Inspection visit

Health inspectionAugust 10, 2023

KISSIMMEE NURSING & REHABILITATION CENTERCMS #1060117 citations on this visit

7 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 7 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure copy of a transfer/discharge notice was sent to a representative of the Office of the State Long-Term Care Ombudsman for 2 of 2 residents reviewed for hospitalization of a total sample of 36 residents. (#6, #21) Findings: 1. Resident #6 was admitted to the facility on [DATE] from an acute care hospital. The resident had multiple readmissions to the facility, with her most recent readmission on [DATE]. Her diagnoses included myocardial infarction, takotsubo syndrome, atherosclerotic heart disease, hypertension, lymphedema, and malignant neoplasm of large intestine. Record review of the resident's clinical records revealed she was transferred to an acute care hospital on 5/08/23 to 5/11/23, 5/25/23 to 5/27/23, 5/31/23 to 6/06/23, 6/20/23 to 6/26/23, and on 7/16/23 to 7/17/23. Notification to the Ombudsman of the resident's hospital transfers could not be identified. 2. Resident #21 was admitted to the facility on [DATE], discharged to an acute care hospital on 6/26/23, and was readmitted to the facility on [DATE]. Her diagnoses included diabetes type II, hypertensive heart and chronic kidney disease, dementia, major depressive disorder, anxiety disorder, bipolar disorder, and Alzheimer's disease. Record review of the resident's clinical records revealed she was transferred to an acute care hospital from [DATE] to 6/28/23. A notification to the Ombudsman of the resident's hospital transfer could not be identified. On 8/10/23 at 2:21 PM, the Social Services Director (SSD) stated that notification to the Ombudsman was done when a resident leaves the facility against medical advice (AMA), but the Ombudsman was not notified when a facility initiated transfer/discharge to the hospital occurred. The SSD stated the resident and family were notified of the transfer/discharge to the hospital, but a copy of the notice was not sent/provided to the Ombudsman. She stated she did not know notification to a representative of the Office of the State Long-Term Care Ombudsman was required for facility-initiated transfer/discharges to the hospital. The facility's policy Transfer/Discharge Notification & Rights to Appeal with effective date of 4/01/22, indicated that the resident/resident representative must be notified of the transfer/discharge, and read, the Center must send a copy of the notice to a representative of the office of the state (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 14 Event ID: 106011 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 08/10/2023 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 0623 long-term care ombudsman. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106011 If continuation sheet Page 2 of 14 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 08/10/2023 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to initiate a baseline care plan to address infection and a peripherally inserted central catheter (PICC) line for 1 resident reviewed for antibiotic use of a total sample of 36 residents. (#78). Findings Resident #78, a [AGE] year-old female was admitted to the facility on [DATE], with her most recent readmission on [DATE]. Her diagnoses included osteomyelitis, generalized muscle weakness, cystitis, diabetes type II, chronic obstructive pulmonary disease, and atrial fibrillation. The resident's physician orders dated 7/25/23 included, Meropenem 1000 milligram every 8 hours, with a stop date of 8/18/23, and change dressing on admission or 24 hours after insertion and weekly thereafter and as needed. Meropenem is an antibiotic that is used to treat severe infections of the skin and stomach. (retrieved on 8/18/23 from www.drugs.com). Review of the resident's Baseline Care plan dated 7/24/23 revealed the resident was on intravenous (IV) medications. There was no documentation regarding the resident's IV access, or antibiotic therapy/infection. On 8/08/23 at 4:07 PM, Registered Nurse (RN) A stated resident #78 had a PICC line to her right upper arm and had physician orders for IV antibiotic Meropenem every eight hours. A PICC line is a thin, soft tube that is inserted into a vein in the arm, leg or neck for long-term IV (intravenous) antibiotics, nutrition, medications, and blood draws. (retrieved on 8/18/23 from www.chop.edu). On 8/09/23 at 2:42 PM, the General and Restorative Unit (G&R) Unit Manager (UM), stated a care plan should be developed for IV antibiotic and the resident's PICC line. The resident's care plans were reviewed with the UM, she confirmed that a care plan could not be identified to address the resident's infection, antibiotic therapy, or the PICC line. The UM stated that care plans were discussed in the AM clinical meetings, and care plans would be initiated based on the resident's diagnosis/identified needs. On 8/10/23 at 10:11 AM, the G&R UM, provided copies of care plans for infection and PICC line for resident #78. Review of the care plans revealed documentation to indicate the care plans were initiated on 7/24/23, with revision on 8/09/23. However, the UM confirmed that care plans were not in place on 7/24/23 and explained that she initiated/developed the care plans for infection/antibiotic use, and PICC line on 8/09/23. She said she put the initiated date as 7/24/23 because that was the date the resident returned to the facility with the PICC line, and orders for IV antibiotics. On 8/10/23 at 10:17 AM, the Director of Nursing (DON), stated baseline care plans should be developed within 24 to 48 hours of a resident's admission. She confirmed that the G &R UM verbalized that care plans for infection/antibiotic therapy, and PICC line for resident #78 were initiated/developed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106011 If continuation sheet Page 3 of 14 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 08/10/2023 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete by her on 8/09/23. The DON stated care plans to address the resident's care should have been developed prior to 8/09/23. The facility's policy Baseline Care Plan indicated that a baseline care plan would be initiated on admission and completed within 48 hours of admission. The document read, Information for the baseline care plan will be based upon admission orders The care plan will include at the minimum .physician orders . Instructions needed to provide effective and person-centered care that meets professional standards of quality care . The baseline care plan will include conditions and risks affecting the resident's health and safety. Examples include . infection(s). Event ID: Facility ID: 106011 If continuation sheet Page 4 of 14 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 08/10/2023 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 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure an individualized activity program was provided to 1 of 1 resident reviewed for Activities from a total sample of 36 residents. (#313) Residents Affected - Few Findings: Review of the medical record revealed resident #313 was admitted to the facility from an acute care hospital on 7/22/23. The resident had diagnoses that included major depressive disorder, single episode, moderate, multiple myeloma, seizures, type 2 diabetes mellitus, weakness, and pressure ulcers of the sacral region and the left heel. The Minimum Data Set (MDS) admission assessment with Assessment Reference Date 7/29/23 noted the resident scored 12 out of 15 for the Brief Interview for Mental Status (BIMS) and did not require further cognitive assessment. The Resident Mood Interview showed the resident felt down, depressed, or hopeless, and he had trouble concentrating for 7 to 11 days. Medications noted the resident received antidepressants for 7 out of 7 days during the look back period. The Preferences for Routine and Activities showed that the resident felt it was somewhat important to participate in groups, and he wanted to go outside to get fresh air as it was, very important. The Functional Status assessment noted he required 2 staff for transfers and was assisted to transfer to or from his bed to a chair, only once or twice. On 8/08/23 at 9:13 AM, resident #313 was observed lying in bed. He said he had asked various staff to help him go outside since he came to the facility. He stated that he was frustrated and felt better when he could get some fresh air. He explained he was a former smoker and was accustomed to being outside. Review of the Psychiatric Evaluation completed 8/01/23 noted resident #313 was cognitively intact and had good judgement, insight, and memory. Treatment was provided for depression, and it was noted that the resident had no past use of psychotropic medications. His limitations were noted as, ADL dependent. The Psychology Evaluation completed on 8/07/23 noted the resident had good insight and judgement, had an increased score of 14 out of 15 on the BIMS, reported anxiety due to medical issues and pain, and he had no psychiatric history. The Treatment Plan included continuance of psychotherapy weekly for 90 days with goals for the resident to utilize at least 3 healthy ways to increase mood and manage stress. The Comprehensive Care Plan did not include a plan of care for Activities. The Order Summary Report noted physician's orders for medication to treat major depressive disorder that included Sertraline HCI 25 milligrams (MG) oral tablet once daily started 7/22/23, and Mirtazapine 15 MG oral tablet at bedtime started 7/27/23. On 8/09/23 at 9:25 AM, the Activities Assistant said she was not aware resident #313's activities preferences included that it was important for him to go outside for fresh air. She explained that she only assisted residents who ambulated or propelled themselves in wheelchairs and congregated periodically outside the activities office to go out together as a group. She stated it was difficult to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106011 If continuation sheet Page 5 of 14 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 08/10/2023 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 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few include residents that required staff assistance to transfer out of bed and transported to the group area because, the Certified Nursing Assistants (CNA) don't get them out of bed and they're here to get better. On 8/09/23 at 9:31 AM, the Community Life Director said she was responsible for the facility's resident activities programs. She explained residents were interviewed and assessed within 7 days after they were admitted to the facility and reassessed periodically and as needed. She stated residents were able to go outside if they wanted to, and only residents who were out of their rooms and among a group were supervised and assisted to go out for fresh air. On 8/09/23 at 10:17 AM, the Community Life Director said she completed resident #313's MDS assessment for Preferences for Routines and Activities. She checked the medical record and acknowledged when she interviewed the resident, he told her it was very important for him to go outside for fresh air. She could not explain why resident #313 was not included with the group when outside activities were conducted. She explained activity preferences and routines were important to well-being and the resident should have been able to enjoy going outside as part of his activities while in the facility. The facility's policies and procedures titled Activities Programs dated February 2012, read, To encourage self-care, resumption of normal activities and maintenance of an optimal level of psychosocial functioning. These programs take into consideration the needs and former interests of the resident and are designed to promote opportunities for engaging in normal pursuits including . activities of their choice . The activities are designed to promote the physical, social, and mental well-being of the residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106011 If continuation sheet Page 6 of 14 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 08/10/2023 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure physician's orders and care plan interventions were implemented to meet the resident's needs for 1 resident reviewed for edema of a total sample of 36 residents. (#1) Residents Affected - Few Findings: Resident # 1, a 91- year-old female was admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included chronic systolic (congestive) heart failure, venous insufficiency, mononeuropathy of bilateral lower limbs, diabetes type II, and cardiac pacemaker. Physician's order dated 7/05/23 was for knee high light compression stocking to the left lower extremity, on in the AM, and off at nights as tolerated, for lymphedema of left lower extremity, with start date of 7/06/23. Lymphedema is swelling due to build-up of lymph fluid in the body. (retrieved on 8/18/23 from www.cdc.gov). On 8/07/23 at 11:15 AM, on 8/08/23 at 12:00 PM, and on 8/08/23 at 4:11 PM, resident #1, was sitting in her wheelchair at the entrance of her room, she had edema to her left lower extremity. Resident #1 stated she had thigh high compression stockings for her leg, but they were too tight, so she needed knee high compression stocking. The resident stated she was told she would get the knee-high compression stocking approximately three weeks ago, but had not received them yet. On 8/08/23 at 4:17 PM, Registered Nurse (RN) A stated resident#1 said the cardiologist visited and told her he would order below the knee compression stocking for her. RN A reviewed the resident's Treatment Administration Record (TAR) and stated she did not see an order for compression stocking. On 8/09/23 at 10:17 AM, resident # 1 was sitting in her wheelchair in her room and the knee high compression stocking to her left lower extremity was not in place. On 8/09/23 at 1:51 PM, the resident's physician orders were reviewed with RN C. She confirmed that a physician order for knee high compression stocking was identified and was dated 7/05/23. The RN stated, the physician's order did not populate to the resident's TAR. However, review of the physician's order indicated the order was placed by the cardiology nurse practitioner and confirmed by nursing. This was confirmed by RN C. On 8/09/23 at 2:04 PM, observation of the resident was conducted with RN C. She confirmed that knee high compression stocking for the resident's left lower extremity was not in place. On 8/09/23 at 2:20 PM, the General and Restorative Unit (G&R) Unit Manager (UM), stated new orders were reviewed within 24 to 48 hours, and orders should populate on the TAR. She recalled that a previous order for compression stocking was discontinued because the resident was refusing to wear the stocking. She stated she did not know that the compression stocking was reordered. The UM explained that normally she would review new orders, via a report generated from all orders placed, and would review the facility's 24 hours order listing. She stated the process included checking to ensure orders were in place, populated to the Medication Administration Record (MAR)/TAR, and that orders were (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106011 If continuation sheet Page 7 of 14 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 08/10/2023 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 0684 Level of Harm - Minimal harm or potential for actual harm spelled correctly. Resident #1's physician orders were reviewed with the UM. She confirmed that an order for knee-high compression stocking was included in the resident's active orders, but the order did not populate to the resident's TAR. She verbalized the facility had systems in place to follow up and check up on orders to ensure orders populated to the MAR/TAR. However, she was unable to explain why the resident's physician's order for the knee-high compression stocking was not implemented. Residents Affected - Few On 8/10/23 at 10:39 AM, the Director of Nursing (DON) stated the expectation was that nurses would pick up the physician's order. She said if the facility did not have the knee-high compression stocking ordered, the physician should be notified, and an order should be obtained to hold the order or obtain an alternative order. The DON confirmed that there was no documentation to indicate resident #1 refused application of the knee-high compression stocking. The resident's care plan for diuretics' therapy related to edema, and hypertension, initiated on 8/10/20 with revision on 6/18/23 interventions included, 7/24/23 knee high compression stocking on in AM and off at bedtime. The policy Physician Order's Policy and Procedures, revised on 3/23, read, Physician orders will be followed by appropriate discipline . Meds and treatments will be followed by nursing. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106011 If continuation sheet Page 8 of 14 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 08/10/2023 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 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a Peripherally Inserted Central Catheter (PICC) line dressing was changed in accordance with professional standards to prevent the potential for infection for 1 of 1 resident reviewed for antibiotic use of a total sample of 36 residents, (#78). Residents Affected - Few Findings: Resident #78, a [AGE] year-old female was admitted to the facility on [DATE], with her most recent readmission on [DATE]. Her diagnoses included osteomyelitis, generalized muscle weakness, cystitis, diabetes type II, chronic obstructive pulmonary disease, and atrial fibrillation. The resident's physician orders dated 7/25/23 included, Meropenem 1000 milligram every 8 hours, with a stop date of 8/18/23, and change dressing on admission or 24 hours after insertion and weekly thereafter and as needed. Meropenem is an antibiotic that is used to treat severe infections of the skin and stomach. (retrieved on 8/18/23 from www.drugs.com). On 8/08/23 at 11:46 AM, resident # 78 was lying in bed on her back. A PICC line was noted to her right upper arm, and the dressing was dated 7/31/23. Resident #78 stated she received antibiotic via the PICC line three times daily. A PICC line is a thin, soft tube that is inserted into a vein in the arm, leg or neck for long-term IV (intravenous) antibiotics, nutrition, medications, and blood draws. (retrieved on 8/18/23 from www.chop.edu). On 8/08/23 at 4:07 PM, Registered Nurse (RN) A acknowledged that she was assigned to resident #78. She stated the resident had a PICC line to her right arm and received antibiotic via the PICC line every eight hours. RN A said the PICC line dressing should be changed weekly. On 8/08/23 at 4:13 PM, observation of the resident's PICC line dressing was conducted with RN A. She confirmed date on the dressing was 7/31/23 and stated dressing should have been changed on 8/07/23. The resident's clinical records were reviewed with the RN. She stated the order for dressing change for the PICC line was in the Electronic Medical Record, but order did not show on the resident's Medication Administration Record/Treatment Administration Record (MAR/TAR). On 8/08/23 at 4:21 PM, the General and Restorative Unit (G&R) Unit Manager (UM) stated intravenous access, which included a PICC line should be changed on admission, then weekly thereafter. The UM stated physician's order for resident #78 on 7/25/23, was to change the PICC line dressing on admission, then weekly thereafter and as needed. Observation conducted with RN A was shared with the UM. She stated the resident's PICC line dressing should have been changed on 8/07/23, but the order was not populating on the resident's MAR/TAR. She explained that all new orders were reviewed by the UM within 24 to 48 hours, but verbalized she did not recall the resident's PICC line dressing order. The UM explained that usually she would pull up an order to ensure it was elected to show on the MAR/TAR. She stated something was missing from the resident's PICC line dressing order. On 8/10/23 at 10:17 AM, orders not populating on MAR/TAR were discussed with the Director of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106011 If continuation sheet Page 9 of 14 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 08/10/2023 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 0694 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Nursing (DON). She stated the facility became aware of a glitch in their system approximately two months ago, and the UM has been going in and fixing it, however, she verbalized they had not been doing spot checks to ensure orders populated to the MAR/TAR. The DON stated PICC line dressings should be changed weekly. The facility's policy Central Venous Catheter/Central Line Access and Maintenance dated 4/01/2022, indicated, that to ensure appropriate infection prevention and control measures were taken to prevent the spread of infection, Dressings that are wet, soiled, or dislodged should be replaced using aseptic techniques with sterile or clean gloves .transparent dressings are changed every seven (7) days. Event ID: Facility ID: 106011 If continuation sheet Page 10 of 14 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 08/10/2023 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure 1 monthly Medication Regimen Review (MRR) recommendation was reviewed timely by the physician, and failed to act timely on 1 monthly MRR with physician's orders for 2 of 5 residents reviewed for Unnecessary Medications out of a total sample of 36 residents. (#27, #313) Findings: 1. Review of the medical record revealed resident #27 was admitted to the facility on [DATE] from an acute care hospital and had diagnoses that included hypertensive heart disease, chronic kidney disease, liver cirrhosis, anemia, ileostomy, stroke, muscle weakness, depression, and bipolar II disorder. The Order Summary Report noted the resident's medication orders included Magnesium Oxide 400 milligrams (MG) for low magnesium ordered 6/03/23, Lasix 20 MG for edema ordered 6/03/23, Omeprazole Delayed Release 20 MG for gastroesophageal reflux disease (GERD) ordered 6/03/23, Pantoprazole Sodium Delayed Release 40 MG for GERD ordered 6/09/23, Ondansetron HCI 4 MG for nausea and vomiting ordered 6/03/23, Folic Acid 1 MG for anemia, Zinc Oxide 50 MG for vitamin deficiency ordered 7/18/23 to 8/01/23, Vitamin B12 500 micrograms (MCG) for vitamin deficiency ordered 6/09/23, and Vitamin D3 25 MCG for vitamin deficiency ordered 6/09/23, and Multivitamin-Minerals for low hemoglobin and skin integrity ordered 7/07/23. The New admission MRR dated 6/26/23 received by the facility from the consulting pharmacist showed recommendations to order laboratory testing for a Basic Metabolic Panel (BMP) (blood chemistry) and a Magnesium (Mg) level. On the document, there were handwritten notes that read, BMP + Mg with the date 8/08/23, 43 days after the pharmacist's recommendation. The Electronic Health Record (EHR) showed on 8/08/2023, the Director of Nursing (DON) entered physician's orders for, BMP and Mg in the am every weds (Wednesday) for level for Mg supplement. On 8/09/2023 at 1:38 PM, the DON stated she had been in her position for one month. She said the MRR pharmacy reports were received by email, and she had received the July 2023 reports. She explained that when surveyors asked for the MRR records, she found resident #27's recommendations for 6/26/23 among records in a binder kept in the DON's office. She said after checking the medical record, she could not find any evidence to show it was addressed by the physician, so she obtained an order for the labs. She stated MRR recommendations are expected to be addressed right away and it must have been missed. 2. Review of the medical record revealed resident #313 was admitted to the facility on [DATE] from an acute care hospital and had diagnoses that included low back pain, multiple myeloma, bursitis, muscle weakness, diabetes, seizures, and pressure ulcers of the left heel and sacral region. The Order Summary Report noted the resident's medication orders included Aspercreme Lidocaine Patch 4% one time a day to lower back for back pain ordered from 7/22/23 to 8/08/23, and wound treatment for a sacral pressure wound ordered 7/22/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106011 If continuation sheet Page 11 of 14 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 08/10/2023 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The New admission MRR dated 7/24/23 received by the facility from the consulting pharmacist showed recommendations to remove the Lidocaine patch after 12 hours to avoid tachyphylaxis (sudden decrease in response to a drug). The physician signed an order to implement the recommendation on 7/30/23. The EHR showed the DON entered a physician's order to remove the lidocaine patch after 12 hours starting 8/09/23, 10 days after the physician signed it. On 8/09/23 at 1:38 PM, the DON stated she was responsible for ensuring MRRs with physician's orders were implemented. She said she provided them to Unit Managers to transcribe and enter to the EHR. She explained orders were expected to be entered and implemented no later than the end of nurses 12 hour shifts. She said she entered resident #27's order herself after surveyors requested MRR records and she discovered it had not been done. She stated there was an excessive delay and it must have been missed by the nursing staff. Review of the facility's policies and procedures titled Pharmacy Services - Drug Regimen Review, read, The intent of this policy is that the facility maintains the highest practicable level of physical, mental and psychosocial well-being and prevents or minimizes adverse consequences related to medication therapy. , reports will be acted upon . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106011 If continuation sheet Page 12 of 14 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 08/10/2023 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review, the facility failed to maintain safe and sanitary conditions for food storage in 2 of 2 nutrition stations, (Specialized Subacute Unit and General and Restorative Unit). Findings: On 8/10/23 at 10:30 AM, during a tour of the Specialized Subacute Unit (SSU) nutrition station with the SSU Unit Manager (UM), the following concerns were identified: * The countertop sink was leaking underneath the cabinet into bath basin and overflowing pink colored water noted to be eroding cabinet. The cabinet had brownish/black substance noted in the corners. * The cabinet above the sink was disheveled with dirt/crumbs scattered as well as miscellaneous items inside the cabinet including staff's bag lunch with avocado, apple, orange, sunscreen, water bottle, phone cord, melting frozen water bottle thawing and pooling water on shelf, thickener packets, salt/pepper packets, mayo packets, staff empty plastic thermos drink holder. * The refrigerator included two half cheese sandwiches with no date/label, another empty staff drink thermos, resident submarine sandwich, not dated or labeled to identify which resident it belonged to. * A missing drawer in cabinet under the microwave which was noted with dirty, gray dust and sugar packets. * The baseboard under the sink cabinet was jagged and broken, apparently due to water damage. There was approximately 8 to 10 inches of missing base board. Dead space under the sink cabinet had gray dust matter and trash which included a drinking straw and lid. After observing the SSU nutrition station the UM acknowledged that the room was dirty and disorganized. She added, the staff are supposed to label and date food with resident's name and should keep their own food and drinks in the staff break room. The UM said she was not aware of the leaking sink or poor condition of cabinets, but this did not appear to her to be a new problem. She added that the maintenance staff would be responsible for having cabinets repaired or replaced and housekeeping needs wipe the cabinets/drawer's interior surface areas. On 8/10/23 at 10:51 AM, the Director of Maintenance (DOM) observed the condition of the sink and cabinet and said that he fixed the leaking faucet last week, but did not notice the decayed/missing wood at the base of the cabinet under the sink. He explained that he fixed the faucet because it would not turn off, but did not notice the hole in the cabinet base or water damage. The DOM agreed, it is obvious that the leaking has been going on now for a while as evidenced by the condition of the cabinet base. He said the sink is now leaking at the P trap and that he is not a certified plumber, but thinks he can fix the leaking pipes. He verified that the nutrition room was dirty and unkept and could attract pests due to leaking and pooling water, dust, and crumbs in cabinets. He stated, the cabinet is really old and falling apart. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106011 If continuation sheet Page 13 of 14 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 08/10/2023 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 8/10/23 at 11:23 AM, the following concerns were identified with the General and Restorative (G&R) unit nutrition station in the presence of the G&R UM: * A hole in the drywall left of the kitchen sink approximately 8 inches by 2 inches. * Cabinet under sink with large cracks at the interior base as well as disintegrating particle board not 2 feet by 2 inches at base opening of cabinet. * Cabinet veneer is lifting off the particle board and showing in 3 of 4 cabinets. * Cabinets and drawers were dirty with gray dust matter and food crumbs inside. * Cabinets/drawers were disorganized including staff large thermos type cup, straws, sugar packets, salt/pepper packets, container lid, coffee filters, and staff 50 once water bottle 1/3 full. * On top of the refrigerator there was another 16 once staff water bottle 1/3 full. * The bottom cabinets were literally falling apart. * Inside the refrigerator was another 16 once staff water bottle and a glass container with 2 half-eaten pieces of pepperoni pizza not dated or labeled with a resident name, 2 half size cheese sandwiches not dated, 4 mini muffins not wrapped or dated. * In the upper cabinet found another 33 once staff water bottle 1/3 empty. After observing the G&R unit nutrition station the UM said, it was not homelike, cabinets were falling apart, and she had not reported any concerns to the maintenance department to date. She added, the staff should keep their food in drinks in the staff lounge and refrigerator. She verified that housekeeping should be cleaning nutrition station daily but was not possible due to cabinets literally falling apart and would not be possible to clean them properly. The UM said she did not notice the condition of the nutrition station until it was brought to her attention by surveyor and the current condition is not homelike. On 8/10/23 11: 50 AM, the DOM said the cabinets have been falling apart since he has been here for a year and one half. He added the nursing home was bought out by a new company and he thinks they are going to be doing some renovations but could not say when. He added, this is an old building and the cabinets in both the nutrition stations need to be replaced and it is not possible to clean them properly because they are literally falling apart. Review of the facility policy for, Food: Safe Handling for Food from Visitors read, It is the center policy to assist resident in properly storing and safely consuming food brought into the center for residents by visitor .When food items are intended for later consumption, the staff member will: Ensure the foods are in a sealed container to prevent cross contamination. Label foods with resident name and current dated .Cleaned weekly . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106011 If continuation sheet Page 14 of 14

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Citations

7 citations recorded^*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

0679GeneralS&S Dpotential for harm
F679 - Activities
Provide activities to meet all resident's needs.
0684GeneralS&S Dpotential for harm
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
0694GeneralS&S Dpotential for harm
F694 - Parenteral Fluids
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
0756GeneralS&S Dpotential for harm
F756 - Drug Regimen Review
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
0812GeneralS&S Epotential for harm
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
0623GeneralS&S Dpotential for harm
F623 - Transfer and discharge-
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
0655GeneralS&S Dpotential for harm
F655 - Comprehensive Person-Centered Care Planning
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

FAQ · About this visit

Common questions about this visit

What happened during the August 10, 2023 survey of KISSIMMEE NURSING & REHABILITATION CENTER?

This was a inspection survey of KISSIMMEE NURSING & REHABILITATION CENTER on August 10, 2023. The surveyor cited 7 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at KISSIMMEE NURSING & REHABILITATION CENTER on August 10, 2023?

Yes, 7 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide activities to meet all resident's needs."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

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Data from CMS Care Compare public records. Dataset last refreshed June 22, 2026. If you believe any information is inaccurate, report it here.

Health inspection·August 10, 2023