Inspection·December 23, 2025

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure the Minimum Data Set (MDS) assessments accurately reflected health conditions for 1 of 3 residents reviewed for falls, of a total sample of 12 residents, (#2).Findings: Review of resident #2's medical record revealed she was originally admitted to the facility on [DATE] and readmitted from an acute care hospital on [DATE]. Her diagnoses included seizures, disorders of bone density and structure, anxiety, muscle weakness, and dementia with mood disturbance. Review of resident #2's medical record revealed an Event Report dated 11/18/25 that documented a fall that resulted in bleeding from the nose and a skin tear above the right eyebrow. Review of the Observation Detail List Report dated 11/18/25 revealed resident #2 was transferred to the hospital due to the fall. Review of Section J - Health Conditions of resident #2's Discharge Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 11/18/25 revealed she had one fall with no injury since her Admission/Entry or Reentry of Prior Assessment. Review of the hospital History and Physical form dated 11/19/25 revealed that upon evaluation of resident #2 at the hospital she was found to have a subdural hematoma (a type of bleeding near the brain that can occur after a head injury) with midline shift. The note mentioned resident #2 had a laceration/abrasion over the nasal bridge, dried blood in the nares, and facial abrasions. Results of a Computed Tomography scan revealed comminuted (broken apart or in pieces) nasal bone fractures and possible nondisplaced fracture of the nasal septum. A right frontal scalp hematoma with soft tissue gas was also identified. A right femoral neck (hip) fracture was also documented. On 12/23/25 at 6:21 PM, the MDS Coordinator confirmed the hospital documentation was reviewed upon resident #2's return to the facility. She validated the discharge MDS assessment with an ARD of 11/18/25 showing one fall with no injury was incorrect. She stated that despite the incorrect entry, she could not make a correction to the MDS assessment until the next assessment was completed, possibly at the next 90-day assessment, where the fracture/major injury would be captured. She stated she used the Resident Assessment Instrument (RAI) Manual as her guide. On 12/23/25 at 6:49 PM, the Director of Nursing (DON) stated she did not think the fracture would be captured on the discharge MDS assessment with an ARD of 11/18/25 because it was completed before they learned resident #2 sustained fractures due to the fall. She validated the discharge MDS assessment was inaccurate because resident #2's injury was documented in the medical record and injury should have been selected instead of no injury. On 12/23/25 at 7:08 PM, in a telephone interview, the Regional MDS Nurse validated the discharge MDS assessment with an ARD of 11/18/25 was incorrect and should have been coded as one fall with minor injury. She stated they completed 5-day MDS assessments for some residents upon return from the hospital and confirmed that was not the case for resident #2. She reviewed the RAI Manual and stated that based on the rationale, the MDS assessment needed to be modified to reflect the fracture. Review of the facility's policy and procedure titled Resident Assessments, revised October 2023, read, All persons who have completed any portion of the MDS resident assessment form must sign Residents Affected - Few (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 3 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 12/23/2025 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)