Cycle 1
Health 2025-03-20 · Fire 2025-03-20
6 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Bermuda Run, NC
Bermuda Village Retirement Center
3-star overall rating with 3-star inspections with $12,184 in total fines with 6 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
142 Bermuda Village Drive, Bermuda Run, NC
(336) 998-6112
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
36
Certified beds
Average residents
35
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1992-03-10
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.26
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
1.35
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
3.01
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
4.61
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
1.61
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
4.52
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.26
Weekend registered nurse coverage · state 0.38 · national 0.47
Physical therapist
0.13
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.28
CMS adjusted RN staffing hours
Adjusted total hours
4.93
CMS adjusted total nurse staffing hours
Case-mix index
1.28
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
1,119
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
59.67
Composite VBP score used to determine payment impact.
Payment multiplier
1.0149
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
7
Baseline 23.02% · Performance 18.53% · Measure score 7 · Achievement 6.26 · Improvement 7
Healthcare-associated infections
8.85
Baseline 7.19% · Performance 5.19% · Measure score 8.85 · Achievement 8.85 · Improvement 8.61
Total nurse turnover
0
Performance 76.19% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
8.02
Baseline 4.81 hours · Performance 5.36 hours · Measure score 8.02 · Achievement 8.02 · Improvement 5.19
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.07% |
10.72%
0.7 pts better
|
No Different than the National Rate · Eligible stays 148 · Observed rate 8.78% · Lower 95% interval 7.48% |
| Discharge to community | 68.87% |
50.57%
18.3 pts better
|
Better than the National Rate · Eligible stays 149 · Observed rate 63.09% · Lower 95% interval 57.1% |
| Medicare spending per beneficiary | 0.88 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 120 · Denominator 120 |
| Falls with major injury | 2.5% |
0.77%
1.7 pts worse
|
Numerator 3 · Denominator 120 |
| Discharge self-care score | 38% |
53.69%
15.7 pts worse
|
Numerator 38 · Denominator 100 |
| Discharge mobility score | 41% |
50.94%
9.9 pts worse
|
Numerator 41 · Denominator 100 |
| Pressure ulcers or injuries, new or worsened | 3.33% |
2.29%
1 pts worse
|
Numerator 4 · Denominator 120 · Adjusted rate 3.39% |
| Healthcare-associated infections requiring hospitalization | 5.19% |
7.12%
1.9 pts better
|
No Different than the National Rate · Eligible stays 86 · Observed rate 1.16% · Lower 95% interval 2.68% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 57 |
| Staff flu vaccination coverage | 4.55% |
42%
37.5 pts worse
|
Numerator 2 · Denominator 44 |
| Discharge function score | 47% |
56.45%
9.5 pts worse
|
Numerator 47 · Denominator 100 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 23 · Denominator 23 |
| Transfer of health information to patient | 98.68% |
96.28%
2.4 pts better
|
Numerator 75 · Denominator 76 |
| Resident COVID-19 vaccinations up to date | 20.29% |
25.2%
4.9 pts worse
|
Numerator 14 · Denominator 69 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
91.5%
8.5 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.3% |
3.6%
2.3 pts better
|
3.3%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 0.0% · Q4 0.0% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
4.8%
4.8 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 6.5% |
7.2%
0.7 pts better
|
5.4%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 6.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 10.2% |
21.6%
11.4 pts better
|
19.6%
9.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 10.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 7.0% |
15.0%
8 pts better
|
16.7%
9.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 7.0% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.0% |
16.8%
3.8 pts better
|
14.9%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 13.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 11.7% |
0.9%
10.8 pts worse
|
1.0%
10.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q3 15.1% · Q4 13.0% · 4Q avg 11.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
2.6%
2.6 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.4% |
21.2%
3.2 pts worse
|
19.8%
4.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q4 26.2% · 4Q avg 24.4% |
| Percentage of long-stay residents with pressure ulcers | 2.0% |
6.0%
4 pts better
|
5.1%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 3.4% · Q4 0.0% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.0% |
79.9%
19.1 pts better
|
81.7%
17.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.2% · Q2 99.1% · Q3 98.9% · Q4 98.6% · 4Q avg 99.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 3.3% |
13.2%
9.9 pts better
|
12.0%
8.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 3.3% · Observed 3.0% · Expected 10.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.4% |
1.5%
1.1 pts better
|
1.6%
1.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 82.4% |
78.1%
4.3 pts better
|
79.7%
2.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 82.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 28.9% |
22.9%
6 pts worse
|
23.9%
5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 28.9% · Observed 26.3% · Expected 21.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-15 · Fire 2023-12-15
9 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2022-06-09 · Fire 2022-06-09
5 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
8 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-03-20
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-04-25
D · Potential for more than minimal harm
2025-03-20
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-04-25
D · Potential for more than minimal harm
2023-12-15
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-02-01
D · Potential for more than minimal harm
2023-12-15
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2024-02-01
D · Potential for more than minimal harm
2023-12-15
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-02-01
F · Potential for more than minimal harm
2022-06-09
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2022-07-07
E · Potential for more than minimal harm
2022-06-09
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-08-17
D · Potential for more than minimal harm
2022-06-09
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2022-08-17
D · Potential for more than minimal harm
2022-06-09
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-08-17
D · Potential for more than minimal harm
2022-06-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-08-17
D · Potential for more than minimal harm
2022-06-09
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-08-17
D · Potential for more than minimal harm
2022-06-09
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2022-08-17
D · Potential for more than minimal harm
2022-06-09
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-08-17
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-03-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-22
E · Potential for more than minimal harm
2025-03-20
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-04-22
D · Potential for more than minimal harm
2025-03-20
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2025-04-22
D · Potential for more than minimal harm
2025-03-20
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2025-04-22
D · Potential for more than minimal harm
2025-03-20
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-04-22
D · Potential for more than minimal harm
2025-03-20
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-04-22
F · Potential for more than minimal harm
2023-12-15
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-01-12
F · Potential for more than minimal harm
2023-12-15
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-01-12
D · Potential for more than minimal harm
2023-12-15
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-01-12
D · Potential for more than minimal harm
2023-12-15
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2024-01-12
D · Potential for more than minimal harm
2023-12-15
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-01-12
D · Potential for more than minimal harm
2023-12-15
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2024-01-12
D · Potential for more than minimal harm
2023-12-15
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-01-12
C · Minimal harm
2023-12-15
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-01-12
B · Minimal harm
2023-12-15
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-01-12
F · Potential for more than minimal harm
2022-06-09
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-07-07
F · Potential for more than minimal harm
2022-06-09
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2022-07-07
F · Potential for more than minimal harm
2022-06-09
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2022-07-07
E · Potential for more than minimal harm
2022-06-09
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2022-07-07
B · Minimal harm
2022-06-09
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2022-07-07
Penalties and ownership
What sits behind the stars
$7,976
2024-01-22
Fine
Fine · fine $7,976
Fine
$2,797
2023-06-12
Fine
Fine · fine $2,797
Fine
$1,411
2023-05-15
Fine
Fine · fine $1,411
Fine
Ownership
Montage Living
5% Or Greater Direct Ownership Interest · Organization
Angell, Don
W-2 Managing Employee · Individual
Haynes, Larry
W-2 Managing Employee · Individual
Lambert, Ryan
Corporate Officer · Individual
Little, David
Operational/Managerial Control · Individual
Paugh, Emma
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Bermuda Commons Nursing and Rehabilitation Center
Advance, NC
1-star overall rating with 2-star inspections with $28,043 in total fines with 9 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
#2
Trinity Elms
Clemmons, NC
2-star overall rating with 3-star inspections with $15,646 in total fines with 5 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Cedar Hills Center for Nursing and Rehabilitation
Clemmons, NC
1-star overall rating with 2-star inspections with $70,269 in total fines with 12 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
Jump out