Bermuda Commons Nursing and Rehabilitation Center

Inspectors wroteBased on record review, observations and staff interviews, the facility failed to discard expired nutritional supplement drinks that were past the use by date in 2 of 2 nourishment rooms (300 Hall and 500 Hall Nourishment rooms).

Inspectors wroteBased on record review and staff interviews, the facility failed to document education was provided in the medical record regarding the benefits and potential side effects of the influenza and pneumonia vaccines prior to the administration of vaccines. This occurred for 4 of 5 residents (Resident #98, Resident #77, Resident #262, and Resident #27) reviewed for vaccines.

Inspectors wroteBased on record review and staff interviews, the facility failed to document education was provided in the medical record regarding the benefits and potential side effects of the COVID-19 vaccines prior to administration of the vaccines. This occurred for 5 of 5 residents reviewed for immunizations (Resident #43, Resident #98, Resident #77, Resident #262, and Resident #27).

Inspectors wroteBased on review of Resident Council meeting minutes, and resident and staff interviews, the facility failed to resolve and communicate the facility's efforts to address repeated concerns by residents of noise at night during Resident Council meetings for 3 of 10 months reviewed (January 2024, February 2024 and October 2024).

Inspectors wroteBased on record review, resident and staff interviews, the facility failed to have a signed Medical Orders for Scope of Treatment (MOST) form for 1 of 7 residents reviewed for advance directives (Resident #55).

Inspectors wroteBased on observations and interviews with a resident and staff, the facility failed to provide an adequate supply of bath linens for 3 of 6 halls (Halls 100, 500, and 600) observed for a homelike environment.

Inspectors wroteBased on observation, record review, and resident, staff and Medical Director interviews, the facility failed to provide humidified oxygen (oxygen that has been moistened with water vapor) as ordered by the physician for 1 of 1 resident reviewed for respiratory care (Resident #20)

Inspectors wrote2. Resident #19 was admitted to the facility on [DATE] with diagnoses including late onset Alzheimer's disease and dementia. The quarterly Minimum Data Set (MDS) dated [DATE] noted Resident #19 had moderate cognitive impairment. On 03/03/25 at 12:14 PM Resident #19 was observed to have a tube of antibiotic/pain reliever ointment on her bedside table. Resident #19 stated I put it on my forehead, but reported she did not remember why she was using it. When asked, she said she did not remember where she got the ointment. During an observation of Resident #19's room on 03/04/25 at 8:10 AM the tube of antibiotic/pain reliever ointment remained on her bedside table. During an interview with Nurse #1 on 3/4/25 at 2:06 PM, she reported that she was not aware of any medication on Resident #19's bedside table. [...]

Inspectors wroteBased on observations and staff interviews, the facility failed to post a list of names, addresses (mailing and email), and telephone numbers of all pertinent State agencies and advocacy groups, such as the State Survey Agency, the State licensure office, adult protective services where state law provides for jurisdiction in long-term care facilities, the Office of the State Long-Term Care Ombudsman program, the protection and advocacy network, home and community based service programs, and the Medicaid Fraud Control Unit for 4 of 4 days of the recertification survey.

Inspectors wroteBased on record review, staff, and Medical Director interviews the facility failed to provide care in a safe manner to prevent a resident from rolling out of bed during incontinent care for 1 of 6 residents reviewed for accidents (Resident #344) . During incontinence care Resident #344 was rolled onto her side by staff and then rolled out of the bed onto the floor. She was admitted to the hospital for five days due to worsening atrial fibrillation with rapid ventricular response (very fast heartbeat) caused by significant sympathetic response (the body's response to stress) from pain from the fall.

Inspectors wroteBased on observations, resident, and staff interviews the facility failed to provide a clean homelike environment for 1 of 6 units (Unit 600). The facility failed to repair a missing lower closet door and failed to repair a upper closet door, failed to repair missing and cracked dry wall at the base of the air conditioning unit that daylight could be seen through and had the potential to allow small rodents into the facility (room [ROOM NUMBER]), failed to clean a privacy curtain that was noted to have a white outline of hand print and a brown stain that was approximately 3 centimeters by 5 centimeters, failed to repair chipped and missing dry wall near the bathroom, failed to clean the brown ring of dirt and grim around the base of the toilet (room [ROOM NUMBER]), and failed to clean and repair the floor at the bathroom room threshold (room [ROOM NUMBER]), and failed to secure [...]

Inspectors wroteBased on observations, record review and staff interviews, the facility failed to secure a urinary catheter tubing to prevent tension or trauma and failed to prevent the catheter bag and tubing from touching the floor to reduce the risk of infection for 1 of 2 residents reviewed for urinary catheters (Resident #66).

Inspectors wroteBased on observations, record reviews and staff and resident interviews the facility failed to administer supplemental oxygen as prescribed by the physician for 2 of 3 residents reviewed for respiratory care (Resident #4 and #10) and failed to ensure oxygen concentrator filters were clean for 2 of 3 residents ( Resident #10 and Resident #69) reviewed for respiratory care.

Inspectors wroteBased on record reviews and staff interviews the facility failed to have a system for disposition and an accurate reconciliation of controlled medications for 1 of 1 resident (Resident #24) reviewed for pharmacy services.

Inspectors wroteBased on observations, record review, staff, and Medical Director interviews the facility failed to ensure they had a medication error rate less than 5 % by having 2 errors out of 32 opportunities resulting in a 6.25% medication error rate for 1 of 3 residents observed during medication pass (Resident #97).

Inspectors wroteBased on observations, record reviews and staff and resident interviews, the facility failed to secure medicated creams that were stored at bedside for 2 of 2 residents (Resident #8 and Resident #66) reviewed for medication storage.

Inspectors wroteBased on record review, observations, staff and resident interviews, and test tray, the facility failed to provide palatable food to a resident that was appetizing in temperature for 1 of 3 residents reviewed for food palatability. (Resident #29)

Inspectors wroteBased on observations, record reviews, resident, and staff interviews, the facility's Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and monitor interventions the committee put into place following the recertification and complaint survey conducted on 05/05/22 and for the complaint investigation conducted on 09/14/23. This failure was for three deficiencies that were originally cited in the areas of Resident Rights (F584), Quality of Care (F689), and Dietary Services (F804) that were subsequently recited on the current recertification and complaint investigation survey of 01/11/24. The repeat deficiencies during three federal surveys of record showed a pattern of the facility's inability to sustain an effective QA program.

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to implement their policy for Personal Protective Equipment (PPE) when Nurse #4 failed to don protective eyewear (goggles or face shield) before entering 1 of 4 resident's room with signage for transmission-based precautions (Resident #85).

Inspectors wroteBased on record review and staff interviews, the facility failed to accurately code Minimum Data Set assessments when they failed to document a gradual dose reduction for an antipsychotic medication and documented the use of an ostomy for a resident without an ostomy, for 4 of 23 residents reviewed. (Resident's #35 and Resident #50)

Inspectors wroteBased on observations, record reviews and resident, staff, and Medical Director (MD) interviews the facility Transport Driver failed to ensure the lift gate (a mechanical platform designed to raise and lower to allow an individual with a wheelchair to enter and exit a vehicle) was in the elevated position before unloading a resident from the back of the facility van. On 08/11/23 Resident #1 was rolled out of the back of the transportation van in her wheelchair and fell approximately 2.5 feet to the ground landing on her right side and hitting the back of her head. The Resident complained of mid back pain and right rib pain at 9 out of 10 (10 being the worst pain imaginable) and pain in her head at a 7 out of 10. Resident #1 was sent to the emergency department for evaluation and diagnosed with right 4th and 5th nondisplaced rib fractures. [...]