Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Terrace Of Delray Beach Nursing And Rehabilita during CMS and state inspections, most recent first.
Incomplete informed consent for psychotropic medications was found for multiple residents. Records showed that residents with diagnoses including depression, anxiety, dementia, ESRD on dialysis, COPD, and heart disease were prescribed psychotropic medications such as antidepressants, a benzodiazepine, and divalproex, but the consent forms did not list the medications, doses, frequencies, indications, or targeted behaviors, and one form was not signed or dated by the person completing it.
A resident with dementia, MDD, anxiety, and other chronic conditions was found without consistent access to a working phone for family communication or a TV remote for independent leisure. She stated the facility phone had not worked for nearly a week and she could not change channels herself; the room was observed without a visible phone or remote, and staff interviews showed the LPN was unaware of the issue while the CNA and Maintenance Director had incomplete or delayed awareness of the problem.
Resident Denied Ordered Showers Due to Dialysis Port: A resident with intact cognition and ESRD on dialysis stated he wanted more showers but had received only one since admission. Although physician orders called for showers three times weekly, a CNA said she was told not to shower the resident because of his dialysis port, and the wound care RN confirmed she had instructed staff that the port could not get wet. The DON stated dialysis residents are allowed to shower and was unaware the resident had been denied showers for this reason.
Failure to Follow Resident Preferences for Incontinence Care: A resident with intact cognition, hospice services, and bowel/bladder incontinence repeatedly stated she wanted more frequent brief changes and described long gaps between care. Observations showed the resident in bed waiting to be changed, while staff said they checked and provided incontinence care every 2 hours and the DON stated facility staff would provide the care because the resident was part of the facility.
Failure to provide and document structured activities for a resident with dementia and major depressive disorder. A resident with severely impaired cognition and a care plan for daily group activities plus 1:1 programming was repeatedly observed alone in her room with minimal stimulation while activities were occurring elsewhere. The AD stated the 1:1 plan was to be carried out by CNAs, but there were no progress notes, the activity plan lacked detail, and the activity log contained only two incomplete entries.
The facility failed to provide privacy curtains for residents in 14 rooms, specifically for Bed A, which is closest to the door. This deficiency affected two residents. During a tour, it was observed that residents residing nearest the door did not have privacy curtains. A nurse confirmed the absence of privacy curtains while providing care to a resident. The spouse of a resident reported that the curtain had been missing for many months. A subsequent tour with the Maintenance Director confirmed the absence of privacy curtains in the specified rooms and noted that the existing curtains between beds were too short to provide complete privacy.
A resident was discharged from a facility without the necessary Home Health Services, despite physician orders for RN evaluation, PT, OT, and HHA. The Social Worker Director claimed to have sent documents to the Home Health Agency, but there was no evidence of this, and the agency did not receive any documentation. Consequently, the resident did not receive the required services upon discharge.
A resident with minimal cognitive impairment did not receive showers as per the facility's schedule. Despite instructions to contact the resident's significant other if he refused, there was no documentation of refusals or attempts to contact. Interviews revealed the resident and his significant other were dissatisfied with the care, and staff were confused about the shower schedule. The ADON confirmed documentation issues since a company change.
A facility failed to implement a resident's DNR status, resulting in a deficiency. The resident's electronic medical record and physician's orders indicated a Full Code, while a DNR document was present but not updated in the system. An LPN was unaware of the DNR status, and the resident's son, who requested the DNR, noted a delay in its implementation. This reflects a breakdown in communication and documentation of the resident's advance directive.
The facility failed to maintain a clean and homelike environment, with issues such as peeling paint, stained furniture, broken carts, and wheelchairs with torn armrests. The Maintenance Director acknowledged these deficiencies and plans to audit wheelchairs, having been in the role for only a few months.
A facility failed to provide adequate restorative services to a resident, as required by their policy. The resident, who was cognitively intact, had a physician order for AROM and bed mobility services, but the order lacked specified frequency and duration. Documentation showed the resident received services only twice in a month, contrary to the standard of three times a week. Interviews revealed a lack of documentation for service provision and resident refusals.
A resident requiring substantial assistance with ADLs did not receive timely nail care, despite facility policy and CNA documentation indicating otherwise. The resident's care plan lacked nail care details, and observations showed long, dirty nails over several days. The Activity Assistant confirmed the delay in providing care, despite the resident's requests.
A resident with a BIMS score of 15 was observed with a skin tear on her right forearm, but the facility failed to document the incident, notify the physician, or create a care plan. The Infection Control Preventionist applied a dressing without obtaining a physician's order, and the RN was unaware of the bandage, highlighting a lack of communication and documentation.
The facility failed to provide proper urinary catheter care for two residents. One resident received improper cleaning of the catheter tubing, contrary to the facility's policy, and had a history of UTIs with MDROs. Another resident's catheter was not secured with an anchoring device as ordered, risking urethral traction, and also had a history of UTIs. The ADON was informed of these issues.
The facility failed to provide adequate pain management for a resident with chest wall pain and did not administer medications as per physician orders for two other residents. Despite complaints, pain management was delayed, and medications were marked unavailable without proper documentation or monitoring. The pharmacy confirmed delivery, highlighting issues in medication management.
The facility failed to document pain levels for two residents at risk for pain, blood glucose levels for a diabetic resident, and meal consumption percentages for another resident. Additionally, a resident's care plan lacked nail care information, and another resident's care plan incorrectly included peritoneal dialysis. The Director of Nursing and other staff confirmed these documentation deficiencies.
The facility failed to implement Enhanced Barrier Precautions (EBP) effectively, as observed in several residents with wounds, indwelling devices, and infections. There was a lack of appropriate signage and PPE availability, and staff demonstrated confusion about EBP protocols, such as when to wear gowns during care. The Infection Control Preventionist acknowledged these issues, despite prior in-service training, leading to the deficiency identified by surveyors.
The facility's Admission Agreement improperly required residents to waive their right to a jury trial as a condition for admission and care, affecting all 88 residents. The agreement failed to inform residents that arbitration was not mandatory and did not allow them to rescind the agreement within 30 days, contrary to federal regulations.
The facility failed to provide the required CMS Form 10055 (SNF ABN) to two residents discharged from Medicare Part A services, despite having skilled benefit days remaining. The Social Services Director was unaware of the form's requirement, leading to a deficiency noted by surveyors.
Incomplete informed consent for psychotropic medications
Penalty
Summary
The facility failed to obtain informed consent for psychotropic medications for 4 of 5 sampled residents reviewed for unnecessary medication use. The facility policy stated that before initiating or increasing a psychotropic medication, the resident, family, and/or resident representative must be informed of the benefits, risks, and alternatives, including black box warnings for antipsychotic medications, and the resident has the right to accept or decline the medication. Review of records showed Resident #129, who had diagnoses including encephalopathy, acute osteomyelitis of the right ankle and foot, major depressive disorder, and anxiety disorder, had a BIMS score of 13 and was prescribed duloxetine for neuropathy, but the informed consent form did not list the medication, dose, frequency, or indication. Staff acknowledged the consent was incomplete. Resident #87, with diagnoses including ESRD on dialysis, anxiety, and COPD, had a BIMS score of 15 and was prescribed mirtazapine for depression and temazepam for insomnia, but the informed consent form did not document these drugs, dose, frequency, or indication. Resident #4, who had diagnoses including atherosclerotic heart disease, type 2 diabetes, and atrial fibrillation, had a BIMS score of 15 and was prescribed escitalopram for depression, but the informed consent form did not include the drug, dose, or frequency. Resident #14, with diagnoses including dementia, cognitive communication deficit, mood disorder, and anxiety disorder, had a BIMS score of 11 and was prescribed divalproex sodium and mirtazapine, but the informed consent form was missing the medication names, dosage, frequency, targeted behaviors, and did not confirm whether the resident or representative agreed with the psychoactive therapy; it was also not signed or dated by the person completing the form.
Resident lacked access to working phone and TV remote
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of a resident by not ensuring consistent access to a functional telephone for communication with family members or an accessible television remote control for independent leisure activities. Resident #12 had diagnoses including dementia without behavioral disturbance, major depressive disorder, anxiety disorder, poly-osteoarthritis, Waldenstrom macroglobulinemia, drug-induced pancytopenia, muscle wasting and atrophy, and abnormal posture. Her care plan stated she was able to communicate leisure needs and preferences, preferred a balance of social and independent activities, and was to be encouraged to use in-room leisure activities such as television viewing and telephone or video communication with family and friends. During observation, the resident was lying in bed in her private room and stated she did not have access to a working telephone to contact a relative. She reported her personal cellular phone had been taken by another relative and that the facility-provided telephone had not been functioning for nearly one week. She also stated she did not have access to a television remote control and could not change channels independently. The room was observed without a visible landline telephone or television remote control, and when the nightstand drawer was opened, a telephone wrapped with its cord was found but no remote control was present. Staff interviews showed the assigned LPN was unaware of the telephone issue, the CNA believed the resident had access to a telephone and had a remote the previous day, and the Maintenance Director stated he had been notified the phone was not functioning but had not considered a cordless phone as an interim solution. The Activity Director also stated no documentation was maintained showing when activities were offered or provided.
Resident Denied Ordered Showers Due to Dialysis Port
Penalty
Summary
The facility failed to provide showers per resident request for one resident who had intact cognition and had expressed a preference for more showers. The resident was admitted with diagnoses including End Stage Renal Disease on dialysis, anxiety, and COPD. The MDS dated 01/06/26 showed a BIMS score of 15. During an interview, the resident stated he thought he had only had one shower since admission and wanted more, but he had not been given showers. Physician orders directed showers on Monday, Wednesday, and Friday on the 3-11 shift. A CNA stated she had been told the resident could not get showers because he had a dialysis port and that the wound care RN told her the port could not get wet. The wound care RN confirmed she told staff the resident could not have a shower due to the dialysis port and said this was her protocol, although she acknowledged it was not facility policy and that she had not discussed it with the DON. The DON stated residents on dialysis are allowed to take showers and was unaware the resident had been denied showers for this reason.
Failure to Follow Resident Preferences for Incontinence Care
Penalty
Summary
The facility failed to follow a resident’s preferences for incontinence care for a resident with intact cognition, a BIMS score of 15, and diagnoses including COPD, anxiety disorder, hemorrhoids, constipation, Crohn’s disease, restlessness and agitation, and hospice services. The resident’s physician orders included barrier cream to the sacrum and turning and positioning every 2 to 3 hours as indicated, every shift and as needed. The care plan identified bowel and bladder incontinence and skin breakdown risk, with interventions to check the resident every 2 hours, assist with toileting as needed, keep skin clean and dry, and provide peritoneal care after each incontinent episode. The CNA task documentation did not include information about when peritoneal care or brief changes were provided. During multiple observations and interviews, the resident stated she wanted to be changed more often and described long gaps between brief changes, including waiting until around 11:00 AM and then not being changed again until later in the day or overnight. On several occasions, the resident was observed in bed and stated she had not yet been changed, including one instance when she had pressed the call light and asked the CNA if she was there to change her. Staff stated they checked and provided incontinence care every 2 hours, and the DON stated the hospice CNA came daily but facility staff would always provide care because the resident was part of the facility. The resident later confirmed she would like to be changed prior to 11:00 AM but not too early, and said the facility had previously changed her before dinner but later returned to changing her later.
Failure to Provide and Document Structured Activities
Penalty
Summary
Provide activities to meet all resident's needs. The facility failed to coordinate and implement structured activities for Resident #13, who was admitted with diagnoses including Dementia and Major Depressive Disorder and had a BIMS score of 5, indicating severely impaired cognition. The resident was documented as a foreign-speaking woman who had difficulty adjusting to the facility, experienced confusion, and was at increased risk for anxiety and depression related to separation from family and adjustment to a new environment. Her care plan stated she would participate in at least one morning activity and one afternoon activity daily and receive 1:1 programming at least twice weekly for a minimum of 15 minutes per session. During observations, Resident #13 was repeatedly found alone in her room with minimal stimulation, including a stuffed animal, pillows, and later a doll, while the television was off or inaudible. She was observed in her room while music activities were occurring in the activity room, and she was also noted lying in the same position on a later date without engagement in activities. The Activity Director stated the resident had a 1:1 activity plan intended to be implemented by CNAs, but no progress notes or records of ongoing activities were maintained, and the plan lacked specific details regarding scheduled or implemented activities. Review of the activity log showed only two entries with no checkmarks or indicators identifying the activities offered or completed, and no evidence was provided that the planned activities occurred.
Lack of Privacy Curtains in Resident Rooms
Penalty
Summary
The facility failed to provide privacy curtains for residents in 14 rooms, specifically for Bed A, which is closest to the door. This deficiency affected two sampled residents. During an initial tour, it was observed that residents residing nearest the door did not have privacy curtains. A registered nurse confirmed the absence of privacy curtains while providing care to one of the residents. The spouse of one resident reported that the curtain had been missing for many months. A subsequent tour with the Maintenance Director and Regional Maintenance Director confirmed the absence of privacy curtains in the specified rooms and noted that the existing curtains between beds were too short to provide complete privacy.
Failure to Arrange Home Health Services for Discharged Resident
Penalty
Summary
The facility failed to ensure adequate discharge documentation and follow physician orders for a resident's discharge home. The resident, who had multiple diagnoses including a fracture, pain, difficulty walking, hypertension, diabetes, depression, and anxiety, was discharged without the necessary arrangements for Home Health Services. The physician's orders specified that the resident should be discharged with RN evaluation, PT, OT, and HHA, and a follow-up with the PCP within a week. However, the discharge notes only mentioned that the resident was discharged in stable condition with instructions to visit the PCP in 3-5 days, without any mention of the Home Health Services setup. Interviews conducted with the resident and the Social Worker Director revealed that the facility did not arrange for the required Home Health Services. The Social Worker Director claimed to have sent the necessary documents to the Home Health Agency, but there was no evidence to support this claim. The Home Health Care Coordinator confirmed that they did not receive any documentation from the facility, as the resident's name was not in their system. This lack of documentation and communication resulted in the resident not receiving the prescribed Home Health Services upon discharge.
Failure to Provide Scheduled Showers for Resident
Penalty
Summary
The facility failed to ensure the provision of showers according to the facility schedule for a resident with minimal cognitive impairment. The resident was admitted to the facility and had a care plan indicating he rejected care, including showers, but lacked an intervention to contact his significant other if he refused. Despite a progress note instructing staff to call the resident's significant other if he refused a shower, there was no documentation of such refusals or attempts to contact the significant other, except for a generic statement during a care plan meeting. Interviews revealed that the resident expressed dissatisfaction with the care provided, specifically mentioning the lack of showers. The resident's significant other, who attended care plan meetings, also voiced concerns about the lack of showers, stating that the resident would accept showers if offered. Staff interviews indicated confusion about the shower schedule, with some staff unable to locate it. The Assistant Director of Nursing confirmed the absence of a place for CNAs to document the provision of showers and acknowledged ongoing issues with documentation since a company change.
Failure to Implement DNR Status for a Resident
Penalty
Summary
The facility failed to ensure staff awareness and implementation of a Do Not Resuscitate (DNR) status for a resident, leading to a deficiency in honoring the resident's advance directive. The facility's policy requires that a resident's code status be clearly documented in designated sections of the medical record, including physician orders, care plans, and documents. However, there was a discrepancy in the documentation for the resident in question. The electronic medical record and physician's orders indicated a Full Code status, while a DNR document was present under the document tab, signed by the physician at a later date. During an interview, a Licensed Practical Nurse (LPN) was unaware of the DNR status, as she relied on the physician's order and code status, which showed Full Code. The DNR document was not found in the facility's DNR book, indicating a lack of communication and update in the resident's code status. The resident's son and Power of Attorney (POA) had requested a DNR order, but there was a delay in its implementation, as the physician signed the form months after the initial request. This oversight highlights a failure in the facility's process to update and communicate the resident's advance directive effectively.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, safe, and comfortable environment for residents, as observed during a survey. In the 100 and 200 units, several deficiencies were noted. In one resident's room, the bathroom had peeling paint under the soap dispenser, and the grout around the toilet was discolored. Another room had a sitting chair with a large stain and tears on the seat. Additionally, a linen cart in the hallway was broken. Multiple wheelchairs were found with torn armrests, affecting several residents. During a follow-up tour, the Maintenance Director and Regional Maintenance Director acknowledged these issues. The Maintenance Director mentioned relying on residents and rehabilitation staff to report wheelchair repairs and stated he would begin auditing all wheelchairs, noting he had only been in the position for a few months.
Deficiency in Restorative Services Documentation and Implementation
Penalty
Summary
The facility failed to ensure that restorative services were adequately provided to a resident, leading to a deficiency. The policy for Restorative Nursing Programs, implemented on 05/01/24, requires that a resident's Restorative Nursing Plan include the frequency and duration of activities, and that restorative aides implement the plan and document the activities. However, for the resident in question, the facility did not adhere to these guidelines. The resident, who was cognitively intact with a BIMS score of 14, was admitted on 05/23/23 and had a physician order for Active Range of Motion (AROM) and bed mobility services dated 06/13/23, but this order lacked specified frequency and duration. The facility's documentation revealed that the resident received AROM services only twice in July 2024, despite the standard program being three times a week. Interviews with restorative CNAs indicated that the resident sometimes refused services, but there was no documentation to support this claim or to show that services were provided three times weekly. The facility administrator confirmed that the frequency and duration should have been documented in the order, highlighting a lapse in following the established restorative care plan and documentation procedures.
Failure to Provide Timely Nail Care for Resident
Penalty
Summary
The facility failed to provide timely and ongoing nail care for a resident who required substantial to maximum assistance with activities of daily living (ADLs). The policy on nail care, implemented on 05/01/24, mandates routine cleaning and inspection of nails during ADL care, with trimming and filing scheduled regularly. However, the care plan for the resident, who was cognitively intact and needed significant assistance, did not include any information related to nail care. Despite daily documentation by CNAs indicating that nail care was performed, observations revealed that the resident's fingernails were long and dirty over several days. Interviews and observations indicated that the resident had requested nail care, but it was not provided in a timely manner. The resident expressed dissatisfaction with the lack of nail care, stating that he had asked for his nails to be trimmed the previous week. The Activity Assistant, responsible for nail care during a weekly beauty hour, confirmed that the resident was on her list but was not attended to until several days later. This delay in providing nail care was acknowledged by a Registered Nurse, who was informed of the issue and the discrepancy in CNA documentation.
Failure to Provide Timely Care for Skin Tear
Penalty
Summary
The facility failed to provide timely care and treatment for a skin tear for a resident reviewed for skin conditions. The facility's policy requires that when a skin tear is discovered, an incident report should be completed, and the attending physician should be notified. However, in this case, there was no documentation in the Electronic Health Record (EHR) regarding the skin tear, no incident report was filed, and no care plan was developed for the skin tear. The resident, who was alert and oriented with a BIMS score of 15, was observed with a bandage on her right forearm, which she believed was due to scraping her arm on the bed rail. The Infection Control Preventionist applied a dressing to the arm after noticing a hematoma and later a skin tear, but did not notify the physician or obtain an order for the dressing. The Registered Nurse caring for the resident was unaware of the bandage, indicating a lack of communication and documentation regarding the resident's care.
Deficient Urinary Catheter Care and Maintenance
Penalty
Summary
The facility failed to provide appropriate indwelling urinary catheter care and maintenance for two residents, leading to deficiencies in care. For one resident, the Certified Nursing Assistant (CNA) did not follow the facility's catheter care policy, which required cleaning from the insertion site outward. Instead, the CNA cleaned the catheter tubing with a back-and-forth motion, which is not in line with the policy. This resident had a history of urinary tract infections (UTIs) with multidrug-resistant organisms (MDROs), indicating poor catheter care. The Assistant Director of Nursing (ADON) was informed of these concerns. For the second resident, the facility failed to secure the urinary catheter tubing with an anchoring device as per the physician's orders. Observations revealed that the resident did not have a leg strap or anchor to secure the catheter tubing, which could lead to urethral traction. This resident also had a history of UTIs with E. Coli. The ADON was made aware of the lack of an anchoring device, but the resident was transferred to the hospital before the issue could be addressed.
Deficiencies in Pain Management and Medication Administration
Penalty
Summary
The facility failed to provide adequate pain management for a resident, identified as Resident #294, who was admitted with diagnoses including syncope, musculoskeletal symptoms, and a cardiac pacemaker. Despite the resident's complaints of right chest wall pain following a fall, which was not alleviated by Tylenol, the nursing staff did not escalate the issue to pain management until prompted by the resident's persistent requests. A delay occurred in documenting and processing a verbal order for Tramadol, resulting in the resident not receiving the prescribed medication until the following day. Additionally, the facility did not administer medications as per physician orders for two other residents. Resident #4, who was at risk for pain, did not receive a Lidocaine patch for several days as it was marked as not available, and there was no documentation of pain monitoring during this period. Similarly, Resident #28, diagnosed with chronic pain syndrome, experienced multiple instances where a Lidoderm patch and Lotrisone cream were marked as unavailable, with no pain monitoring documented on those days. The Director of Nursing and the Pharmacist Consultant were unable to provide explanations for the unavailability of medications or the lack of pain monitoring documentation. The pharmacy confirmed that the medications were delivered to the facility, indicating a failure in the facility's medication management and documentation processes.
Documentation Deficiencies in Pain, Glucose, Nutrition, and ADL Care
Penalty
Summary
The facility failed to document pain levels for two residents who were at risk for pain and receiving pain management. Resident #4, admitted with a diagnosis of pain, had physician orders to monitor and record pain levels every shift, but no documentation was found in the electronic Medication Administration Record (eMAR) or Progress Notes. Similarly, Resident #28, diagnosed with Chronic Pain Syndrome, also had orders for pain monitoring, yet there was no documentation of pain levels recorded in the resident's records. The Director of Nursing confirmed the absence of documentation for both residents. The facility also failed to document blood glucose levels for Resident #81, who was diagnosed with Diabetes Mellitus Type 2 and required blood glucose monitoring before meals. Although nursing staff initialed that monitoring was done, the actual blood glucose numbers were not recorded in the eMAR, Vitals section, or Progress Notes, except for one instance. The Director of Nursing acknowledged the lack of documentation for blood glucose levels, except for the single recorded instance. Additionally, the facility did not document the percentage of meals consumed by Resident #70, who had a physician's order to report the percentage of snacks consumed. The Medication Administration Record showed initials and check marks but lacked specific percentages. The dietician confirmed the absence of documentation for snacks. Furthermore, Resident #22's care plan lacked information on nail care, and despite daily checkmarks indicating nail care was performed, the resident's nails were observed to be long and dirty. Lastly, Resident #292's care plan incorrectly included peritoneal dialysis, which was not applicable, and was later canceled by the MDS Coordinator.
Inadequate Implementation of Enhanced Barrier Precautions
Penalty
Summary
The facility failed to effectively implement its infection prevention and control program, specifically regarding Enhanced Barrier Precautions (EBP) for residents with certain medical conditions and devices. Observations revealed that several residents, including those with wounds, indwelling medical devices, and infections, did not have appropriate signage or Personal Protective Equipment (PPE) readily available in their rooms. For instance, Resident #1, with a sacral wound, had no EBP sign or PPE cart near the room, and Resident #292, with a dialysis catheter, also lacked EBP signage and PPE availability. Staff members demonstrated a lack of understanding and adherence to EBP protocols. For example, a registered nurse was observed administering medication via a PEG tube without wearing a gown, and a certified nursing assistant provided personal care to a resident with an indwelling urinary catheter without donning a gown. Interviews with staff revealed confusion about when PPE was required, indicating insufficient training or reinforcement of the facility's EBP policy. The Infection Control Preventionist acknowledged discrepancies in the implementation of EBP, such as the need for contact precautions for the entire duration of antibiotic treatment for a resident with an active MDRO. Despite in-service training provided in May, the facility's staff did not consistently follow EBP protocols, as evidenced by the lack of signage, PPE availability, and proper use during resident care. This inconsistency in following established infection control measures contributed to the deficiency identified by the surveyors.
Non-compliance with Arbitration Agreement Regulations
Penalty
Summary
The facility failed to comply with federal regulations regarding arbitration agreements in their Admission Agreement. Specifically, the Admission Agreement included a paragraph that required residents and their representatives to waive their right to a jury trial as a condition of admission and to receive care at the facility. This paragraph did not inform residents or their representatives that agreeing to arbitration was not a requirement for admission or continued care, nor did it provide them the right to rescind the agreement within 30 days of signing. This affected all 88 residents who had signed the admission agreement at the time of the survey. During the survey, the Admissions Director was informed of the issue with the wording in the Admission Agreement, which was not aligned with federal regulations. The director acknowledged the problem and stated she would inform the new owners about the need to amend the agreement. The facility owner was also made aware of the concern and acknowledged understanding of the issue. The deficiency was identified through a review of the facility's 'Arbitration Agreement Program Guide' and 'Arbitration Agreement,' which contained the required regulatory language, but the Admission Agreement did not reflect this compliance.
Failure to Provide Required Beneficiary Notification Forms
Penalty
Summary
The facility failed to provide the appropriate Beneficiary Notification Form (CMS Form 10055/SNF ABN) to two residents, identified as Resident #22 and Resident #70, upon their discharge from Medicare Part A services. Both residents had skilled benefit days remaining and chose to remain in the facility after their discharge from Part A services. However, the facility did not provide them with the required CMS Form 10055 (SNF ABN), which is necessary to inform residents of their potential liability for services not covered by Medicare. The Social Services Director (SSD), responsible for providing these notices, was unaware of the requirement for the SNF ABN form and did not have copies available to distribute. This lack of knowledge and preparation led to the failure in providing the necessary documentation to the residents, resulting in a deficiency noted by the surveyors. The SSD was informed of the requirement and provided with the necessary forms and instructions after the deficiency was identified.
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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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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) |
|---|---|---|---|---|
| West Delray Nursing & Rehab Center | 1.1 mi | ★★★★★ | 0 | 0 |
| Abbey Delray South | 1.7 mi | ★★★★★ | 0 | 0 |
| Cascades Health And Rehabilitation Center | 2.1 mi | ★★★★★ | 6 | 0 |
| Harbours Edge | 3.7 mi | ★★★★★ | 1 | 0 |
| Yamato Nursing And Rehabilitation Center | 4 mi | ★★★★★ | 12 | 0 |
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