noted outcomes in subsequent meeting minutes, with no written updates provided to residents and no formal process for tracking group concerns.
A resident with multiple chronic conditions and a DNR order did not have a signed Medical Orders for Scope of Treatment (MOST) form, despite documented discussions about advance directives. The unsigned form was found in the advance directives binder, and interviews with staff and leadership revealed confusion over who was responsible for obtaining the required signature.
A shortage of washcloths and towels on several halls resulted in residents being unable to receive baths as scheduled. Staff interviews confirmed the ongoing linen shortage, with some staff borrowing linens from other halls or waiting for laundry to provide more. The issue was not reported to facility leadership, and the laundry room shelves for clean linens were observed to be empty, directly affecting residents' daily care and comfort.
A resident with chronic respiratory conditions did not receive humidified oxygen as ordered, as the water canister on the oxygen concentrator was repeatedly found empty over multiple observations. Despite documentation indicating humidified oxygen therapy was provided, staff failed to ensure the canister was filled, and only addressed the issue when prompted by surveyors. Interviews revealed inconsistent monitoring practices among nursing staff.
Surveyors found that staff failed to date opened medications and left a loose, unidentified pill unsecured in medication carts. Additionally, a resident with dementia had an antibiotic/pain ointment at bedside without staff knowledge or a physician's order, and the ointment remained accessible for several days before removal. Interviews confirmed that these practices did not meet facility expectations for medication labeling and security.
Surveyors found that the facility did not post the required names and contact information for pertinent State agencies and advocacy groups, including the local department of social services and the State Long Term Care Ombudsman. The Administrator confirmed responsibility for ensuring these postings, but none were observed during the survey.
Expired Nutritional Supplement Drinks Not Removed from Nourishment Rooms
Penalty
Summary
Expired nutritional supplement drinks were found in two nourishment rooms within the facility. Specifically, 17 individual cartons with a use by date that had passed were observed on a lower shelf in the 300 Hall nourishment room, and 121 individual supplement drinks with expired use by dates were found on a lower shelf in the 500 Hall nourishment room. These items were available for use and had not been removed from stock as required by professional standards for food storage and safety. Interviews with facility staff revealed a lack of clarity and accountability regarding the responsibility for removing expired nutritional supplement drinks. The Dietary Manager indicated that Central Supply was responsible for stocking and removing expired items, while Central Supply staff stated that they checked nourishment rooms weekly but did not know why the expired items had not been removed. Both the Administrator and the Dietary Manager were unsure why the expired drinks remained in stock, despite acknowledging that expired food and drink items should be promptly removed.
Failure to Document Vaccine Education Prior to Administration
Penalty
Summary
The facility failed to document that education regarding the benefits and potential side effects of influenza and pneumonia vaccines was provided to residents prior to vaccine administration. This deficiency was identified through record review and staff interviews, which revealed that for four out of five residents reviewed, the immunization records either indicated that education was not provided or lacked any documentation in the education notes section. Specifically, the records for these residents showed that the education tab was marked 'no' and no further notes were entered regarding vaccine education for both influenza and pneumonia vaccines administered by the same nurse. Interviews with the Infection Preventionist, Director of Nursing, and Administrator confirmed that the expectation was for nurses to provide and document vaccine education prior to administration. However, the documentation reviewed did not reflect that this process was consistently followed. The staff responsible for administering the vaccines did not record that education was given, and this omission was acknowledged by facility leadership during interviews.
Failure to Document COVID-19 Vaccine Education Prior to Administration
Penalty
Summary
The facility failed to document that education regarding the benefits and potential side effects of the COVID-19 vaccine was provided to residents prior to vaccine administration. Record reviews for five residents revealed that staff either marked 'no' under the education provided section or left the education notes section blank on the immunization record for each vaccine dose administered. In each case, the vaccine was administered by the same nurse, and there was no documentation to indicate that the required education had been given before the vaccine was provided. Interviews with facility staff, including the Infection Preventionist, Director of Nursing, and Administrator, confirmed that the expectation was for nurses to provide and document education about the COVID-19 vaccine prior to administration. However, the documentation reviewed did not reflect that this process was followed for the residents in question, resulting in a failure to meet the facility's own procedures and regulatory requirements for vaccine education and documentation.
Failure to Resolve and Communicate Resident Council Concerns About Nighttime Noise
Penalty
Summary
The facility failed to adequately resolve and communicate its efforts to address repeated resident concerns about excessive noise at night, as documented in Resident Council meeting minutes over a ten-month period. Residents consistently raised complaints about hallway noise and staff talking loudly during early morning hours, with these concerns first noted in January and persisting in subsequent months. Despite the Activities Director's documentation of these concerns in meeting minutes and verbal communication with the Director of Nursing (DON) and Administrator, there was no evidence of timely or effective follow-up, as the same complaints reappeared in later meetings without documented resolution. The process for addressing group concerns brought up during Resident Council meetings was informal and lacked written documentation beyond the meeting minutes. The Activities Director and facility leadership relied on verbal communication to share concerns and coordinate resolution efforts, with any follow-up or outcomes only noted in the next month's meeting minutes as either resolved or not resolved. Residents were not provided with written updates or documentation regarding the status or resolution of their concerns, and there was no separate grievance process for issues raised in Resident Council meetings. Interviews with residents, the Activities Director, the DON, and the Administrator confirmed that all follow-up actions were conducted verbally and that there was no formal written process for tracking or communicating the resolution of group concerns. Residents were aware of how to file individual grievances but did not have a separate process for group concerns raised in council meetings. The lack of documented follow-up and communication regarding the resolution of repeated noise complaints led to the deficiency cited in the report.
Failure to Obtain Resident Signature on MOST Form
Penalty
Summary
A deficiency was identified when a cognitively intact resident with multiple diagnoses, including diabetes mellitus, congestive heart failure, and hypertensive heart disease, did not have a signed Medical Orders for Scope of Treatment (MOST) form in their medical record. The resident had an active care plan and a documented order from the Nurse Practitioner for Do Not Resuscitate (DNR) status, with specific instructions regarding intubation, hospitalization, IV fluids, antibiotics, and feeding tube use. Although the Nurse Practitioner reviewed the resident's advance directives and completed the MOST form, the form was not signed by the resident or their representative and was found unsigned in the advance directives binder at the nurse's station. Interviews with the resident, staff, and facility leadership revealed confusion and lack of clarity regarding responsibility for obtaining the required signature on the MOST form. The resident did not recall signing any advance directive documents, and staff members, including the social worker, physician, DON, and administrator, each believed that another department or individual was responsible for ensuring the form was signed. The Medical Records Specialist, who had recently assumed responsibility for auditing MOST forms, noted that the missing signature should have been identified in previous audits, as the resident had been at the facility for an extended period.
Inadequate Supply of Bath Linens Impacts Resident Care
Penalty
Summary
The facility failed to provide an adequate supply of bath linens, specifically washcloths and towels, on three of six halls observed. During observations, linen carts on multiple halls were found to be empty of these essential items, and staff interviews confirmed an ongoing shortage. A cognitively intact resident reported being unable to receive a bath due to the lack of washcloths. Multiple nurse aides stated that the shortage had persisted for at least a month, with some having to borrow linens from other halls or wait for laundry to supply more. On the day of observation, the laundry room shelves designated for clean washcloths and towels were empty. Staff interviews revealed that the shortage was known among nurse aides and housekeeping, but not reported to the Director of Nursing or the Administrator. The Housekeeping Supervisor acknowledged the shortage and described efforts to supply washcloths in small increments throughout the day, as well as recent purchases and pending orders for additional linens. The Administrator and DON were unaware of the extent of the shortage at the time of the incident. The lack of available bath linens directly impacted residents' ability to receive daily care and maintain a clean, comfortable, and homelike environment.
Failure to Provide Humidified Oxygen as Ordered
Penalty
Summary
The facility failed to provide humidified oxygen as ordered by the physician for a resident with chronic obstructive pulmonary disease, chronic respiratory failure, and dependence on supplemental oxygen. The resident's care plan and physician orders specified the use of continuous oxygen with humidification, both during the day and at night with a BIPAP machine. Despite documentation in the Medication Administration Record indicating that humidified oxygen therapy was provided, multiple observations over two days revealed that the water canister on the resident's oxygen concentrator was empty. Staff interviews confirmed that the canister should have contained water for humidification and that it was the responsibility of nursing staff to monitor and refill it as needed. The resident was observed on several occasions with an empty water canister attached to the oxygen concentrator, and staff did not refill it until prompted during the survey. The resident reported no discomfort or nosebleeds at the time of the interviews, but the Medical Director acknowledged that the lack of humidification could cause short-term discomfort. Staff interviews revealed inconsistent practices regarding monitoring and refilling the water canister, and the Director of Nursing stated that canisters should be checked every shift. The deficiency was identified through direct observation, record review, and staff and resident interviews.
Medication Labeling, Storage, and Security Deficiencies
Penalty
Summary
Surveyors observed multiple failures in the facility's medication management practices. On one medication cart, an open bottle of moxifloxacin eye drops and an open bottle of fluticasone nasal spray were found without open or discard dates, despite being verified as open by the nurse present. On another medication cart, a loose, unidentified white pill was found unsecured in a drawer, and the nurse was unable to explain its presence. Interviews with nursing staff and the DON confirmed that medications should be dated when opened and that loose pills should not be present in medication carts. Additionally, a resident with late-onset Alzheimer's disease and moderate cognitive impairment was found to have a tube of antibiotic/pain reliever ointment on her bedside table over multiple days. The resident reported using the ointment but could not recall why or where it came from. Nursing staff were unaware of the ointment's presence until it was pointed out, and the DON confirmed that a physician's order is required for bedside medications. The Medical Director indicated the ointment was likely brought in by a family member and expressed surprise that staff had not previously noticed it.
Failure to Post Required State Agency and Advocacy Group Contact Information
Penalty
Summary
The facility failed to post a list of names, addresses (including mailing and email), and telephone numbers of all pertinent State agencies and advocacy groups, such as the State Survey Agency, State licensure office, adult protective services, the Office of the State Long-Term Care Ombudsman, the protection and advocacy network, home and community-based service programs, and the Medicaid Fraud Control Unit. This deficiency was identified during a recertification survey conducted over four days, during which surveyors observed all hallways of the facility and found no postings of the required contact information for the local department of social services, the State Long Term Care Ombudsman, or any resident advocacy group. During an interview with the Administrator, it was confirmed that it was their responsibility to ensure these postings were present and accessible to residents and their representatives. The Administrator acknowledged that all residents and their representatives should be informed of available resources and that the postings should be in a location that is easily visible and accessible. No postings were observed at any time during the survey period.
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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 Advance
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bermuda Village Retirement Center | 1.3 mi | ★★★★★ | 0 | 0 |
| Trinity Elms | 2.5 mi | ★★★★★ | 5 | 0 |
| Cedar Hills Center For Nursing And Rehabilitation | 3.1 mi | ★★★★★ | 38 | 0 |
| Homestead Hills | 8.6 mi | ★★★★★ | 0 | 0 |
| Silas Creek Rehabilitation Center | 9.4 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.