Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Harbours Edge during CMS and state inspections, most recent first.
A deficiency was cited when a facility area was found to contain accident hazards and lacked adequate supervision to prevent accidents, resulting in an unsafe environment for residents.
Surveyors found that two residents did not receive required infection control measures: one with a chronic wound did not have Enhanced Barrier Precautions (EBP) implemented, lacked an EBP care plan, and staff performed wound care without a gown; another on contact precautions had an RN start IV antibiotics wearing only gloves, not a gown, despite posted precautions. These lapses were confirmed by facility leadership.
A resident with severe protein-calorie malnutrition did not receive timely nutritional interventions at an LTC facility. Despite a poor appetite and significant weight loss, the Comprehensive Nutritional Assessment was delayed, and Ensure Plus supplements were not administered promptly. The resident's weight was not recorded as required, leading to continued weight loss. Interviews revealed a lack of urgency in addressing the nutritional needs of high-risk residents.
The facility failed to change nebulizer tubing weekly for two residents, as required by its infection prevention policy. Observations showed that the tubing for both residents was not changed for over a week, and there was no documentation of changes in the Treatment Administration Record or Progress Notes. Interviews with staff confirmed the tubing should be changed weekly, but this was not done, leading to a deficiency in respiratory care.
Staff at the facility failed to follow hand hygiene protocols during food service, as observed in multiple instances. Dietary assistants and a CNA served food and beverages without washing hands, and the dietary manager also neglected hand hygiene. Despite prior education on hand hygiene, these practices did not align with the facility's policy or federal requirements.
A facility failed to accurately document midline dressing changes for a resident, as required by their policy. The resident had orders for weekly dressing changes, but records showed only one documented change despite observations of multiple changes. Interviews with staff revealed inconsistencies in documentation practices, leading to a deficiency in maintaining accurate medical records.
The facility failed to implement proper PPE protocols for residents on Transmission-Based Precautions. A resident on Contact Precautions was assisted by staff who did not adhere to PPE guidelines, including improper mask use and lack of hand hygiene. Another resident on Droplet Precautions for COVID-19 had staff enter their room without appropriate PPE or hand hygiene. Additionally, a resident requiring Enhanced Barrier Precautions was exposed to staff non-compliance, as housekeeping personnel failed to sanitize hands and improperly handled PPE.
The facility failed to respond promptly to call lights for three residents, resulting in significant delays in assistance. One resident experienced wait times exceeding 95 minutes, while another expressed concerns about emergency situations. Additionally, a resident struggled with a broken call light and was unable to reach another, highlighting issues with accessibility and staff response procedures.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which resulted in the presence of accident hazards and insufficient oversight to protect residents from potential harm. No additional details regarding the specific hazards, the number of residents affected, or their medical conditions at the time of the deficiency are provided in the report.
Failure to Implement Enhanced Barrier and Contact Precautions
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) and Contact Precautions as required for two residents. For one resident with a stage 4 pressure ulcer on the right heel and severe cognitive impairment, there was no physician's order for EBP, no EBP care plan in place, and no EBP signage or isolation cart with personal protective equipment (PPE) near the resident's room. During wound care, the registered nurse performed the procedure without donning a gown, and only gloves were used. The infection preventionist confirmed that there was no EBP care plan for this resident, despite the presence of a chronic wound that met the criteria for EBP according to facility policy. For another resident on contact precautions due to a recent diagnosis, the required infection control measures were not fully implemented. Although a sign indicating contact precautions was posted on the resident's door, a registered nurse was observed starting an intravenous medication while wearing gloves but not a gown, contrary to CDC guidelines and facility policy, which require both gown and gloves for all interactions that may involve contact with the resident or their environment. These deficiencies were confirmed through observations, interviews, and record reviews. The administrator and director of nursing acknowledged the findings during the survey. The failures were directly related to lapses in following established infection prevention and control policies, including the absence of required care plans, signage, and proper use of PPE during resident care activities.
Failure to Provide Timely Nutritional Interventions
Penalty
Summary
The facility failed to provide timely nutritional interventions for a resident identified as having severe protein-calorie malnutrition. Upon admission, the resident was noted to have a poor appetite, consuming less than 50% of meals, and expressed a preference for Ensure Plus supplements. Despite these indicators, the Comprehensive Nutritional Assessment was not completed until seven days after admission, and the initial order for Ensure Plus was delayed until eight days post-admission. The resident's weight was not recorded promptly, with the first weight taken six days after admission, and no subsequent weights were documented as per the physician's orders. The resident's medical history included severe protein-calorie malnutrition, anemia, and weakness, with a Body Mass Index (BMI) of 17.0, categorizing them as underweight. The resident's condition was further complicated by recent significant weight loss and a history of decreased food intake. Despite these risk factors, the facility did not implement immediate nutritional interventions, such as increasing the frequency of Ensure Plus supplements, until 12 days after admission. This delay in addressing the resident's nutritional needs contributed to continued weight loss, as evidenced by a further reduction in weight to 120 pounds and a BMI of 16.1. Interviews with facility staff revealed a lack of urgency in assessing and addressing the nutritional needs of high-risk residents. The Clinical Dietitian acknowledged that the initial recommendation of Ensure Plus once a day was insufficient to meet the resident's needs. The facility's policy required weights to be taken on admission, the second day, weekly for four weeks, and monthly thereafter, but these procedures were not followed. The resident's wife expressed concern over the weight loss and emphasized the importance of receiving Ensure supplements daily, highlighting the facility's failure to meet the nutritional requirements of the resident in a timely manner.
Failure to Change Nebulizer Tubing Weekly
Penalty
Summary
The facility failed to adhere to its policy regarding the weekly change of nebulizer tubing for two residents, leading to a deficiency in respiratory care. The policy, revised in November 2020, mandates that nebulizer administration setups be discarded every seven days to prevent infection. However, observations and record reviews revealed that the nebulizer tubing for two residents, identified as Resident #45 and Resident #153, was not changed weekly as required. Resident #45, who was admitted with conditions including surgical aftercare and a Methicillin Resistant Staphylococcus Aureus infection, was observed with nebulizer tubing dated 06/26/24, which was not changed until 07/08/24. The Treatment Administration Record (TAR) and Progress Notes for this resident from 07/01/24 to 07/04/24 showed no documentation of tubing changes, despite physician orders for regular nebulizer treatments. Interviews with nursing staff confirmed that the tubing should be changed weekly, typically by the night shift, and documented on the TAR. Similarly, Resident #153, with a history of lung cancer and shortness of breath, was observed with nebulizer tubing dated 06/26/24, which was not changed until 07/08/24. The TAR and Progress Notes for this resident from 07/01/24 to 07/07/24 also lacked documentation of tubing changes. Interviews with the Director of Nursing and nursing staff confirmed the weekly change policy and the lack of documentation for these residents. The deficiency was identified due to the absence of orders and documentation for the nebulizer tubing changes for both residents.
Failure in Hand Hygiene During Food Service
Penalty
Summary
The facility's staff failed to adhere to hand hygiene protocols during food service, as observed in five separate dining observations. Staff members, including dietary assistants and a certified nursing assistant, were seen serving food and beverages to residents without washing their hands or using hand sanitizers. Specific instances included a dietary assistant serving juices and ice water cups while touching the rims with bare hands, and another assistant serving soup without prior handwashing. Additionally, a certified nursing assistant set up lunch trays for residents without practicing hand hygiene before or after the task. Further observations revealed that the dietary manager also neglected hand hygiene practices. She was seen touching kitchen doors and serving soup and meals to residents without washing her hands. Despite previous education on hand hygiene provided by the Infection Preventionist in May 2024, these lapses in protocol were still evident. Interviews with staff indicated that some were aware of the hand hygiene requirements, yet the observed practices did not align with the facility's policy or federal food safety requirements.
Inaccurate Documentation of Midline Dressing Changes
Penalty
Summary
The facility failed to ensure the accuracy of medical records concerning the documentation of Midline dressing changes for a resident with a midline/central line. The facility's policy requires that all procedures and treatments, including dressing changes, be documented with specific details such as the date, time, and the name of the individual performing the care. However, for one resident, the documentation was inconsistent and incomplete, leading to a deficiency in maintaining accurate medical records. The resident in question was admitted with diagnoses including surgical aftercare and a Methicillin Resistant Staphylococcus Aureus infection. The physician's orders specified that the midline dressing should be changed every Tuesday night shift. However, a review of the Treatment Administration Record (TAR) for July revealed that the only documented dressing change occurred on the second of the month, despite observations indicating that the dressing was changed on other dates without proper documentation. Interviews with nursing staff and the Director of Nursing (DON) revealed discrepancies in the documentation process. The DON acknowledged that if a dressing change was performed, it should have been documented, but there was no record of the change on the observed dates. An agency nurse also admitted to possibly documenting the dressing change late, which contributed to the inconsistency in the records. This lack of accurate documentation violated the facility's policy and professional standards for maintaining medical records.
Failure to Implement PPE Protocols for Residents on Precautions
Penalty
Summary
The facility failed to implement and sustain appropriate Personal Protective Equipment (PPE) protocols for residents on Transmission-Based Precautions. Resident #26, who was on Contact Precautions due to an ESBL infection, was observed with staff not adhering to PPE guidelines. Staff F, a Private Aide, was seen with a mask improperly worn and did not practice hand hygiene while assisting the resident with drinks. Additionally, Staff H, a CNA, entered the resident's room without wearing gloves or a gown and did not perform hand hygiene before or after handling items in the room. Resident #253, on Droplet Precautions for a positive COVID-19 test, was also subject to improper PPE use. Staff A, a Supervisor Lifestyle, entered the resident's room without wearing a gown or gloves and did not perform hand hygiene before or after touching surfaces and linens. This lack of adherence to PPE protocols was observed despite the presence of Droplet Precaution signage outside the resident's room. Resident #261, who required Enhanced Barrier Precautions due to multiple medical conditions and devices, was also affected by staff non-compliance. Staff O, a Housekeeping Personnel, entered the resident's room without sanitizing her hands and was observed touching various items while wearing gloves, which she then used to dig into her personal clothing pockets. This behavior occurred despite the Enhanced Barrier Precaution signage and the staff's training on these precautions.
Delayed Call Light Responses and Inaccessible Call Lights
Penalty
Summary
The facility failed to respond to call lights in a timely manner for three residents, leading to significant delays in assistance. Resident #6, who is cognitively intact but dependent on staff for most activities of daily living (ADLs), experienced multiple instances where call light response times exceeded 30 minutes, with one instance reaching over 95 minutes. Despite reporting the issue to staff, no corrective action was taken. Resident #29, also cognitively intact and dependent on staff for ADLs, reported similar delays, expressing concern about the potential lack of assistance in emergencies. Resident #204, who requires substantial assistance for ADLs, also experienced prolonged wait times for call light responses, with several instances exceeding 30 minutes. The resident and his spouse reported dissatisfaction with the care provided, noting that staff would sometimes turn off the call light without providing immediate assistance. Observations confirmed that staff did not return promptly to assist the resident, even when the call light was activated. Additionally, the facility failed to ensure that the call light was functional and within reach for Resident #254. The resident, who is cognitively intact, was observed struggling to use a broken call light and was unable to reach another call light clipped to the bed sheets. Despite attempts to get staff attention, the resident's needs were not addressed, and staff failed to ensure the call light was accessible. Interviews with staff revealed inconsistencies in call light response procedures, with some staff unaware of the system's functionality and others not adhering to the expected response times.
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What surveyors actually found near you
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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.
Illustrative
A prioritized, do-first checklist
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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 | 1.6 mi | — | 6 | 0 |
| Abbey Delray South | 2 mi | — | 0 | 0 |
| Yamato Nursing And Rehabilitation Center | 3.3 mi | — | 0 | 0 |
| The Terrace Of Delray Beach Nursing And Rehabilita | 3.7 mi | — | 0 | 0 |
| Isles Of Boynton Nursing And Rehab Center | 4.3 mi | — | 9 | 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 August 2026) and official state health department websites.