Cycle 1
Health 2025-02-20 · Fire 2025-02-20
13 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Delray Beach, FL
Abbey Delray South
4-star overall rating with 2-star inspections with $4,963 in total fines with 13 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
1717 Homewood Blvd, Delray Beach, FL
(561) 454-5200
Overall
4 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
90
Certified beds
Average residents
71
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Lifespace Communities
Operator or chain grouping
Approved since
1982-07-15
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
16 facilities
Chain averages 4 overall / 3 health / 4 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.56
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.26
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
2.41
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
4.24
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.82
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
3.77
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
1.17
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.13
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
1.43
CMS adjusted RN staffing hours
Adjusted total hours
3.89
CMS adjusted total nurse staffing hours
Case-mix index
1.49
Higher values indicate more complex resident acuity
RN turnover
14%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
17%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,212
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
40.9
Composite VBP score used to determine payment impact.
Payment multiplier
0.9938
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 24.95% · Performance 24.62% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
3.33
Baseline 4.86% · Performance 6.84% · Measure score 3.33 · Achievement 3.33 · Improvement 0
Total nurse turnover
10
Baseline 43.75% · Performance 20.29% · Measure score 10 · Achievement 10 · Improvement 9
Adjusted total nurse staffing
3.03
Baseline 3.98 hours · Performance 3.94 hours · Measure score 3.03 · Achievement 3.03 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.44% |
10.72%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 895 · Observed rate 10.06% · Lower 95% interval 9.43% |
| Discharge to community | 71.35% |
50.57%
20.8 pts better
|
Better than the National Rate · Eligible stays 843 · Observed rate 67.73% · Lower 95% interval 67.55% |
| Medicare spending per beneficiary | 0.85 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 99.02% |
95.27%
3.8 pts better
|
Numerator 604 · Denominator 610 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 610 |
| Discharge self-care score | 40.65% |
53.69%
13 pts worse
|
Numerator 174 · Denominator 428 |
| Discharge mobility score | 38.79% |
50.94%
12.1 pts worse
|
Numerator 166 · Denominator 428 |
| Pressure ulcers or injuries, new or worsened | 0.82% |
2.29%
1.5 pts better
|
Numerator 5 · Denominator 610 · Adjusted rate 0.8% |
| Healthcare-associated infections requiring hospitalization | 6.84% |
7.12%
0.3 pts better
|
No Different than the National Rate · Eligible stays 481 · Observed rate 5.82% · Lower 95% interval 4.85% |
| Staff COVID-19 vaccination coverage | 71.21% |
8.2%
63 pts better
|
Numerator 94 · Denominator 132 |
| Staff flu vaccination coverage | 80.39% |
42%
38.4 pts better
|
Numerator 82 · Denominator 102 |
| Discharge function score | 47.2% |
56.45%
9.2 pts worse
|
Numerator 202 · Denominator 428 |
| Transfer of health information to provider | 98.84% |
95.95%
2.9 pts better
|
Numerator 170 · Denominator 172 |
| Transfer of health information to patient | 98.8% |
96.28%
2.5 pts better
|
Numerator 412 · Denominator 417 |
| Resident COVID-19 vaccinations up to date | 17.66% |
25.2%
7.5 pts worse
|
Numerator 59 · Denominator 334 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| 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% · 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 | 4.2% |
2.6%
1.6 pts worse
|
3.3%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · 4Q avg 4.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
3.7%
3.7 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 9.6% |
5.9%
3.7 pts worse
|
5.4%
4.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 9.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 9.4% |
15.7%
6.3 pts better
|
19.6%
10.2 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 9.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.0% |
9.8%
5.2 pts worse
|
16.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 15.0% · 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% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 0.0% |
11.7%
11.7 pts better
|
16.3%
16.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 2.1% |
9.8%
7.7 pts better
|
14.9%
12.8 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.4%
0.4 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.9% |
0.8%
2.1 pts worse
|
1.7%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 10.5% |
12.5%
2 pts better
|
19.8%
9.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 10.5% |
| Percentage of long-stay residents with pressure ulcers | 4.1% |
5.1%
1 pts better
|
5.1%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · 4Q avg 4.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.7% |
94.3%
4.4 pts better
|
81.7%
17 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.0% · Q2 98.4% · Q3 98.4% · Q4 99.0% · 4Q avg 98.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.6% |
9.3%
0.3 pts worse
|
12.0%
2.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.6% · Observed 8.6% · Expected 10.0% · 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 2.8% · Q2 2.1% · Q3 0.3% · Q4 0.6% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.3% |
94.7%
1.6 pts better
|
79.7%
16.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 96.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 31.5% |
26.2%
5.3 pts worse
|
23.9%
7.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 31.5% · Observed 27.6% · Expected 20.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-10-12 · Fire 2023-10-12
10 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2022-06-09 · Fire 2022-06-09
6 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-02-20
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-03-24
D · Potential for more than minimal harm
2025-02-20
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-03-24
D · Potential for more than minimal harm
2023-10-12
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2023-11-10
D · Potential for more than minimal harm
2023-10-12
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-11-10
D · Potential for more than minimal harm
2022-06-09
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2022-07-23
D · Potential for more than minimal harm
2022-06-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-07-23
D · Potential for more than minimal harm
2022-06-09
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-07-23
D · Potential for more than minimal harm
2022-06-09
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2022-07-23
D · Potential for more than minimal harm
2022-06-09
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-07-23
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-02-20
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-03-20
E · Potential for more than minimal harm
2025-02-20
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2025-03-20
D · Potential for more than minimal harm
2025-02-20
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-03-20
D · Potential for more than minimal harm
2025-02-20
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 2025-03-20
D · Potential for more than minimal harm
2025-02-20
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-03-20
D · Potential for more than minimal harm
2025-02-20
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-03-20
D · Potential for more than minimal harm
2025-02-20
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-03-20
D · Potential for more than minimal harm
2025-02-20
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-03-20
D · Potential for more than minimal harm
2025-02-20
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2025-03-20
D · Potential for more than minimal harm
2025-02-20
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 2025-03-20
D · Potential for more than minimal harm
2025-02-20
F807 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
Corrected 2025-03-20
D · Potential for more than minimal harm
2025-02-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-20
B · Minimal harm
2025-02-20
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2025-03-20
D · Potential for more than minimal harm
2024-07-11
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-08-11
D · Potential for more than minimal harm
2023-10-12
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-11-11
D · Potential for more than minimal harm
2023-10-12
F572 · Resident Rights Deficiencies
Health
Give residents a notice of rights, rules, services and charges.
Corrected 2023-11-11
D · Potential for more than minimal harm
2023-10-12
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-11-11
D · Potential for more than minimal harm
2023-10-12
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-11-11
D · Potential for more than minimal harm
2023-10-12
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2023-11-11
D · Potential for more than minimal harm
2023-10-12
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2023-11-11
D · Potential for more than minimal harm
2023-10-12
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-11-11
D · Potential for more than minimal harm
2023-10-12
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-11-11
D · Potential for more than minimal harm
2023-10-12
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-11-11
D · Potential for more than minimal harm
2023-10-12
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 2023-11-11
D · Potential for more than minimal harm
2022-06-09
F557 · Resident Rights Deficiencies
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2022-07-09
D · Potential for more than minimal harm
2022-06-09
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-07-09
D · Potential for more than minimal harm
2022-06-09
F807 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
Corrected 2022-07-09
D · Potential for more than minimal harm
2022-06-09
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-07-09
D · Potential for more than minimal harm
2022-06-09
F825 · Quality of Life and Care Deficiencies
Health
Provide or get specialized rehabilitative services as required for a resident.
Corrected 2022-07-09
Penalties and ownership
What sits behind the stars
$4,963
2023-12-15
Fine
Fine · fine $4,963
Fine
Ownership
Lifespace Communities Inc
5% Or Greater Direct Ownership Interest · Organization
Lifespace, Inc.
5% Or Greater Indirect Ownership Interest · Organization
Blackford, Gary
Corporate Director · Individual
Darkey-Hrinya, Joyce
Corporate Director · Individual
Dutra, Ana
Corporate Director · Individual
Fields, Venita
Corporate Director · Individual
Gorman, Joseph
Corporate Officer · Individual
Harshfield, Nicholas
Corporate Officer · Individual
Jantzen, Jesse
Corporate Officer · Individual
Jensen, Claus
Corporate Director · Individual
Kresse, Nikki
Corporate Officer · Individual
Lifespace Communities Inc
Operational/Managerial Control · Organization
Mcdonough, Amy
Corporate Director · Individual
Pope, Erin
Corporate Officer · Individual
Salamino, Jenifer
Corporate Director · Individual
Sokeye, Jonathan
Corporate Director · Individual
Spangler, Patrick
Corporate Director · Individual
Spaulding, Taylor
W-2 Managing Employee · Individual
Stretch, Clyde
Corporate Director · Individual
Williams, David
Corporate Director · Individual
Yanofsky, Neal
Corporate Director · Individual
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#2
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4-star overall rating with 3-star inspections with 13 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#3
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4-star overall rating with 3-star inspections with 7 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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