Bermuda Commons Nursing and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Bermuda Commons Nursing and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Sep 14, 2023

  Based 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. […]

• Actual harm, isolatedF689Jan 11, 2024

  Based 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. The findings included: Resident #344 was admitted to the facility on [DATE] and expired in the facility on [DATE]. […]

• No harm, potential for more than minimal, patternF812Mar 6, 2025

  Based 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). The findings included: An observation was made on [DATE] at 2:33 PM of the nourishment room on the 300 Hall. The observation revealed that there were 17 individual nutritional supplement drink cartons with a use by date of [DATE] available for use located on a lower shelf in the nourishment room. An observation was made on [DATE] at 2:44 PM of the nourishment room on the 500 Hall. The observation revealed that there were 121 individual nutritional supplement drinks with a use by date of [DATE] available for use located on a lower shelf in the nourishment room. […]

• No harm, potential for more than minimal, patternF883Mar 6, 2025

  Based 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. The findings included: a. Resident #98 was admitted to the facility on [DATE]. The resident's immunization record was reviewed and revealed that staff answered no under the education provided tab for influenza vaccine administered by Nurse #7 on 10/03/24 and for pneumonia vaccine administered by Nurse #7 on 10/18/24. […]

• No harm, potential for more than minimal, patternF887Mar 6, 2025

  Based 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). The findings included: a. Resident #43 was admitted to the facility on [DATE]. The Resident's immunization record was reviewed and revealed that staff answered no under the education provided tab for COVID-19 vaccine administered by Nurse #7 on 11/06/24. The immunization record review also revealed that nothing was documented under the education notes section on the immunization record for this dose. b. […]