Cycle 1
Health 2025-03-12 · Fire 2025-03-12
19 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Delray Beach, FL
West Delray Nursing & Rehab Center
1-star overall rating with 1-star inspections with $39,841 in total fines with 19 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
16200 S Jog Road, Delray Beach, FL
(561) 638-0000
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
103
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Excelsior Care Group
Operator or chain grouping
Approved since
1999-02-19
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
33 facilities
Chain averages 3 overall / 2 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.93
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.53
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
2.31
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
3.77
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.46
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
3.42
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.73
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.98
CMS adjusted RN staffing hours
Adjusted total hours
3.98
CMS adjusted total nurse staffing hours
Case-mix index
1.30
Higher values indicate more complex resident acuity
RN turnover
63%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
41%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,562
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
39.45
Composite VBP score used to determine payment impact.
Payment multiplier
0.9924
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.05
Baseline 25.23% · Performance 22.32% · Measure score 3.05 · Achievement 0 · Improvement 3.05
Healthcare-associated infections
4.71
Baseline 8.93% · Performance 6.88% · Measure score 4.71 · Achievement 3.19 · Improvement 4.71
Total nurse turnover
6.13
Baseline 45.37% · Performance 38.64% · Measure score 6.13 · Achievement 6.13 · Improvement 2.78
Adjusted total nurse staffing
1.89
Baseline 3.59 hours · Performance 3.62 hours · Measure score 1.89 · Achievement 1.89 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.05% |
10.72%
0.7 pts better
|
No Different than the National Rate · Eligible stays 207 · Observed rate 9.18% · Lower 95% interval 6.78% |
| Discharge to community | 48.46% |
50.57%
2.1 pts worse
|
No Different than the National Rate · Eligible stays 184 · Observed rate 42.93% · Lower 95% interval 41.36% |
| Medicare spending per beneficiary | 1.04 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 94.74% |
95.27%
0.5 pts worse
|
Numerator 126 · Denominator 133 |
| Falls with major injury | 1.5% |
0.77%
0.7 pts worse
|
Numerator 2 · Denominator 133 |
| Discharge self-care score | 50.7% |
53.69%
3 pts worse
|
Numerator 36 · Denominator 71 |
| Discharge mobility score | 54.93% |
50.94%
4 pts better
|
Numerator 39 · Denominator 71 |
| Pressure ulcers or injuries, new or worsened | 2.26% |
2.29%
About the same
|
Numerator 3 · Denominator 133 · Adjusted rate 1.6% |
| Healthcare-associated infections requiring hospitalization | 6.88% |
7.12%
0.2 pts better
|
No Different than the National Rate · Eligible stays 104 · Observed rate 6.73% · Lower 95% interval 4.48% |
| Staff COVID-19 vaccination coverage | Not Available |
8.2%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 54.93% |
56.45%
1.5 pts worse
|
Numerator 39 · Denominator 71 |
| Transfer of health information to provider | 92.59% |
95.95%
3.4 pts worse
|
Numerator 50 · Denominator 54 |
| Transfer of health information to patient | 96.97% |
96.28%
0.7 pts better
|
Numerator 32 · Denominator 33 |
| Resident COVID-19 vaccinations up to date | 13.7% |
25.2%
11.5 pts worse
|
Numerator 10 · Denominator 73 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.1 |
2.1
1 pts worse
|
1.9
1.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.1 · Observed 3.0 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.0 |
1.2
0.2 pts better
|
1.8
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 0.9 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.9% |
97.8%
0.9 pts worse
|
93.4%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 93.5% · Q3 97.1% · Q4 97.0% · 4Q avg 96.9% |
| 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 | 1.8% |
2.6%
0.8 pts better
|
3.3%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 0.0% · Q3 2.0% · Q4 3.0% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.8% |
3.7%
0.9 pts better
|
11.4%
8.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 2.7% · Q3 2.5% · Q4 4.7% · 4Q avg 2.8% |
| Percentage of long-stay residents who lose too much weight | 4.9% |
5.9%
1 pts better
|
5.4%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.7% · Q2 3.8% · Q3 0.0% · Q4 3.8% · 4Q avg 4.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 29.4% |
15.7%
13.7 pts worse
|
19.6%
9.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.7% · Q2 34.6% · Q3 35.8% · Q4 15.9% · 4Q avg 29.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 16.3% |
9.8%
6.5 pts worse
|
16.7%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.8% · Q2 17.0% · Q3 15.5% · Q4 17.2% · 4Q avg 16.3% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 16.6% |
11.7%
4.9 pts worse
|
16.3%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 23.2% · Q3 10.9% · Q4 15.1% · 4Q avg 16.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.7% |
9.8%
1.9 pts worse
|
14.9%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.0% · Q2 18.3% · Q3 8.6% · Q4 8.8% · 4Q avg 11.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.6% |
0.4%
0.2 pts worse
|
1.0%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.3% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
0.8%
0.8 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 8.8% |
12.5%
3.7 pts better
|
19.8%
11 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.3% · Q2 18.5% · Q3 2.4% · Q4 3.4% · 4Q avg 8.8% |
| Percentage of long-stay residents with pressure ulcers | 6.1% |
5.1%
1 pts worse
|
5.1%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 9.1% · Q3 4.1% · Q4 6.1% · 4Q avg 6.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 89.8% |
94.3%
4.5 pts worse
|
81.7%
8.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.9% · Q2 92.2% · Q3 83.3% · Q4 83.3% · 4Q avg 89.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.8% |
9.3%
0.5 pts worse
|
12.0%
2.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.8% · Observed 10.0% · Expected 11.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.8% |
1.5%
2.3 pts worse
|
1.6%
2.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 6.3% · Q3 0.0% · Q4 2.6% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 89.1% |
94.7%
5.6 pts worse
|
79.7%
9.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 89.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 38.4% |
26.2%
12.2 pts worse
|
23.9%
14.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 38.4% · Observed 38.2% · Expected 23.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-30 · Fire 2023-11-30
11 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-07-28 · Fire 2022-07-28
10 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-03-12
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-04-11
F · Potential for more than minimal harm
2025-03-12
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-04-11
E · Potential for more than minimal harm
2025-03-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-04-11
D · Potential for more than minimal harm
2025-03-12
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 2025-04-11
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-06-16
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2025-07-16
D · Potential for more than minimal harm
2025-06-16
F635 · Resident Assessment and Care Planning Deficiencies
Health
Provide doctor's orders for the resident's immediate care at the time the resident was admitted.
Corrected 2025-07-16
D · Potential for more than minimal harm
2025-03-12
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-04-11
D · Potential for more than minimal harm
2025-03-12
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2025-04-11
D · Potential for more than minimal harm
2025-03-12
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 2025-04-11
D · Potential for more than minimal harm
2025-03-12
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-04-11
D · Potential for more than minimal harm
2025-03-12
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 2025-04-11
D · Potential for more than minimal harm
2025-03-12
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 2025-04-11
D · Potential for more than minimal harm
2025-03-12
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-04-11
D · Potential for more than minimal harm
2025-03-12
F712 · Nursing and Physician Services Deficiencies
Health
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Corrected 2025-04-11
D · Potential for more than minimal harm
2025-03-12
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2025-04-11
D · Potential for more than minimal harm
2025-03-12
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2025-04-11
D · Potential for more than minimal harm
2025-03-12
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 2025-04-11
D · Potential for more than minimal harm
2025-03-12
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-05-16
D · Potential for more than minimal harm
2025-03-12
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 2025-04-11
D · Potential for more than minimal harm
2025-03-12
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 2025-04-11
D · Potential for more than minimal harm
2025-03-12
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-04-11
D · Potential for more than minimal harm
2025-03-12
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2025-05-16
D · Potential for more than minimal harm
2025-03-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-11
G · Actual harm
2023-11-30
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-12-30
F · Potential for more than minimal harm
2023-11-30
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 2023-12-30
E · Potential for more than minimal harm
2023-11-30
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 2023-12-30
D · Potential for more than minimal harm
2023-11-30
F567 · Resident Rights Deficiencies
Health
Honor the resident's right to manage his or her financial affairs.
Corrected 2023-12-30
D · Potential for more than minimal harm
2023-11-30
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-12-30
D · Potential for more than minimal harm
2023-11-30
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 2023-12-30
D · Potential for more than minimal harm
2023-11-30
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 2023-12-30
D · Potential for more than minimal harm
2023-11-30
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2023-12-30
D · Potential for more than minimal harm
2023-11-30
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-12-30
D · Potential for more than minimal harm
2023-11-30
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2023-12-30
D · Potential for more than minimal harm
2023-11-30
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-12-30
F · Potential for more than minimal harm
2022-07-28
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 2022-08-27
E · Potential for more than minimal harm
2022-07-28
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 2022-08-27
E · Potential for more than minimal harm
2022-07-28
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2022-08-27
D · Potential for more than minimal harm
2022-07-28
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2022-08-27
D · Potential for more than minimal harm
2022-07-28
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 2022-08-27
D · Potential for more than minimal harm
2022-07-28
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2022-08-27
D · Potential for more than minimal harm
2022-07-28
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 2022-08-27
D · Potential for more than minimal harm
2022-07-28
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2022-08-27
D · Potential for more than minimal harm
2022-07-28
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2022-08-27
D · Potential for more than minimal harm
2022-07-28
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 2022-08-27
Penalties and ownership
What sits behind the stars
$4,147
2025-03-12
Fine
Fine · fine $4,147
Fine
$4,979
2025-03-12
Fine
Fine · fine $4,979
Fine
$30,715
2023-11-30
Fine
Fine · fine $30,715
Fine
Ownership
West Delray Intermediate Opoc Holdco LLC
5% Or Greater Direct Ownership Interest · Organization
Fischl, Mayer
5% Or Greater Indirect Ownership Interest · Individual
Flnho Capital Group LLC
5% Or Greater Indirect Ownership Interest · Organization
Landa, Benjamin
Corporate Officer · Individual
Merchant, Denesha
W-2 Managing Employee · Individual
Palm Beach Health Partners LLC
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Other facilities in reach
#1
The Terrace Of Delray Beach Nursing And Rehabilita
Delray Beach, FL
4-star overall rating with 3-star inspections with 13 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#2
Abbey Delray South
Delray Beach, FL
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
#3
Cascades Health and Rehabilitation Center
Delray Beach, FL
3-star overall rating with 2-star inspections with abuse icon flag with $29,780 in total fines with 7 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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