Health inspection·October 14, 2021

F 0686 Level of Harm - Actual harm Residents Affected - Few wound healing. The care plan directed staff to monitor, document, and report any changes in skin status as needed. The document indicated resident #96 needed reminders or assistance to turn and reposition at least every two hours, and more often as needed or requested. The care plan showed the resident required a pressure relieving device, but it did not specify whether for the bed or chair. The document directed staff to treat pain as ordered prior to wound treatment or turning and repositioning to ensure the resident's comfort. An intervention for weekly treatment documentation included measurement of each area of skin breakdown with width, length, depth, type of tissue and drainage. An additional care plan for potential for further skin impairment related to incontinence of bowel, impaired mobility, and weakness was initiated on 6/24/21. The goal was to minimize the risk for skin impairment with current interventions and for current skin impairments to show signs of healing as evidenced by reduction in size. The interventions included staff to assist with repositioning, keep skin clean and dry, pressure reduction mattress to bed, and apply treatment as ordered. The care plan directed nurses to document measurement of each area of skin breakdown and any other notable changes or observations of the skin. On 10/11/21 at 10:06 AM, resident #96 was observed in bed lying flat on his back. Later that day at 1:39 PM, resident #96 remained on his back. Approximately two hours later on 10/11/21 at 3:25 PM, resident #96's position was unchanged. On 10/12/21 at 10:10 AM, resident #96 was in bed, lying on his back, now moaning loudly with pronounced facial grimacing. He stated he had pain in his legs and feet which he rated as 7 on a 0 to 10 scale. The resident requested staff assistance with repositioning. Registered Nurse (RN) C entered the room and offered to change the dressings on his foot wounds, but she did not reposition him. On 10/12/21 at 10:48 AM, resident #96 was still in the same position, flat on his back in bed. On 10/12/21 at 12:58 PM, resident #96 remained on his back, and now complained of pain to his bottom. A few minutes later at 1:01 PM, RN C was informed of resident #96's complaints of pain to his bottom. She denied knowledge of any pressure ulcer or skin issue on his bottom. On 10/12/21 at 1:12 PM, RN C and Patient Care Assistant (PCA) E entered resident #96's room and he informed them of the pain to his bottom. RN C and PCA E turned resident #96 to his side to assess the area. They removed his incontinence brief which was soiled with feces, to reveal a reddened, open wound to his sacrum. RN C cleaned the open area with normal saline, applied a barrier ointment and covered the area with a dry dressing. RN C was asked about wound measurements and if physician's orders were in place for the treatment she applied. RN C stated the wound doctor would be in the facility the following day and he would give appropriate orders then. PCA E was unsure of the turning frequency required for resident #96. Review of resident #96's medical record revealed RN D documented a progress note dated 10/11/21 that read, pressure area seen in sacrum .5x.5x.3, consult with wound DR (doctor) for eval. A Weekly Skin Integrity Review dated 10/11/21 at 12:47 PM, indicated a new open area was noted to be 0.5 centimeters (cm) by 0.5 cm by 0.3 cm located on resident #96's sacrum. Review of the Order Summary Report revealed no orders for preventative treatment or wound care to address the area of skin breakdown on resident #96's bottom as identified by RN D. On 10/13/21 at 1:52 PM, RN C stated the wound doctor was scheduled to evaluate resident #96 later (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106011 If continuation sheet Page 2 of 6 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 106011 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kissimmee Nursing & Rehabilitation Center 2511 John Young Parkway North 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 0686 Level of Harm - Actual harm Residents Affected - Few that afternoon. She explained he needed to be turned and repositioned to prevent development of pressure sores, and staff should use barrier cream as a preventative intervention. RN C stated residents with pressure wounds should have air mattress ordered by the wound doctor. She confirmed resident #96 was not currently on an air mattress. RN C stated she entered an order the previous day to change resident #96's position every two hours because he was not being turned and repositioned. She stated to her knowledge, resident #96 had not refused to be turned. She explained that it was the CNA's duty to perform this task, but ultimately it was the nurse's responsibility to ensure it was done. On 10/13/21 at 2:22 PM, the wound doctor measured resident #96's sacral wound to be 2 cm by 1 cm by 0.2 cm deep. He stated resident #96 previously had a sacral wound, but it had been healed for several months. He stated resident #96 should have been on an air mattress due to his multiple pressure wounds. Review of the wound doctor's Visit Report dated 10/13/21 revealed resident #96's sacral pressure ulcer measured 2 cm by 1 cm by 0.2 cm, an increase in size from 0.5 cm by 0.5 cm by 0.3 cm as documented by RN D on 10/11/21. In the doctor's report the wound was described as a Stage 3 Pressure Injury with a light amount of thin, liquid drainage. On 10/14/21 at 10:35 AM, RN D recalled on Monday, 10/11/21 PCA F informed her he noticed an area of concern on resident #96's bottom while giving incontinence care. She stated she entered a progress note regarding the wound, and she expected the wound doctor to give appropriate orders when he visited on Wednesday, 10/13/21. She stated she informed the primary doctor who told her, Put cream on it, cover it and put in the wound consult. She acknowledged if resident #96 was left in the same position and not turned, he would likely develop pressure wounds or his current wounds would worsen. On 10/14/21 at 10:57 AM, PCA F stated when he noticed an open wound on resident #96's bottom on Monday 10/11/21, he notified RN D. He stated he had not used barrier cream on resident #96's bottom. PCA F demonstrated use of the electronic documentation system used by PCAs to chart. He indicated there were no instructions regarding turning and repositioning for resident #96. On 10/14/21 at 3:16 PM, in a telephone interview, resident #96's attending physician stated he was informed of the resident's new pressure wound on Tuesday 10/12/21, not on Monday 10/11/21 as reported by RN D. He confirmed he did not order any wound treatments at that time as described by RN D and applied by RN C. The attending physician did not recall giving any preventative wound care orders for resident #96 as he was being seen by a wound care doctor. On 10/14/21 at 4:14 PM, the Director of Nursing (DON) stated her expectation was if a resident had redness to their skin the nurse should obtain appropriate skin treatment orders. She said, If it's an open wound they are asked to put in an intervention, not to wait. She explained the nurse should address the issue immediately, implement appropriate interventions, notify the DON, and request a wound consult. She confirmed resident #96 had a standard pressure reducing mattress, but noted it was not a specialty air mattress used for residents at high risk for pressure ulcers. She recalled resident #96 had a stage 1 sacral pressure ulcer at the beginning of his stay which had healed with care. She stated since resident #96 was at risk to develop pressure ulcers, the nursing staff should have ensured he was turned and repositioned every two hours. She acknowledged there was no documentation in resident #96's medical record to validate he was being turned regularly. The DON verbalized there were no orders for preventative treatments after the stage 1 pressure ulcer healed in July to prevent further skin breakdown. The DON explained on Tuesday 10/12/21, after the facility was made aware of the acquired pressure ulcer, RN C obtained physician orders for repositioning every two hours, a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106011 If continuation sheet Page 3 of 6 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 106011 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kissimmee Nursing & Rehabilitation Center 2511 John Young Parkway North 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 0686 wound consult, and wound treatment. The DON stated RN D should have obtained an order for wound treatment as soon as the area of skin breakdown was identified to prevent worsening. Level of Harm - Actual harm Residents Affected - Few On 10/14/21 at 7:03 PM, the Care Plan Coordinator stated resident #96 required extensive assistance for bed mobility. She stated he was not able to turn himself independently and required staff to reposition him every two hours or possibly more frequently. She acknowledged that although his care plans indicated he required assistance with repositioning, clear instructions for staff to turn and reposition resident #96 were not on the CNA [NAME] or care plan. The Care Plan Coordinator said, I would say he is high risk for pressure ulcers. She acknowledged it would be much better if he was on an alternating air mattress since he was at high risk for pressure ulcers. On 10/14/21 at 7:27 PM, the DON acknowledged resident #96 was at high risk for developing pressure wounds. She stated there was no documentation to show this resident refused care. She stated turning and repositioning was an effective preventative measure and she felt a physician's order for this task should be written more often. The DON could not provide a reason why resident #96 had not received barrier cream as a preventative measure and noted it was not documented anywhere. A review of the policy and procedure, Clinical Guideline Skin and Wound dated 4/01/17 revealed an overview, To provide a system for identifying skin at risk, implementing individual interventions including evaluation and monitoring as indicated to promote skin health, healing and decrease worsening of/prevention of pressure injury. The process directed the licensed nurse to report changes in skin integrity to the physician and resident's responsible party and to document in the medical record. It further instructed the licensed nurse to develop individualized goals and interventions for the resident, to document on the care plan, the CNA [NAME], to monitor the resident's response to treatment and modify the treatment as indicated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106011 If continuation sheet Page 4 of 6 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 106011 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kissimmee Nursing & Rehabilitation Center 2511 John Young Parkway North 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 0805 Level of Harm - Minimal harm or potential for actual harm Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Based on observation, interview and record review, the facility failed to provide mechanically altered foods to meet the individual needs for 1 of 5 residents reviewed for nutrition, out of 40 sampled residents, (#52). Residents Affected - Some Findings: Resident #52 was admitted to the facility from an acute care hospital on 9/20/19 with diagnoses including muscle weakness, diabetes, anemia. The Minimum Data Set (MDS) Quarterly assessment with assessment reference date of 8/16/21 revealed resident #52 had a Brief Interview for Mental Status score of 14 indicating her cognition was intact. She required set up help only to eat her meals. The MDS assessment indicated she required a mechanically altered, therapeutic diet. Review of resident #52's medical record revealed a care plan for activities of daily living initiated on 10/10/19. The interventions noted the resident had a mechanically altered diet and was able to feed herself. A care plan for nutrition initiated on 9/27/19 revealed resident #52 had a nutritional problem related to altered food texture. The care plan directed staff to provide and serve diet as ordered. Review of the Order Summary Report revealed a physician order dated 7/29/21 for Dysphagia Mechanical soft texture, regular/thin liquids consistency diet. Dysphagia or difficulty swallowing means it takes more time and effort to move food or liquid from your mouth to your stomach. (retrieved on 10/19/21 from www.mayoclinic.org). Review of Diet and Nutrition Care Manual for Dysphagia Mechanically Altered (Level 2) or Mechanical Soft Diet dated 2019, revealed that difficult to chew foods are chopped, ground, shredded, cooked or altered to make them easier to chew and swallow. Foods should be soft and moist enough to form a bolus and prepared according to the individual's tolerance to the food. On 10/11/21 at 11:55 AM, resident #52 was observed in her room waiting for her lunch tray to be delivered. She complained that sometimes the food, especially the vegetables were not cooked enough. She described the vegetables as too hard and stated she could not chew them because she had no teeth. The resident explained she had gum surgery in the past and was on a mechanical soft diet as the food needed to be chopped, soft and moist for her to eat it. She stated she reported her concerns to the facility staff several times and even met with someone from the dietary department, but she continued to receive food that was the wrong texture. On 10/13/21 at 12:26 PM, resident #52's lunch tray was observed to have medium sized chunks of chicken, whole dumplings about 1 inch in diameter, mashed potatoes, and whole green peas on her plate. Reconciliation of her food with the meal ticket revealed she did not receive the dysphagia mechanical ground chicken and dumplings. The ticket listed marinated green bean salad and pureed corn bread which she did not receive. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106011 If continuation sheet Page 5 of 6 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 106011 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kissimmee Nursing & Rehabilitation Center 2511 John Young Parkway North 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 0805 Level of Harm - Minimal harm or potential for actual harm On 10/13/21 at 12:31 PM, the Regional Certified Dietary Manager (CDM) could not explain why resident #52 received regular sized chicken and dumplings and whole peas on her lunch tray. He explained that for mechanical dysphagia diet, resident #52 should have received ground chicken and dumplings and pureed green peas as an alternate. The Regional CDM showed a sample of the finely chopped chicken and dumplings that resident #52 should have received. Residents Affected - Some On 10/13/21 at 12:35 PM, resident #52 was still seated in her room with her partially eaten lunch. She stated the peas needed to be cooked more. She lifted her fork to demonstrate how hard the peas were and said, You can't even mash them with a fork. She explained she could mash some of the meat in her mouth, but some of the pieces were too tough. Resident #52 reiterated her food needed to be cut into smaller pieces or made softer. On 10/13/21 at 12:57 PM, the Speech Therapist (ST) stated resident #52 required a mechanical dysphagia diet with most of the items either ground or pureed. The ST confirmed the issues with resident #52's food had been going on forever and she explained the problem was with the kitchen not providing the correct texture. The ST stated she had discussed it with the previous CDM many times. The ST acknowledged resident #52 could have an aspiration or choking issue if her food were not properly modified. On 10/13/21 at 1:19 PM, Registered Nurse (RN) C stated resident #52 was alert, oriented and able to make her needs known. She stated the resident did not have teeth and had problems chewing. RN C explained she had to crush resident #52's medications as she had trouble swallowing. Review of the Diet Guide Sheet for Lunch Day 25 (Week: 4-Wednesday) for Dysphagia Mechanical revealed the entree Ground Chicken and Dumplings. The document listed Pureed [NAME] Peas as the alternate vegetable selection. On 10/14/21 at 1:09 PM and 1:44 PM, the Regional CDM stated the facility conducted a monthly audit of one test tray to determine temperature and taste. He explained the focus of the audit was on speed of delivery, temperature and if any items were missing, but not to verify accuracy of diet type or food texture. The CDM concluded that dietary staff placed the wrong plate on resident #52's tray. He confirmed that if a resident received food in the wrong form, it could by life threatening. A review of the policy Texture Modification Inservice (undated), read, Proper preparation and delivery of texture modified diets is critical for resident safety and wellness. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106011 If continuation sheet Page 6 of 6