Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
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 Glades West Rehabilitation And Nursing C during CMS and state inspections, most recent first.
Failure to respond promptly to call lights and provide timely ADL care led to residents waiting extended periods after bowel movements or while soiled. A resident with COPD and dysphagia was observed calling for help while multiple staff walked by, and a CNA did not arrive to change her for about 40 minutes. Another resident with a tibia fracture said she had waited hours to be changed, and a third resident with a leg fracture and chronic AF reported sitting in a dirty brief for over an hour after her colonic drainage fell out. Staff and the DON stated residents should be assisted right away and that 30-minute waits are not acceptable.
A resident receiving continuous oxygen was observed multiple times on oxygen without a current physician order on file, despite staff confirming the therapy was being used and the resident’s chart lacking oxygen parameters in the POS, MAR, and TAR. In a separate issue, a resident with a nebulizer order for weekly tubing and mouthpiece replacement was found with the mouthpiece not stored in a plastic bag and tubing dates that did not match staff documentation, with staff giving inconsistent accounts of the change schedule and documentation process.
Medication administration errors occurred for two residents, resulting in a 12.9% error rate. An RN on her first day working independently gave Sucralfate after breakfast instead of before meals for one resident, and for another resident she documented morning meds as given even though eye drops, Calcium 600+D3, and Aspirin were not administered. The DON stated the RN had just finished orientation and should not have been administering meds on her own.
A resident with a history of cerebral infarction and other conditions sustained a skin tear during a fall, but the facility failed to obtain physician orders and perform dressing changes according to standards. Observations showed the dressing was unchanged for days, and staff did not follow proper hand hygiene. The facility's protocol for skin tear care was not initiated, and key staff were unaware of the injury.
Failure to Respond Promptly to Call Lights and Provide Timely ADL Care
Penalty
Summary
The facility failed to respond to call lights and provide timely ADL care for residents who were unable to complete toileting and hygiene needs on their own. The facility policy titled Call Bell Policy stated that staff should determine the resident's need, find a nurse or CNA who can assist if they cannot perform the task, not walk by, and ensure the call bell is turned off once needs are attended to. Surveyors observed multiple staff members pass by a room without responding to an audible call light while a resident with moderate cognitive impairment and a right knee immobilizer was trying to use the bathroom and repeatedly asked for help to be changed after a bowel movement. Resident #70, who had diagnoses including dysphagia following cerebrovascular disease and COPD, was observed lying in bed and then calling for assistance after stating she needed a bowel movement. The call light was audible at the nurse's station and visible in the hallway, but multiple staff members passed by without responding. A nurse said she would call a CNA because she was not a CNA, and the resident continued calling out in distress. The RN supervisor stated the assigned CNA was busy with another resident and was trying to find another CNA, and the DON later entered the room. A CNA did not arrive to change the resident until about 40 minutes after the need was identified. Resident #110, who had a left tibia fracture and no cognitive impairment, stated that aides took a long time to provide ADL care and that she had been waiting since 8:00 AM to be changed at 12:50 PM, saying she felt uncomfortable and dirty. Resident #99, who had a displaced trimalleolar fracture of the right lower leg and chronic atrial fibrillation with moderate cognitive impairment, stated that her colonic drainage fell out and she had been sitting in a dirty brief for over an hour while waiting to be changed. The DON and staff interviews confirmed that residents should be cleaned as soon as possible after a bowel movement, that waiting 30 minutes is not acceptable, and that call lights should be answered right away, yet the residents described prolonged waits for assistance.
Respiratory Care Orders Not Followed
Penalty
Summary
Failure to provide safe and appropriate respiratory care was identified for a resident receiving continuous oxygen therapy. The resident was re-admitted with diagnoses including respiratory failure, COPD, diabetes mellitus type II, and dementia, and had a BIM score of 9 indicating moderate cognitive impairment. During multiple room observations, the resident was seen receiving oxygen at 3 liters per minute via nasal cannula through an oxygen concentrator, but no current physician’s order for oxygen administration was in place at the time of those observations. Record review showed the resident’s respiratory care plan included interventions for oxygen as ordered, but the initial physician’s order sheet only documented monitoring vital signs and oxygen saturation daily and reporting abnormalities as necessary. A physician pulmonary progress note documented continuous oxygen and to keep oxygen saturations above 92%, but the December physician’s order sheet, MAR, and TAR did not contain current physician’s orders for oxygen therapy parameters after the resident’s re-admission. Staff interviews confirmed the resident was receiving oxygen at 3 liters, but staff were unable to explain why no current physician order was on file. A current order for continuous oxygen at 2 liters per minute via nasal cannula every shift was written only after surveyor inquiry. A second deficiency involved failure to follow physician’s orders for nebulizer tubing changes. A resident with diagnoses including acute and chronic respiratory failure with hypercapnia, dementia, adult failure to thrive, and sepsis had an order to replace nebulizer tubing and mouthpiece weekly every Sunday for prophylaxis. During observation, the resident’s nebulizer mouthpiece was found lying on the bedside table rather than stored in a plastic bag, and the nebulizer tubing was dated 12/01/25. Later observation showed the mouthpiece placed in a plastic bag in the bedside table drawer and the tubing changed and dated 12/15/25. The TAR documented tubing changes on 12/07/25 and 12/14/25, while staff interviews reflected differing understanding of when tubing should be changed and how it should be documented.
Medication Administration Errors
Penalty
Summary
The facility failed to ensure residents were free of medication errors for 2 of 8 sampled residents, resulting in a medication error rate of 12.9% from 4 errors during 31 opportunities. The facility policy required medications to be administered safely, as prescribed, within one hour of the ordered time unless otherwise specified, and the nurse administering medications was to verify the right resident, medication, dose, time, and route before administration. Staff E, an RN on her first day working on her own after orientation, was observed administering medications without completing the required checks and without being mentored as planned. For one resident with COPD, HTN, esophageal diverticulum, and GERD, Staff E administered Sucralfate after the resident had already finished breakfast, even though the order required it before meals. For another resident with diagnoses including pelvic fractures, Parkinsonism, HTN, and atrial fibrillation, Staff E administered morning medications and documented that all scheduled medications were given, but observation and order review showed that Carboxymethylcellulose eye drops, Calcium 600+D3, and Aspirin were not actually administered. During interview, Staff E stated she reviewed orders on the computer and medication bingo sheet and did not realize the Sucralfate had to be given before breakfast. The DON stated Staff E had just finished orientation, had not yet done medication pass with her, and should not have been administering medications on her own.
Failure to Obtain Physician Orders and Perform Dressing Change for Skin Tear
Penalty
Summary
The facility failed to obtain physician orders for a skin tear sustained by a resident during a fall and did not perform a dressing change according to professional standards. The resident, who had a history of cerebral infarction, memory deficit, pneumonia, and major depressive disorder, fell in their room and sustained a skin tear on the right elbow. Despite the incident being documented in a progress note, there was no evidence of a physician's order for the treatment of the skin tear, and the treatment administration record lacked documentation of care for the injury. Observations revealed that the dressing on the resident's right elbow was unchanged for several days, with the date on the dressing unreadable. Interviews with the resident and staff indicated a lack of awareness and communication regarding the dressing change. Staff A, a registered nurse, was observed performing a dressing change without following proper hand hygiene protocols, using the same pair of gloves throughout the procedure, and failing to perform hand hygiene before applying a new dressing. The facility's wound care nurse and director of nursing were not informed of the skin tear, and the facility's protocol for skin tear care was not initiated. Staff B, who initially treated the skin tear, did not activate the facility's skin tear protocol batch order and was unaware of the protocol. The director of nursing acknowledged the lack of communication and protocol adherence, which contributed to the deficiency in care for the resident's skin tear.
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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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How nearby facilities compare on the same public inspection record.
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| Villa Maria West Skilled Nursing Facility | 2.7 mi | ★★★★★ | 2 | 0 |
| Nspire Healthcare Miami Lakes | 3.2 mi | ★★★★★ | 7 | 0 |
| Palmetto Care Center And Rehab | 6.1 mi | ★★★★★ | 8 | 0 |
| Memorial Manor | 6.3 mi | ★★★★★ | 1 | 0 |
| Alexander "sandy" Nininger State Veterans Nursing | 7 mi | ★★★★★ | 0 | 0 |
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