Kissimmee Nursing & Rehabilitation Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote dignity in dining for 1 of 4 residents reviewed for dignity, of a total sample of 59 residents, (#51).

Inspectors wroteBased on interview, and record review, the facility failed to notify emergency contact and Power of Attorney of changes in medication for 1 of 1 residents reviewed for notification of emergency contact, of a total sample of 59 residents, (#20).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident was evaluated for safe self-administration of medications for 1 of 2 residents reviewed for choices, of a total sample of 59 residents, (#5).

Inspectors wroteBased on observation, interview and record review, the facility failed to report allegations of abuse and neglect to the State Agency (SA) and protect the resident during the investigation for 1 of 2 residents reviewed for abuse, of a total sample of 59 residents, (#56).

Inspectors wroteBased on interview, and record review, the facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected fall with major injury status for 1 of 4 residents reviewed for falls, of a total sample of 59 residents, (#109).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an individualized comprehensive care plan was implemented for 1 of 1 resident reviewed for seizure safety precautions, (#92); and for 1 of 2 residents reviewed for communication, (#56), of a total sample of 59 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to revise and implement appropriate interventions including the provision of adequate supervision to prevent falls for 2 of 4 residents reviewed for falls, of a total sample of 59 residents, (#3 and #51).

Inspectors wroteBased on observation, interview, and record review the facility failed to provide an ongoing program of activities to meet the needs and interests of 1 of 5 residents reviewed for activities, of a total sample of 59 residents, (#58).

Inspectors wroteBased on interview, and record review, the facility failed to have ongoing communication and collaboration with the dialysis facility regarding dialysis care and services for 1 of 1 sampled residents who receive hemodialysis, of a total sample of 59 residents, (#12).

Inspectors wroteBased on observation, interview and record review, the facility failed to accurately document the administration of medications in the Medication Administration Record (MAR) for 1 of 3 residents reviewed for pain, of a total sample of 59 residents, (#18).

Inspectors wroteBased on interview, and record review, the facility failed to maintain effective communication between nursing staff and hospice to promote adequate treatment, monitoring, and continuity of care for 2 of 2 residents reviewed for hospice care and services, out of a total sample of 59 residents, (#3 and #469).

Inspectors wroteBased on observation, interview, and record review during the medication administration task, facility staff failed to disinfect the blood pressure monitor between residents for 1 out of 5 residents reviewed for medication administration, of a total sample of 59 residents, (#1).

Inspectors wroteBased on record review, and interview, the facility failed to develop a comprehensive system to monitor antibiotic use in the facility from January 2025 through the time of the survey.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow physician orders related to the monitoring of vital signs and medication administration for 1 of 5 residents reviewed for following physician orders, (#1).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary treatment and services to promote healing and prevent worsening of existing pressure ulcers for 3 of 13 residents reviewed for pressure ulcers, of a total sample of 20 residents, (#3, #9, and #17).

Inspectors wroteBased 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).

Inspectors wroteBased 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)

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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)

Inspectors wroteBased 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)

Inspectors wroteBased 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).

Inspectors wroteBased 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)

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services to prevent development of a pressure ulcer and promote healing of a newly identified area of skin breakdown for 1 of 4 residents reviewed for pressure ulcers, of a total sample of 40 residents, (#96). The facility's failure to implement preventative interventions consistent with the resident's risk for skin breakdown, and failure to initiate treatment according to accepted standards of practice resulted in actual harm, development of a stage 3 sacral pressure ulcer.

Inspectors wroteBased 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).