Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Abbey Delray South during CMS and state inspections, most recent first.
The facility failed to maintain food safety and sanitary conditions, with staff not using facial hair restraints and improper food storage in the kitchen. A resident's perishable food was left unrefrigerated, contrary to facility policy. The resident, with cognitive communication deficit and Parkinsonism, had food items brought by relatives left on their overbed table without refrigeration.
The facility failed to maintain an effective system for timely MDS assessments, affecting all residents. The MDS Coordinator identified the issue and initiated a PIP, but assessments remained consistently late due to high turnover and workload in the Social Services Department. The Administrator was not fully aware of the PIP's progress, and communication among staff was insufficient, contributing to the ongoing deficiency.
The facility failed to implement fall prevention measures for two residents, leading to deficiencies in care. One resident, with a hip fracture and dementia, did not receive a post-fall assessment, and fall mats were inconsistently placed. Another resident, with severe cognitive impairment, had their bed left in a high position without staff presence, and personal items were out of reach. Staff interviews revealed misunderstandings of fall risk status, and the DON acknowledged the lapses in protocol adherence.
A resident with Dementia, Osteoporosis, and Hemiplegia was not provided with necessary dining assistance despite a physician's order and care plan indicating the need for such support. Observations showed the resident eating without staff help, leading to a reported weight loss. The resident expressed needing more help during meals, while a CNA believed minimal assistance was sufficient.
The facility failed to obtain a physician order and initiate a care plan for a resident with a urinary catheter, and did not secure the catheter for another resident, despite physician orders. The first resident had a urinary catheter without documented orders or a care plan, and staff were unclear about responsibilities. The second resident, with severe cognitive impairment and recurrent UTIs, had a catheter that was not secured as required, with staff acknowledging the absence of a leg strap.
A resident with cerebral infarction and dementia experienced significant weight loss due to the facility's failure to provide the recommended Ensure high-protein supplements. Instead, the resident received Ensure original, which did not meet the caloric and protein requirements. Staff interviews revealed issues with ordering and stocking the correct supplement, leading to the deficiency in meeting the resident's nutritional needs.
A resident with COPD and other health issues was observed using oxygen therapy without a physician's order, contrary to facility policy. The care plan mentioned oxygen use, but no formal order was documented, and the oxygen tubing lacked a date tag. The resident confirmed the oxygen was helpful, highlighting a deficiency in care management.
A facility failed to limit a resident's PRN psychotropic medication to 14 days, as required by regulations. The resident, diagnosed with bipolar disorder and major depressive disorder, had a physician's order for Lorazepam for 30 days, which was not addressed by the Consultant Pharmacist during a review. Interviews revealed that the facility did not adhere to its policy of reviewing PRN psychotropic medications exceeding 14 days with the prescribing physician.
The facility failed to monitor behaviors and side effects for two residents on psychotropic medications. One resident on Rexulti for bipolar disorder had no documented monitoring of side effects, while another on Escitalopram for depression lacked documented monitoring of depression symptoms. Staff interviews revealed inconsistencies in documentation and awareness of monitoring procedures.
A resident was found with unsecured medications at the bedside, contrary to facility policy requiring locked storage. The resident, with a history of myocardial infarction and tongue neoplasm, had not been evaluated for self-administration. Staff confirmed the policy breach, and the CNA removed the medication.
A resident with a history of tongue cancer and on nectar thickened liquids was found with regular ice water at their bedside, contrary to physician orders. The care plan lacked documentation for nutrition or hydration, and staff interviews revealed inconsistencies in providing thickened liquids. A nurse acknowledged the error and removed the water, while the Speech Therapist confirmed the resident's liquid consistency needs.
The facility failed to maintain effective infection control, as staff did not adhere to Enhanced Barrier Precautions (EBP) for three residents. A CNA did not wear a gown for wound care, a resident lacked EBP orders for a pressure ulcer, and an LPN administered medications without proper PPE. Staff misunderstandings and documentation oversights contributed to these deficiencies.
The facility failed to provide a homelike environment by not having pull cords on overbed lights for two residents. Observations confirmed the absence of pull cords in rooms 22-B and 28-B, which was acknowledged by the Maintenance Supervisor. The supervisor stated that each light should have a pull cord for residents to operate the lights independently.
A resident with multiple diagnoses, including arthritis and MRSA infection, experienced a deficiency in medication administration due to the facility's failure to process a physician's order for an increased dosage of Percocet. The MAR inaccurately reflected the administration of the higher dosage without a valid order, as staff did not follow through to ensure the prescription was received. The DON acknowledged the error after reviewing the records.
Food Safety and Storage Deficiencies in Facility
Penalty
Summary
The facility failed to adhere to professional standards for food service safety and sanitary conditions during two visits to the central kitchen. Observations revealed that staff members, including a dietary aide and a chef, did not wear facial hair restraints while in the food production area. Additionally, garbage bins in the food production area were uncovered and contained food debris. The walk-in refrigerator contained improperly labeled and stored food items, including raw fish, cooked shrimp, and raw ground meat with bloody drainage. Unlabeled and undated raw meat, as well as exposed raw chicken and pork, were also noted. The walk-in freezer had condensation above the food, with food boxes exposed. In the satellite kitchen, a dietary aide was observed wearing long earrings and handling prepared foods without changing gloves after using a sanitation bucket. The facility also failed to store a resident's food at the appropriate temperature. A resident with cognitive communication deficit and Parkinsonism had perishable food items brought by relatives left on their overbed table without being refrigerated. The food items, including cut-up mango, egg salad, and fish, were not labeled according to facility policy and had been left unrefrigerated over the weekend. A registered nurse acknowledged that the food should have been refrigerated and was likely no longer safe for consumption.
Deficiency in Timely MDS Assessments Due to Ineffective System
Penalty
Summary
The facility failed to maintain an effective system for obtaining and utilizing feedback from the Minimum Data Set (MDS) Department, which resulted in untimely completion of MDS assessments. This deficiency had the potential to affect all 70 residents in the facility. The facility's Quality Assurance and Performance Improvement (QAPI) program plan indicated that the Administrator, along with the QAPI Committee, was responsible for coordinating care and services, including the timely completion of MDS assessments. However, the facility's Performance Improvement Project (PIP) for late MDS assessments, initiated by the MDS Coordinator, showed that assessments were consistently late, with percentages ranging from 47.62% to 78% over several weeks. Interviews revealed that the MDS Coordinator identified the issue of late assessments in December 2024 and notified the Administrator, Director of Nursing (DON), and Regional MDS Director. Despite this, the problem persisted, and the Administrator was not fully aware of the PIP's effectiveness or its details. The Social Services Department was identified as a significant contributor to the delays due to high turnover and a high volume of admissions and discharges, compounded by having only one full-time social worker. The Administrator acknowledged the issue but was uncertain about the PIP's progress and had not reviewed it thoroughly. The QAPI Committee meetings included discussions about the late MDS assessments, but there was a lack of clear communication and coordination among the staff. The MDS Coordinator had initiated the PIP independently, and not all relevant staff members were informed or involved in the process. The Social Service Director confirmed that the issue had been ongoing for several weeks and was mentioned in QAPI meetings, but without detailed discussion. This lack of effective communication and coordination contributed to the continued deficiency in timely MDS assessments.
Failure to Implement Fall Prevention Measures for Residents
Penalty
Summary
The facility failed to adhere to the care plan interventions designed to prevent falls for two residents, leading to deficiencies in their care. Resident #69, who was readmitted to the facility with a right hip fracture, dementia, and general anxiety, experienced a fall that was not followed by a post-fall assessment as required. Observations revealed inconsistencies in the implementation of fall prevention measures, such as the absence of a floor mat on one side of the bed, despite the care plan's directive for mats on both sides. Interviews with staff highlighted a lack of awareness and adherence to the care plan, with the Director of Nursing acknowledging the oversight. Resident #64, admitted with severe cognitive impairment and a high fall risk score, also experienced lapses in fall prevention measures. Observations showed that the resident's bed was left in a high position without staff presence, and personal belongings and call lights were not within reach. Despite the care plan's instructions, a floor mat was not consistently placed on the floor, and staff interviews revealed a misunderstanding of the resident's fall risk status. The Director of Nursing confirmed the discrepancies and acknowledged that the fall prevention protocol was not properly followed. The facility's policies on comprehensive care planning and fall prevention were not effectively implemented, resulting in a failure to meet the residents' needs. The lack of post-fall assessments, incorrect implementation of care plan interventions, and staff's misunderstanding of residents' fall risks contributed to the deficiencies observed. These actions and inactions highlight the need for improved adherence to care plans and staff training to ensure resident safety and compliance with established protocols.
Failure to Provide Dining Assistance
Penalty
Summary
The facility failed to provide necessary assistance during dining for a resident who was reviewed for nutrition. The resident, who was admitted with diagnoses of Dementia, Osteoporosis, and Hemiplegia, was found to have a Brief Interview of Mental Status (BIMS) score indicating cognitive intactness. Despite a physician's order for careful oral assisted feeding by hand with every meal, observations revealed that the resident was eating meals without staff assistance. The resident reported eating as much as she could and noted weight loss, although she was unsure of the amount. A nutrition dietary progress note indicated a 9.6% weight loss over three months, with meal intake varying between 25% and 75%. The care plan identified the resident as being at nutritional and dehydration risk, requiring staff to provide necessary meal assistance. However, during interviews, the resident expressed needing more help during meals, contrary to the statement from a Certified Nursing Assistant who believed the resident could eat independently with minimal assistance. This discrepancy between the care plan, physician's orders, and staff actions contributed to the deficiency in providing adequate dining assistance to the resident.
Deficiencies in Urinary Catheter Management for Two Residents
Penalty
Summary
The facility failed to acquire a physician order for a urinary catheter and did not initiate a urinary catheter care plan for Resident #502. The resident was admitted with diagnoses including malignant neoplasm of the cervix, acute cystitis, and a urinary tract infection. Despite the presence of a urinary catheter, there were no physician orders or care plans documented for the catheter's care and maintenance. Observations revealed that the resident had a urinary bag strapped to her leg, and staff interviews indicated a lack of clarity regarding who was responsible for emptying the urinary bag. Additionally, the admission registered nurse admitted to only recently placing the order for the urinary catheter, despite the resident having had it for an unspecified duration. For Resident #69, the facility failed to keep the urinary catheter anchored, as required by the physician's orders. The resident, who was severely cognitively impaired, had a diagnosis of neurogenic bladder and recurrent UTIs. Despite orders to secure the catheter to the leg to prevent tension, there was no documentation of this being done from the beginning of February to February 19th. Observations confirmed that the catheter was not secured during care, and staff interviews revealed that they were aware of the need for a leg strap but acknowledged that the resident did not have one. The Director of Nursing confirmed that anchoring the catheter is best practice.
Nutritional Needs Not Met for Resident
Penalty
Summary
The facility failed to meet the nutritional needs of a resident, identified as Resident #47, who was admitted with diagnoses of cerebral infarction and dementia. The resident experienced significant weight loss, dropping from 180.2 pounds to 155.0 pounds over several months. Despite a recommendation for Ensure high-protein supplements twice a day to meet the resident's nutritional needs, the facility provided Ensure original, which did not meet the caloric and protein requirements. The resident's intake was only meeting 65% to 75% of his estimated nutritional needs, as documented in the facility's records. Interviews with staff revealed a lack of proper ordering and stocking of the required Ensure high-protein supplement. The Registered Dietitian and other staff members acknowledged the absence of the high-protein supplement in the facility's inventory and the failure to provide the correct nutritional support. Staff members were unsure of when the high-protein supplement was last available, and the resident was consistently given the wrong type of Ensure, which contributed to the deficiency in meeting the resident's nutritional needs.
Lack of Physician's Order for Oxygen Administration
Penalty
Summary
The facility failed to obtain a physician's order for oxygen administration for a resident, leading to a deficiency in providing safe and appropriate respiratory care. The resident, who was admitted with diagnoses including a displaced intertrochanteric fracture of the right femur, COPD, and chronic systolic congestive heart failure, was observed using oxygen without a corresponding physician's order. The facility's policy on oxygen administration, revised in October 2010, requires verification of a physician's order for oxygen use, which was not adhered to in this case. Observations revealed that the resident was using a nasal cannula connected to a portable oxygen tank set at 2 liters per minute, yet there was no physician's order documented for this oxygen therapy. The care plan for the resident included interventions related to COPD, such as monitoring for respiratory issues and administering bronchodilators, but it also mentioned oxygen therapy without a documented order. Additionally, the oxygen tubing lacked a date tag, indicating a lapse in proper equipment management. The resident confirmed that the oxygen was beneficial, but the absence of a formal order represents a significant oversight in care management.
Failure to Limit PRN Psychotropic Medication to 14 Days
Penalty
Summary
The facility failed to ensure compliance with regulations regarding the administration of psychotropic medications on a PRN basis, specifically for a resident diagnosed with bipolar disorder and major depressive disorder. The resident, who was cognitively intact with a BIMS score of 15, had a physician's order for Lorazepam 0.5 milligrams to be administered every 8 hours as needed for anxiety, with a duration of 30 days. This order exceeded the regulatory limit of 14 days for PRN psychotropic medications. Despite a pharmacy review conducted five days after the order was placed, the Consultant Pharmacist did not identify any irregularities or address the extended duration of the PRN medication. Interviews with the Director of Nursing (DON) and the Consultant Pharmacist revealed a lack of adherence to the facility's policy, which requires the nurse and pharmacist to contact the prescribing physician to discuss the necessity of any psychotropic medication that has been PRN for more than 14 days. The DON acknowledged the findings, indicating a lapse in the facility's protocol to ensure that psychotropic medications are not administered unnecessarily or beyond the regulatory timeframe without proper justification and physician review.
Failure to Monitor Psychotropic Medication Effects
Penalty
Summary
The facility failed to adequately monitor behaviors and side effects for two residents on psychotropic medications, leading to deficiencies in care. Resident #17, who was admitted with bipolar disorder and major depressive disorder, was prescribed Rexulti, an antipsychotic medication. However, there were no documented orders to monitor the medication's side effects or behaviors, and the Medication Administration Record (MAR) for February 2025 lacked documentation of such monitoring. Despite the care plan's directive to monitor and document for side effects and effectiveness, staff interviews revealed a lack of awareness and documentation regarding the antipsychotic medication. Resident #501, admitted with multiple diagnoses including anxiety disorder, was prescribed Escitalopram for depression. The physician's orders included monitoring for signs and symptoms of depression using numerical codes, but the MAR did not reflect this monitoring. Additionally, there was no care plan addressing the resident's depression. Interviews with staff indicated a general understanding of behavior monitoring procedures, but inconsistencies in documentation and uncertainty about monitoring side effects were evident. The deficiencies highlight a failure in the facility's processes for monitoring psychotropic medication effects and behaviors, as evidenced by the lack of documentation and staff awareness. This oversight could potentially impact the residents' well-being, as monitoring is crucial for identifying adverse reactions and ensuring the effectiveness of the prescribed medications.
Medication Security Deficiency
Penalty
Summary
The facility failed to ensure medications were secured at the bedside for one resident. The facility's policy requires that all medications and biologicals be stored in locked compartments and that only authorized personnel have access to them. Additionally, the policy on self-administration of medications mandates an evaluation of the resident's cognitive and physical abilities to determine if self-administration is safe and appropriate. However, there was no documentation of such an evaluation for the resident involved. The resident, who had a history of acute myocardial infarction and malignant neoplasm of the tongue, was observed with a clear plastic bag containing ChapStick and Nystatin ointment on the nightstand and overbed table. The resident mistakenly identified the Nystatin ointment as denture adhesive. Staff interviews confirmed that medications should not be at the bedside, and the resident had not been evaluated for self-administration of medications. The CNA removed the medication and gave it to the Director of Nursing.
Failure to Provide Appropriate Hydration for Resident on Thickened Liquids
Penalty
Summary
The facility failed to provide water consistent with the needs of a resident on thickened liquids, leading to a deficiency. Resident #645, who was admitted with diagnoses including Acute Myocardial Infarction and a history of tongue cancer, was observed with a full 20-ounce Styrofoam cup of regular ice water at their bedside, despite having a physician's order for nectar thickened liquids. The resident's care plan lacked documentation for nutrition or hydration, and there was no record of a Brief Interview of Mental Status being completed. During an observation, a Registered Nurse acknowledged the resident should not have regular water and removed it. The Speech Therapist confirmed the resident was on nectar thickened liquids and could use a straw due to tongue issues. Interviews with staff revealed inconsistencies in how water was provided to residents on thickened liquids, with reliance on verbal communication from nurses. The Certified Nursing Assistant stated that water is provided once or twice a shift, but there was no clear protocol for ensuring residents on thickened liquids received the appropriate consistency.
Infection Control Deficiencies in PPE Use and EBP Implementation
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program, as evidenced by staff not adhering to Enhanced Barrier Precautions (EBP) for three residents. For Resident #545, a CNA did not wear a gown while assisting with wound care and changing briefs, despite the presence of an EBP sign and orders requiring gown and glove use for high-contact care. The CNA admitted to not checking the EBP sign and was reminded by the RN, who confirmed that staff received training on EBP. Resident #501 did not have an EBP order or care plan related to a right heel pressure ulcer, despite the need for such precautions. A CNA incorrectly believed that gowns were only necessary for highly contagious diseases, indicating a lack of understanding of EBP requirements. This oversight in documentation and staff education contributed to the deficiency. For Resident #38, an LPN administered medications and assisted with a transfer without wearing a gown, despite EBP orders and signs indicating the need for gown and glove use during high-contact care. The LPN was unsure about the requirements and sought clarification from the surveyor. The DON, acting as the Infection Preventionist, acknowledged the need for PPE during direct contact activities, especially when transferring residents.
Missing Pull Cords on Overbed Lights
Penalty
Summary
The facility failed to ensure a homelike environment by not having pull cords attached to overbed lights for two out of seventy occupied beds. Observations were made on multiple occasions in room 22-B, where the overbed light located on the wall above the head of the bed had no pull cord attached. This was confirmed during a side-by-side observation with the Maintenance Supervisor, who acknowledged the missing pull cords in rooms 22-B and 28-B. The Maintenance Supervisor stated that each overbed light should have a pull cord long enough for each resident to be able to turn the light on and off themselves.
Failure to Process Physician's Order for Pain Medication
Penalty
Summary
The facility failed to process a physician's order in a timely manner for a resident, leading to a deficiency in medication administration. The resident, who was admitted with multiple diagnoses including arthritis, muscle wasting, and MRSA infection, had a physician's order for Oxycodone with Acetaminophen to be administered as needed for pain. However, there was a discrepancy in the medication administration record (MAR) and the controlled substance utilization record, indicating that the resident was documented as receiving a higher dosage of Percocet without a corresponding physician's order. The issue arose when the resident's orthopedic surgeon was supposed to provide a prescription for an increased dosage of Percocet, but the facility did not receive or document this order in a timely manner. Staff A, a registered nurse, attempted to contact the orthopedic surgeon's office to obtain the prescription but did not follow through to ensure it was received. As a result, the MAR inaccurately reflected that the resident was administered the higher dosage of Percocet, despite the absence of a valid physician's order. Further investigation revealed that other nursing staff members also signed off on the MAR for the increased dosage without verifying the existence of a physician's order. The Director of Nursing acknowledged the error after reviewing the records, confirming that the medication was signed off as administered without proper authorization. This lack of documentation and verification led to the deficiency in medication administration for the resident.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 268 citations issued within 25 miles in the last 12 months — including the 6 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Delray Beach
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cascades Health And Rehabilitation Center | 0.5 mi | ★★★★★ | 6 | 0 |
| The Terrace Of Delray Beach Nursing And Rehabilita | 1.7 mi | ★★★★★ | 0 | 0 |
| Harbours Edge | 2 mi | ★★★★★ | 0 | 0 |
| West Delray Nursing & Rehab Center | 2.8 mi | ★★★★★ | 0 | 0 |
| Yamato Nursing And Rehabilitation Center | 3.2 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.