F 0550
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or
her rights.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to promote dignity in dining for 1 of 1 resident
reviewed for dignity, of a total sample of 16 residents, (#4).
Findings:
Review of resident #4's medical record revealed she was admitted to the facility on [DATE] with diagnoses
including Alzheimer's disease, dementia, and legal blindness.
Review of resident #4's Minimum Data Set (MDS) annual assessment with Assessment Reference Date
2/22/24 revealed a Brief Interview for Mental Status score of 0 out of 15, which indicated she was
cognitively impaired. The MDS assessment noted resident #4 was totally dependent on staff for activities of
daily living (ADLs), including eating.
Review of resident #4's care plan, revised on 2/23/24, revealed she required staff assistance with ADLs.
Approaches included to, Assure dignity by providing privacy during care, and Provide assistance with meals
as needed.
Review of resident #4's nutritional status care plan, revised on 2/29/24, revealed she received a
mechanically altered diet and required feeding assistance.
On 4/10/24 at 1:20 PM and 1:25 PM, Certified Nursing Assistant (CNA) A was observed feeding resident
#4 while standing over her in the hallway.
On 4/10/24 at 1:31 PM, CNA A acknowledged she was standing while feeding resident #4 her lunch. She
indicated resident #4 usually ate in the dining room but was unable to make it there because she had an
appointment with the podiatrist just before lunch. She mentioned she had asked her co-worker to bring her
a chair, but the other CNA was busy. She validated she should sit down when she fed residents who
needed assistance to eat but was unable to explain why she had not been sitting. She said, I know I am not
supposed to be standing because of safety and positioning.
On 4/10/24 at 2:10 PM, CNA B explained she had a new resident who required eating assistance and she
performed this task while standing. She indicated when the resident ate in bed, it was more comfortable for
her to stand next to the resident to feed her. She added she knew she should sit down but could see what
was going on with the resident better while standing.
On 4/10/24 at 2:46 PM, CNA C explained when one of her residents returned from dialysis, she warmed
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
105839
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105839
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/12/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Terrace of Kissimmee, The
221 Park Place Blvd
Kissimmee, FL 34741
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0550
Level of Harm - Minimal harm
or potential for actual harm
his food up and fed him because he was a, Feeder. When asked if she referred to residents who needed
eating assistance as, Feeders, she stated she was not sure if she should refer to them as, Feeders, or not.
On 4/10/24 at 4:02 PM, CNA D stated her unit had, A lot of Feeders. When asked if residents who required
eating assistance should be referred to in that way, she apologized.
Residents Affected - Some
On 4/11/24 at 10:09 AM, the Unit Manager (UM) for the South Wing explained she tried to send the
Feeders to the dining room because they had more help there. She indicated she sent one to two CNAs to
the dining room and always the unit secretary for each meal to assist with the Feeders. She added there
was an assigned area for the Feeders. The UM stated she did not observe CNA A assisting resident #4 to
eat while standing and acknowledged it was not the facility's practice to do so. When asked if staff should
refer to residents as Feeders, she said it was their culture and they needed to fix it.
On 4/11/24 at 4:31 PM, the Assistant Director of Nursing explained they had an area for residents who
required staff assistance in the dining room, and they were served last. She indicated residents who
preferred to stay in their rooms, were assisted by their assigned CNAs. She stated CNAs were expected to
be seated at resident's eye level, while assisting them to eat. She indicated staff were expected to refer to
residents who required eating assistance as, Assisted diners. She said, It is a dignity issue. She explained
they often reviewed resident rights and covered these topics. The Assistant Director of Nursing stated she
was very surprised by these findings. Later at 5:30 PM, she indicated they had 13 residents who were
dependent on staff for eating assistance.
Review of the facility's policy titled Resident Rights dated 11/23/20 read, Employees shall treat all residents
with kindness, respect, and dignity.
Review of the facility's policy titled Assistance with Meals dated 2001 read, Residents shall receive
assistance with meals in a manner that meets the individual needs of each resident. The form included a
section for Residents Requiring Full Assistance which read, residents who cannot feed themselves will be
fed with attention to safety, comfort, and dignity, for example: Not standing over residents while assisting
them with meals; . avoid the use of labels when referring to residents (e.g. Feeders) .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105839
If continuation sheet
Page 2 of 2
