Pembroke Pines, FL

Glades West Rehabilitation And Nursing C

5-star overall rating with 4-star inspections with 3 recent health deficiencies

15955 Bass Creek Road, Pembroke Pines, FL

(954) 437-3422

Compare this facility

Overall

5 / 5

CMS overall stars

Health inspections

4 / 5

Survey and complaint cycles

Staffing

4 / 5

RN + nurse staffing

Quality measures

5 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

120

Certified beds

Average residents

112

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

No chain reported

Operator or chain grouping

Approved since

2015-09-29

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Changed ownership

No

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

1.20

Registered nurse staffing · state 0.73 · national 0.68

LPN hours / resident day

0.50

Licensed practical nurse staffing · state 0.79 · national 0.87

Aide hours / resident day

2.27

Nurse aide staffing · state 2.34 · national 2.35

Total nurse hours

3.98

All reported nurse hours · state 3.86 · national 3.89

Licensed hours

1.70

RN + LPN hours · state 1.52 · national 1.54

Weekend hours

3.57

Weekend nurse staffing · state 3.51 · national 3.43

Weekend RN hours

0.76

Weekend registered nurse coverage · state 0.53 · national 0.47

Physical therapist

0.12

Reported PT staffing · state 0.10 · national 0.07

Adjusted RN hours

1.09

CMS adjusted RN staffing hours

Adjusted total hours

3.60

CMS adjusted total nurse staffing hours

Case-mix index

1.51

Higher values indicate more complex resident acuity

RN turnover

28%

Annual RN turnover · state 46% · national 45%

Total nurse turnover

23%

Annual nurse turnover · state 42% · national 46%

SNF VBP

Value-based purchasing

Program rank

6,397

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

33.04

Composite VBP score used to determine payment impact.

Payment multiplier

0.9875

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

0

Baseline 24.22% · Performance 24.42% · Measure score 0 · Achievement 0 · Improvement 0

Healthcare-associated infections

2.81

Baseline 9.74% · Performance 8.17% · Measure score 2.81 · Achievement 0 · Improvement 2.81

Total nurse turnover

8.87

Baseline 39.20% · Performance 27.42% · Measure score 8.87 · Achievement 8.87 · Improvement 7.71

Adjusted total nurse staffing

1.54

Baseline 3.73 hours · Performance 3.52 hours · Measure score 1.54 · Achievement 1.54 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	9.38%	10.72% 1.3 pts better	No Different than the National Rate · Eligible stays 480 · Observed rate 8.75% · Lower 95% interval 7.04%
Discharge to community	59.55%	50.57% 9 pts better	Better than the National Rate · Eligible stays 488 · Observed rate 51.43% · Lower 95% interval 54.13%
Medicare spending per beneficiary	1.35	1.02 0.3 pts worse
Drug regimen review with follow-up	99.54%	95.27% 4.3 pts better	Numerator 431 · Denominator 433
Falls with major injury	0.46%	0.77% 0.3 pts better	Numerator 2 · Denominator 433
Discharge self-care score	52.44%	53.69% 1.2 pts worse	Numerator 118 · Denominator 225
Discharge mobility score	35.56%	50.94% 15.4 pts worse	Numerator 80 · Denominator 225
Pressure ulcers or injuries, new or worsened	0.46%	2.29% 1.8 pts better	Numerator 2 · Denominator 433 · Adjusted rate 0.36%
Healthcare-associated infections requiring hospitalization	8.17%	7.12% 1 pts worse	No Different than the National Rate · Eligible stays 322 · Observed rate 9.01% · Lower 95% interval 6.06%
Staff COVID-19 vaccination coverage	3.16%	8.2% 5 pts worse	Numerator 8 · Denominator 253
Staff flu vaccination coverage	20.57%	42% 21.4 pts worse	Numerator 58 · Denominator 282
Discharge function score	54.22%	56.45% 2.2 pts worse	Numerator 122 · Denominator 225
Transfer of health information to provider	99.18%	95.95% 3.2 pts better	Numerator 241 · Denominator 243
Transfer of health information to patient	98.59%	96.28% 2.3 pts better	Numerator 140 · Denominator 142
Resident COVID-19 vaccinations up to date	16.52%	25.2% 8.7 pts worse	Numerator 37 · Denominator 224

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	2.2	2.1 0.1 pts worse	1.9 0.3 pts worse	Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 2.5 · Expected 2.2 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	0.9	1.2 0.3 pts better	1.8 0.9 pts better	Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.9 · Expected 1.6 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	100.0%	97.8% 2.2 pts better	93.4% 6.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	100.0%	99.2% 0.8 pts better	95.5% 4.5 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0%
Percentage of long-stay residents experiencing one or more falls with major injury	3.1%	2.6% 0.5 pts worse	3.3% 0.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 2.9% · Q3 4.0% · Q4 4.0% · 4Q avg 3.1% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	24.8%	3.7% 21.1 pts worse	11.4% 13.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 11.9% · Q2 27.4% · Q3 27.3% · Q4 31.3% · 4Q avg 24.8%
Percentage of long-stay residents who lose too much weight	6.9%	5.9% 1 pts worse	5.4% 1.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 1.8% · Q3 10.9% · Q4 12.3% · 4Q avg 6.9%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	8.4%	15.7% 7.3 pts better	19.6% 11.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 8.1% · Q3 5.9% · Q4 8.7% · 4Q avg 8.4%
Percentage of long-stay residents who received an antipsychotic medication	6.7%	9.8% 3.1 pts better	16.7% 10 pts better	Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 10.4% · Q3 6.0% · Q4 7.0% · 4Q avg 6.7% · 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened	1.3%	11.7% 10.4 pts better	16.3% 15 pts better	Long Stay · 2024Q4-2025Q3 · Q1 5.2% · Q3 0.0% · Q4 0.0% · 4Q avg 1.3% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	4.5%	9.8% 5.3 pts better	14.9% 10.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 7.4% · Q3 5.1% · Q4 1.8% · 4Q avg 4.5% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.4%	0.4% About the same	1.0% 0.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.6% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.0%	0.8% 0.8 pts better	1.7% 1.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · 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	1.3%	12.5% 11.2 pts better	19.8% 18.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 3.5% · Q2 0.0% · Q3 0.0% · Q4 1.6% · 4Q avg 1.3%
Percentage of long-stay residents with pressure ulcers	4.4%	5.1% 0.7 pts better	5.1% 0.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 6.3% · Q3 6.2% · Q4 4.2% · 4Q avg 4.4% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	97.5%	94.3% 3.2 pts better	81.7% 15.8 pts better	Short Stay · 2024Q4-2025Q3 · Q1 96.0% · Q2 96.7% · Q3 98.7% · Q4 98.6% · 4Q avg 97.5%
Percentage of short-stay residents who had an outpatient emergency department visit	4.8%	9.3% 4.5 pts better	12.0% 7.2 pts better	Short Stay · 20240701-20250630 · Adjusted 4.8% · Observed 4.9% · Expected 11.4% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	1.4%	1.5% 0.1 pts better	1.6% 0.2 pts better	Short Stay · 2024Q4-2025Q3 · Q1 0.7% · Q2 2.0% · Q3 2.1% · Q4 0.7% · 4Q avg 1.4% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	99.2%	94.7% 4.5 pts better	79.7% 19.5 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 99.2%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	31.7%	26.2% 5.5 pts worse	23.9% 7.8 pts worse	Short Stay · 20240701-20250630 · Adjusted 31.7% · Observed 34.5% · Expected 25.9% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-12-18 · Fire 2025-12-18

3 health deficiencies

Top issue: Quality of Life and Care (2 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Cycle 2 Health 2024-06-20 · Fire 2024-06-20

1 health deficiencies

Top issue: Quality of Life and Care (1 deficiency)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Cycle 3 Health 2023-04-06 · Fire 2023-04-06

1 health deficiencies

Top issue: Pharmacy Service (1 deficiency)

1 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)

Fire safety

Fire-safety citations

D · Potential for more than minimal harm 2023-04-06

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2023-05-04

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-12-18

F677 · Quality of Life and Care Deficiencies

Health

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected 2026-01-23

D · Potential for more than minimal harm 2025-12-18

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2026-01-23

D · Potential for more than minimal harm 2025-12-18

F759 · Pharmacy Service Deficiencies

Health

Ensure medication error rates are not 5 percent or greater.

Corrected 2026-01-23

D · Potential for more than minimal harm 2024-06-20

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2024-07-20

D · Potential for more than minimal harm 2023-04-06

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 2023-05-06

Penalties and ownership