Inspection visit
Inspection
2 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 2 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
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.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4) Resident
#67 was re-admitted to the facility on [DATE] with diagnoses which included Cerebral Infarction, Diabetes
Mellitus Type II, Atherosclerotic Heart Disease and Peripheral Vascular Disease. He had a Brief Interview
Mental Status (BIM) score of 13 (cognitively intact).
During an observational screening tour conducted on 04/03/23 at 11:30 AM it was noted on the bedside
table of Resident #67 that there was a plastic tube container of over-the-counter (OTC) Vicks Vapor inhaler
nasal decongestant main active ingredient Levmetamfetamine (l-Desoxyephedrine) 50 mg; with no
expiration date. (Photographic evidence was obtained).
On 04/03/23 at 11:32 AM, during a brief interview with the resident, he stated that the Vicks Vapor inhaler
was his, brought from home and added that he uses it whenever he has a stuffy nose.
On 04/03/23 at 3:50 PM, during a second observational tour, it was still noted on the bedside table of
Resident #67, that there was a plastic tube container of OTC Vicks Vapor inhaler nasal decongestant.
04/04/23 at 1:57 PM, during a third observational tour, it was still noted on the bedside table of Resident
#67, that there was a plastic tube container of OTC Vicks Vapor inhaler nasal decongestant.
04/05/23 10:48 AM, during a fourth observational tour, it was still noted on the bedside table of Resident
#67, that there was a plastic tube container of OTC Vicks Vapor inhaler nasal decongestant.
An interview was conducted with Staff B, a Licensed Practical Nurse (LPN), on 04/05/23 at 10:55 AM,
regarding the plastic tube container of OTC Vicks Vapor inhaler nasal decongestant. She acknowledged
that the medication should not have been there and should have been properly secured.
An interview was conducted with Staff A, a Registered Nurse (RN), Unit Manager for the 2nd and 3rd floor),
on 04/05/23 at 10:59 AM regarding the plastic tube container of OTC Vicks Vapor inhaler nasal
decongestant. She further acknowledged that the medication should not have been there and should have
been properly secured.
The plastic tube container of OTC Vicks Vapor inhaler nasal decongestant was not removed, until after
surveyor inquisition/intervention.
There was no assessment performed for this resident to ensure that he was able to safely and
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 3
Event ID:
106106
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
106106
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/06/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Glades West Rehabilitation and Nursing C
15955 Bass Creek Road
Pembroke Pines, FL 33027
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
responsibly administer his own medication at the bedside; the facility administers the medications for him,
per Staff A, a Registered Nurse (RN)/Unit Manager (UM) for the 2nd and 3rd floor.
The Director of Nursing (DON) further acknowledged and recognized that Resident #67's, unattended and
unsecured medication should not have been left at his bedside and should have been properly secured;
this was not done.
Based on observations, interviews and record review, the facility failed to store medications in a safe and
secure manner for 4 out of 21 sampled residents reviewed for medications at the bedside (Resident #60,
#62, #24, #67).
The findings included:
Review of the facility's policy titled, Storage of Medications included: The facility shall store all drugs and
biologicals in a safe, secure, and orderly manner. The nursing staff shall be responsible for maintaining
medication storage and preparation areas in a clean, safe, and sanitary manner. Drugs shall be stored in
an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. Each resident's
medications shall be assigned to an individual cubicle, drawer, or other holding area to prevent the
possibility of mixing medications of several residents.
1. During an observation conducted on 04/03/23 at 11:30 AM in Resident #60's room there were
medications on the resident's overbed table that included TKO 8 infused tincture 300 mg with an expiration
date of 12/2022, Venelex wound ointment (no expiration date), Systane Lubricant eye drops with an
expiration date of 07/2024, and Melatonin 10mg with an expiration date of 06/2024 (Photographic Evidence
Obtained).
During an interview conducted on 04/03/23 at 11:35 AM with Resident #60 when asked about the
medications on her overbed table, she stated the ointment is not hers, she found it in one of the nightstand
drawers. She stated the eye drops are for dry eyes. She said the TKO 8 infused tincture and the Melatonin
help her sleep. She stated she was prescribed the Melatonin but told staff she did not want to take it every
night (because it can be addictive) and the staff had the Melatonin discontinued, so her daughter brought
the Melatonin in for her.
During second observation conducted on 04/04/23 at 10:10 AM in the room for Resident #60, on the
overbed table next to the resident was included TKO 8 infused tincture 300 mg with an expiration date of
12/2022, and Systane Lubricant eye drops.
During an interview conducted on 04/04/23 at 10:15 AM with Staff A, Registered Nurse (RN), she
acknowledged that there were medications of TKO 8 infused tincture 300 mg with an expiration date of
12/2022, and Systane Lubricant eye drops at the bedside. When asked if Resident #60 had been assessed
for self-administration of medications, she said no. She immediately took the medications and stated that no
resident is to have medications unlocked at the bedside.
2. During an observation on 04/04/23 at 7:45 AM Resident #62 was resting in bed, upon closer observation
there were 2 bottles of Cystex UTI (Urinary Tract Infection) Prebiotic cranberry liquid on the resident's
overbed table.
During an interview conducted on 04/04/23 at 10:25 AM with Resident #62, when asked what had
happened to her 2 bottles of Cystex UTI Prebiotic cranberry liquid that were on her overbed table, she
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106106
If continuation sheet
Page 2 of 3
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
106106
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/06/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Glades West Rehabilitation and Nursing C
15955 Bass Creek Road
Pembroke Pines, FL 33027
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0761
stated she had no idea, she knows the nurses have given her cranberry medication in the past.
Level of Harm - Minimal harm
or potential for actual harm
During an interview conducted on 04/04/23 at 10:27 AM with Staff A, Registered Nurse (RN), she stated
that Resident #62 had not been assessed to self-administer medications and she should not have had any
medications unlocked at the bedside.
Residents Affected - Few
3) During the initial meal observation conducted on 04/03/23 12:10 PM, the surveyor noted that Resident
#24 had an open bottle of Tums Calcium Chews and an open jar of Vicks Vaporub ointment on her bedside
table. The surveyor asked Resident #24 if these were her medications. Resident #24 said yes, I get heart
burn when I eat.
Record review revealed a Medicare 5-Day Minimum Data Set (MDS) assessment was done on 01/25/23.
This MDS documented Resident #24 had a Brief Interview of Mental Status (BIMS) score of 15, which
indicates she was cognitively intact.
Review of Resident #24's Physician Orders revealed an order was written on 04/04/23 at 11:57 AM by the
facility's Director of Nursing (DON) for Calcium Carbonate 500 mg give 1 tablet by mouth after meals and at
bedtime for prophylaxis. Further review of the orders revealed there was no prior order for Calcium
Carbonate.
Review of Resident #24's medical record revealed there was no assessment documented or Care Plan in
place regarding Resident #24 being safe to self-administer medications.
Further record review revealed an Order Note was written by the facility's DON on 04/04/23 at 12:00 PM
which states, Resident and daughter educated on OTC [sic: over the counter] medications being available
upon request to MD [sic: doctor] for nursing staff to administer to resident as needed or scheduled
depending on resident needs and MD order, daughter and resident verbalized understanding.
An interview was conducted with the facility's DON on 04/04/23 at 6:15 PM regarding the note written
earlier that day. The DON stated she observed the Tums bottle when she entered Resident #24's room that
day to collect her lunch tray. She said she immediately called Resident #24's daughter and explained to
both that residents cannot keep medications in their rooms without the staff's knowledge.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106106
If continuation sheet
Page 3 of 3
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Back to topCitations
2 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F761 - Labeling of Drugs and Biologicals
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.
F918 - Bathroom Facilities
Have generator or other power source capable of supplying service within 10 seconds.
FAQ · About this visit
Common questions about this visit
What happened during the April 6, 2023 survey of GLADES WEST REHABILITATION AND NURSING C?
This was a inspection survey of GLADES WEST REHABILITATION AND NURSING C on April 6, 2023. The surveyor cited 2 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at GLADES WEST REHABILITATION AND NURSING C on April 6, 2023?
Yes, 2 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional princip..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.