Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Village Retirement Center during CMS and state inspections, most recent first.
The facility did not implement Enhanced Barrier Precautions (EBP) or educate staff on its use, leading to a nurse providing wound care without a gown. The DON and Administrator were aware of EBP regulations but failed to implement them, potentially affecting all residents.
The facility failed to create comprehensive care plans for residents on high-risk medications and oxygen therapy. Several residents with conditions like congestive heart failure, atrial fibrillation, and chronic obstructive pulmonary disease were receiving treatments such as anticoagulants, diuretics, opioids, anti-depressants, and oxygen therapy without corresponding care plans. This oversight was acknowledged by the MDS Nurse, who cited a lack of education on care planning for high-risk medications, and was contrary to the expectations of the DON and Administrator.
A facility failed to maintain consistent documentation of a resident's code status, resulting in a discrepancy between a Full Code order and a DNR form. Staff interviews revealed reliance on a Code Status notebook for emergencies, which conflicted with the resident's medical record. The DON and SW had not completed the February audit, contributing to the oversight.
A facility failed to provide a SNF ABN to a resident before the end of Medicare Part A skilled services. The resident was informed of the end of coverage through a NOMNC, but no SNF ABN was issued. The Social Worker was unaware of the requirement to issue a SNF ABN, and the Administrator confirmed the oversight.
A facility failed to develop a comprehensive care plan for a resident receiving insulin for diabetes mellitus. Despite the resident receiving insulin as ordered, the care plan did not address this high-risk medication. The MDS Nurse confirmed the oversight and admitted to not having previously care planned for high-risk medications. The DON and Administrator expected such medications to be included in care plans to ensure staff awareness of potential side effects.
The facility failed to date an open vial of PPD solution in the medication refrigerator and did not secure medications stored at a resident's bedside. The resident, with COPD and respiratory failure, had medications without a self-administration order. The DON confirmed that medications should not be at the bedside without such an order.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to develop and implement an Enhanced Barrier Precautions (EBP) policy and procedures, which are essential for infection prevention and control. This deficiency was identified through observations, staff interviews, and record reviews. The facility's infection control policy did not include EBP, and nursing staff were not educated on its implementation. During an observation, a nurse provided wound care to a resident with a chronic right hip wound without donning a gown, which is a critical component of EBP during high-contact care activities. Interviews with the nursing staff and the Director of Nursing (DON), who also served as the facility's Infection Preventionist, revealed a lack of implementation and education regarding EBP. The DON acknowledged awareness of the regulation and CDC recommendations but had not taken steps to implement EBP. The facility's Administrator also admitted knowledge of the regulation but mistakenly believed compliance was achieved due to the facility's private room setup. This oversight had the potential to affect all residents, as the facility did not adhere to required infection control practices.
Failure to Develop Comprehensive Care Plans for High-Risk Medications and Oxygen Therapy
Penalty
Summary
The facility failed to develop individualized person-centered comprehensive care plans for residents receiving high-risk medications and oxygen therapy. This deficiency was identified for five residents who were reviewed for comprehensive care plans. The care plans did not address the use of anticoagulants, diuretics, opioids, anti-depressants, and oxygen therapy, which are considered high-risk medications and treatments. The absence of these care plans means that staff were not adequately informed about the potential side effects and necessary monitoring associated with these treatments. Resident #7, who was admitted with diagnoses including congestive heart failure, atrial fibrillation, and myocardial infarction, was receiving anticoagulant, diuretic, and opioid medications. However, their care plan did not include any focus on these high-risk medications. Similarly, Resident #8, with diagnoses of cerebral vascular accident, vascular dementia, congestive heart failure, and atrial fibrillation, was also receiving anticoagulant, diuretic, and opioid medications without a corresponding care plan. The MDS Nurse admitted to not having care planned these high-risk medications, citing a lack of education and guidance on the matter. Additionally, Resident #24, who had chronic obstructive pulmonary disease and atrial fibrillation, was receiving anti-depressant and anticoagulant medications without a care plan. Resident #14, with chronic pulmonary edema and cirrhosis, was on diuretics that were not care planned. Lastly, Resident #4, admitted with pneumonia, was receiving oxygen therapy that was not included in their care plan. Interviews with the Director of Nursing and the Administrator revealed an expectation that all high-risk medications and treatments should be care planned to ensure staff awareness of potential side effects, but this was not being implemented effectively.
Inconsistent Code Status Documentation for a Resident
Penalty
Summary
The facility failed to ensure accurate documentation of a resident's code status throughout their medical record, leading to a discrepancy between the physician's order and the Code Status notebook. Resident #11 was admitted to the facility with a physician order indicating a Full Code status dated 02/15/25. However, the Code Status notebook at the nursing desk and the resident's admission History and Physical both indicated a Do Not Resuscitate (DNR) status dated 02/17/25. This inconsistency in documentation could lead to confusion during a medical crisis. Interviews with facility staff revealed that the Code Status notebook is the primary source for determining a resident's code status in an emergency. Nurse #1 confirmed that the notebook and the medical record should match. The Director of Nursing (DON) and the Social Worker (SW) both acknowledged their roles in addressing and auditing code statuses, but admitted that the audit for February 2025 had not been completed. This oversight contributed to the failure in maintaining consistent and accurate documentation of the resident's code status.
Failure to Provide SNF ABN Prior to Medicare Part A Discharge
Penalty
Summary
The facility failed to provide a CMS-10055 Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) to a resident prior to the discharge from Medicare Part A skilled services. The resident was admitted to the facility and began receiving Medicare Part A services on October 21, 2024. A Notice of Medicare Non-Coverage (NOMNC) was discussed with the resident on November 26, 2024, indicating that Medicare Part A coverage for skilled services would end on November 28, 2024. However, the resident remained in the facility, and there was no evidence in the medical record that a SNF ABN was reviewed with or provided to the resident. During an interview, the Social Worker, responsible for issuing the NOMNC, admitted to not knowing about the SNF ABN or the requirement to issue it when a resident had skilled days left and remained in the facility. The Administrator confirmed that the SNF ABN was not issued to the resident prior to the end of Medicare Part A skilled services.
Failure to Care Plan High-Risk Medication for Resident
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident who was receiving high-risk medication, specifically insulin, for diabetes mellitus. The resident was admitted with a diagnosis of diabetes mellitus and had physician orders for glargine insulin to be administered daily. Despite the resident receiving insulin as ordered, the care plan did not address the management of this high-risk medication. This oversight was confirmed during an interview with the MDS Nurse, who acknowledged that the care plan did not include insulin and admitted to not having previously care planned for high-risk medications. The MDS Nurse stated that she had not received education or information related to care planning for high-risk medications, although she used the Resident Assessment Instrument Manual for guidance on completing the MDS. The Director of Nursing expressed an expectation that all high-risk medications, including insulin, should be care planned to ensure staff are aware of potential side effects. The Administrator also expected care plans to reflect the clinical condition of residents, including the use of high-risk medications. This deficiency highlights a gap in the facility's care planning process for residents on high-risk medications.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to properly label and store medications as required by professional principles. During an observation of the medication refrigerator, an open and undated vial of Tuberculin Purified Protein Derivative (PPD) solution was found. Nurse #3 confirmed that the vial should have been dated upon opening to ensure it was used within the 30-day period specified by the manufacturer's instructions. The Director of Nursing stated that it was the responsibility of each nurse to check for undated and expired medications, indicating a lapse in adherence to this protocol. Additionally, the facility did not secure medications stored at the bedside of a resident with chronic obstructive pulmonary disease and respiratory failure. The resident, who was cognitively intact, had fluticasone nasal spray and mupirocin ointment on their bedside table without a physician's order to self-administer these medications. Nurse #1 acknowledged that the resident did not have an order to self-administer medications and that the medications should not have been at the bedside. The Director of Nursing confirmed that medications could not be stored at residents' bedsides without an order to self-administer, highlighting a failure to enforce this policy.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 186 citations issued within 25 miles in the last 12 months — including the 6 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Bermuda Run
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bermuda Commons Nursing And Rehabilitation Center | 1.3 mi | ★★★★★ | 0 | 0 |
| Trinity Elms | 2.4 mi | ★★★★★ | 5 | 0 |
| Cedar Hills Center For Nursing And Rehabilitation | 2.7 mi | ★★★★★ | 38 | 0 |
| Homestead Hills | 8.2 mi | ★★★★★ | 0 | 0 |
| Silas Creek Rehabilitation Center | 9.2 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Bermuda Village Retirement Center.
100% money-back within 48 hours.
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.