Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Aviata At Kissimmee Gardens during CMS and state inspections, most recent first.
Failure to Timely Honor Resident Request for COVID-19 Booster: A cognitively intact resident with stroke, DM2, insomnia, and anxiety requested a COVID-19 booster and remained waiting after giving consent. The MAR showed vaccine orders entered but not administered, a note said the facility was waiting on the pharmacy, and the IP acknowledged she knew the resident wanted the vaccine but did not follow up. The pharmacy rep stated no electronic COVID-19 vaccine order had been submitted, and the IP said insurance and cost issues delayed acquisition.
Inaccurate documentation of TED hose application and removal was found for a resident with stroke-related weakness, heart disease, altered mental status, and depression. The MAR showed the stockings were applied and removed, but staff observed the resident without them, and interviews confirmed the entries were incorrect. The resident said he had never worn the TED hose and did not want to wear them, while the UM, RN, CNA, and the resident’s sister/POA all confirmed the documentation did not match what was actually happening.
An LPN failed to perform hand hygiene during a medication pass for a resident and did not sanitize a used BP cuff after use. She handled the med cart, med machine, and medications without cleaning her hands and passed an available sanitizer dispenser multiple times without using it. The IP and DON confirmed staff were expected to perform hand hygiene before and after resident care and before handling medications, per facility policy.
The facility failed to ensure sufficient nursing staff on two of three units, resulting in significant delays in administering scheduled medications. Observations showed RNs and LPNs administering 9:00 AM medications several hours late, with staff acknowledging that such delays were considered medication errors. Despite identifying the issue in QAPI meetings, the facility had not addressed staffing concerns or interim actions to ensure timely medication administration.
The facility failed to store and serve beverages and dishware in a safe and sanitary manner. Plate bases and wet trays were stacked without air flow for drying, and wet drinking glasses were improperly stored. Additionally, a container of thickened lemon water was found with an outdated label, and another container was kept past its safe usage period.
The facility failed to promote dignity in dining for three residents who were totally dependent on staff for eating assistance. Staff were observed standing while feeding residents, contrary to the expectation to be seated to ensure a dignified dining experience. The facility's policy emphasized ongoing training for staff to respect residents' rights, but observations revealed a lack of adherence to this policy.
A resident with intact cognition and multiple medical conditions was observed using Biofreeze gel on her shoulders and neck without a physician's order for self-administration. The facility failed to conduct an evaluation and obtain the necessary physician's order, as confirmed by the RN and Director of Clinical Services.
The facility failed to update care plans to reflect accurate and individualized interventions for three residents regarding their ADLs. Despite MDS assessments indicating total dependence on staff, the care plans inaccurately noted varying levels of assistance required for bathing, dressing, and eating.
The facility failed to obtain physician orders for the treatment of non-pressure related skin conditions for two residents. One resident had a wound on his lower left leg with no physician orders for treatment, and another resident had a dressing on his left arm with no orders or documentation for wound care after a fall.
A facility failed to implement OT recommendations for a resident with contractures, leading to a lack of ROM exercises and potential worsening of the resident's condition. The resident was not on the RNP, and there was no documentation to indicate that the therapy recommendations were followed.
The facility failed to administer oxygen therapy per physician orders for two residents. One resident with COPD was observed with an oxygen concentrator set at 6 LPM instead of the ordered 10 LPM, and another resident with Alzheimer's and heart failure had their concentrator set at 1.5 LPM instead of the ordered 2 LPM. The discrepancies were confirmed and corrected by the Unit Manager.
The facility failed to administer medications within the designated guidelines for two residents. One resident received her 9:00 AM medications significantly late on multiple occasions, and another resident's 9:00 AM medications were administered at 12:08 PM without informing him about the medications being given. The facility's policy of administering medications within one hour of their prescribed time was not followed.
The facility's QAPI committee failed to sustain improvement measures for self-administration of medications, leading to repeat concerns and noncompliance with F554. Despite staff education and daily room rounds, medications were still found at bedside without proper resident assessments.
The facility failed to maintain a sanitary environment by improperly handling linens and not following hand hygiene and PPE practices. A Laundry Attendant placed a contaminated sheet with clean linens, and a CNA moved between rooms without changing gloves or sanitizing hands. Both actions were acknowledged as mistakes by the staff involved.
The facility failed to ensure a call light system was available in the bathroom shared by two residents, as observed during inspections. The absence of the call light system was confirmed by the residents and acknowledged by the Director of Maintenance and the Administrator. Regular audits of call lights were not conducted, and the issue was not reported or noticed until the surveyors' inspection.
Failure to Timely Honor Resident Request for COVID-19 Booster
Penalty
Summary
The facility failed to honor a resident's preference and did not respond timely to her request for a COVID-19 booster vaccine. The resident was a cognitively intact female with diagnoses including cerebral ischemia (stroke), type 2 diabetes, insomnia, and anxiety disorder. Her MDS assessment showed a BIMS score of 14 out of 15, with no behavioral symptoms and no rejection of care or treatment during the look-back period. She stated she requested the booster in October 2025 and was still waiting to receive it, reporting she had been told the vaccine was not available. The record showed the resident signed informed consent for the COVID-19 vaccine, and the MAR documented a vaccine order entered in November 2025 that was not administered, followed by another order with a notation of "Other / See Nurse Notes." A progress note stated the facility was waiting on the pharmacy for the booster. Interviews revealed the IP knew the resident wanted the vaccine but did not follow up on the request, and the IP stated vaccines were not acquired because of insurance-related issues and cost concerns. The DON stated the vaccine should be ordered through the pharmacy after consent and physician order, while the pharmacy representative stated no COVID-19 vaccine order had been submitted electronically by the facility.
Inaccurate Documentation of TED Hose Application and Removal
Penalty
Summary
The facility failed to maintain accurate documentation for the application and removal of TED hose for one resident. The resident was admitted with diagnoses including partial weakness and paralysis after a stroke affecting the right dominant side, heart disease, altered mental status, and major depressive disorder. The annual MDS showed a BIMS score of 13 out of 15, indicating normal cognition. On 12/10/25, the medical record documented pitting edema in the right lower leg and a physician order was initiated for TED stockings to be applied in the morning and removed at night for venous stasis. The MAR showed nursing documentation that the TED hose were applied and removed from 12/10/25 through 1/13/26 except for 12/28/25, but there was no corresponding progress note documentation of refusal, supply issues, or sizing problems. On 1/12/26 and 1/13/26, the resident was observed without the TED hose even though the MAR indicated they had been applied. During interviews, an RN acknowledged the resident did not have the ordered TED hose on and stated he was unaware of the order, while another nurse said the documentation must have been entered in error. The UM confirmed the order was not new, verified the MAR entries were incorrect, and found the TED hose in the resident’s drawer after the resident stated he had never worn them and did not wish to wear them. The CNA and the resident’s sister/POA also stated they had not seen him wearing the TED hose. The facility policy required clinical records to be maintained in accordance with professional practice standards and to provide complete and accurate information on every resident.
Hand Hygiene and Equipment Cleaning Lapses During Medication Pass
Penalty
Summary
An infection prevention and control deficiency was identified when an LPN was observed during medication administration for resident #128 and did not perform hand hygiene at required times. During the medication pass, the LPN took the resident’s blood pressure and placed the used cuff on top of the medication cart without cleaning or sanitizing it. She then made two trips to the medication room, touched the medication machine, and handled medications without performing hand hygiene. She also passed the hand sanitizer dispenser located beside the doorway each time she entered the resident’s room and did not use the full bottle of alcohol-based hand sanitizer on her cart. During interview, the LPN stated she knew she should sanitize her hands with alcohol-based hand sanitizer each time she entered or exited a room and said she forgot. The Infection Preventionist confirmed staff were expected to perform hand hygiene before handling medications, before and after putting on gloves, between residents, before entering the medication room, and after leaving any room. The DON stated staff had been educated since hire on hand hygiene, PPE, and cleaning equipment before and after use. The facility’s Hand Hygiene policy required hand hygiene before and after patient care and after contact with inanimate objects, including medical equipment, and the Medication - Oral Administration policy directed staff to perform hand hygiene prior to administration.
Failure to Ensure Timely Medication Administration Due to Insufficient Staffing
Penalty
Summary
The facility failed to ensure sufficient nursing staff was available on two of three units, leading to delays in the administration of scheduled medications. Observations on multiple dates showed that RNs and LPNs were administering 9:00 AM medications several hours late. For instance, RN O was still administering 9:00 AM medications at 12:43 PM, and RN M had not completed the 9:00 AM medications by 10:50 AM. LPN J was observed giving 9:00 AM medications over two hours late at 12:08 PM, and LPN C completed the 9:00 AM medications approximately two hours late at 12:00 PM. The staff acknowledged that medications should be given within one hour before or after the scheduled time, and delays were considered medication errors. The Director of Clinical Services (DCS) and the Regional DCS confirmed that the facility had identified on-time medication administration as a concern and had held QAPI meetings to address the issue. However, the audits and QAPI meetings did not address staffing concerns or actions needed to ensure timely administration of medications in the interim. The facility had considered transitioning to liberalized medication administration times, but this process required time for implementation and staff education. Meanwhile, the facility continued to experience delays in medication administration due to insufficient staffing and other operational challenges.
Improper Storage and Labeling of Beverages and Dishware
Penalty
Summary
The facility failed to ensure beverages and dishware were stored and served in a safe and sanitary manner to prevent foodborne illness. During an initial observation of the kitchen, it was noted that plate bases and wet trays were stacked together without room for air flow for drying. Wet drinking glasses were also placed upside down on a tray without room for air flow. The Certified Dietary Manager (CDM) acknowledged that tray liners were supposed to be used to allow air flow but were found unused in a corner of the kitchen. A follow-up observation confirmed that the same issues persisted, with plate bases and wet drinking glasses still improperly stored for drying. Additionally, during a meal observation in the dining room, a container of thickened lemon water dated 3/01 was found open on the beverage cart. The Activities Director stated that the container was not present when he poured drinks and would have returned it to the kitchen if he had seen the date. The CDM and other staff later explained that the date indicated when the container was received, but it was not labeled with the opened date. Another observation in the nourishment pantry found an opened container of thickened lemon water dated 3/10, which was well past the 7-day safe usage period as indicated by the label. The Executive Director confirmed this and disposed of the container.
Failure to Promote Dignity in Dining
Penalty
Summary
The facility failed to promote dignity in dining for three residents who were totally dependent on staff for eating assistance. Resident #77, diagnosed with Alzheimer's disease and dysphagia, was observed being fed by a CNA and a Unit Manager while they stood next to her bed. The CNA stated she sometimes sits but often stands while feeding residents, and the Unit Manager was unaware of specific requirements about assisting residents to eat. Resident #86, with diagnoses including stroke and Alzheimer's disease, was also observed being fed by staff while they stood next to his bed. The CNA assisting him mentioned the lack of space for a chair as a reason for standing, despite acknowledging the expectation to be seated while assisting residents to eat. Resident #265, who was cognitively intact but dependent on staff for eating due to Parkinsonism and contractures, was similarly observed being fed by a CNA who preferred to stand due to being busy and not recalling any specific orientation on the matter. The Director of Nursing confirmed that the facility's Skills Competency Assessment: Eating Support form did not specify whether staff should be seated or standing, only that CNAs needed to be at the same level as the resident. The facility's policy on Resident Rights emphasized the importance of ongoing training for staff to ensure residents' rights are known and respected. Despite this, the observations and interviews revealed a lack of adherence to promoting dignity during dining, as staff frequently stood while assisting residents to eat, contrary to the residents' right to a dignified dining experience.
Failure to Ensure Evaluation and Physician's Order for Self-Administration of Medication
Penalty
Summary
The facility failed to ensure an evaluation for self-administration of medication was conducted and did not obtain a physician's order for a resident to self-administer medication. Resident #30, who had intact cognition and various medical conditions including poly-osteoarthritis and hypertension, was observed using Biofreeze gel on her shoulders and neck for pain relief without a physician's order. The resident had an order for nurses to apply Biofreeze to her knees but not for self-administration or for use on her shoulders and neck. Registered Nurse (RN) M confirmed the absence of a physician's order for the resident to self-administer the medication and acknowledged that medications should not be kept at the resident's bedside without proper authorization. The Director of Clinical Services reiterated that an evaluation and a physician's order were required for residents to self-administer medications. The facility's policy also mandated verification of a physician's order and completion of a self-administration evaluation, which were not followed in this case.
Failure to Update Care Plans for ADLs
Penalty
Summary
The facility failed to revise care plans to reflect accurate, appropriate, and individualized interventions for three residents regarding their activities of daily living (ADLs). Resident #31, who was readmitted with diagnoses including hemiplegia and type 2 diabetes, was noted in the care plan to be able to bathe/shower with maximum assistance and dress with moderate to maximum assistance, despite being totally dependent on staff for these activities according to the Minimum Data Set (MDS) assessment. Similarly, Resident #77, diagnosed with Alzheimer's disease and dysphagia, was incorrectly noted in the care plan to perform eating and personal hygiene tasks with extensive assistance, while the MDS assessment indicated total dependence on staff for all ADLs. Resident #86, with diagnoses including stroke and dementia, was also inaccurately noted in the care plan to perform dressing and personal hygiene with extensive assistance and eat with moderate assistance, despite being totally dependent on staff for all ADLs according to the MDS assessment. The MDS Lead and MDS Coordinator confirmed that the care plans should reflect the results of the MDS assessments and acknowledged the discrepancies. The facility's policy on care plans mandates that an individualized, person-centered plan of care be established and updated based on changing goals, preferences, and needs of the resident. However, the care plans for residents #31, #77, and #86 were not updated to accurately reflect their current needs and levels of dependence, leading to the identified deficiencies.
Failure to Obtain Physician Orders for Wound Care
Penalty
Summary
The facility failed to identify and obtain physician orders for the treatment of non-pressure related skin conditions for two residents. Resident #42, who had severe cognitive impairment and multiple diagnoses including Chronic Obstructive Pulmonary Disease and dementia, was found with a gauze dressing on his lower left leg dated 4/05/24. The Unit Manager and Licensed Practical Nurse were unaware of the wound and there were no physician orders for its treatment, despite skin checks identifying the wound on 3/30/24 and 4/06/24. The wound care required a physician's order, which was not obtained, and there was no documentation indicating the physician was informed about the wound. Resident #56, who had moderate cognitive impairment and multiple diagnoses including metabolic encephalopathy and diabetes, was observed with an undated gauze dressing on his left arm with a dried, dark rust-colored stain. The dressing was likely from a fall on 4/07/24, but there were no physician orders for the dressing or treatment. The Director of Clinical Services and the Wound Care Nurse confirmed the absence of documentation and orders for the wound care. The dressing was removed on 4/18/24, revealing skin tears that were not treated with physician orders until 4/17/24, despite being noted after the fall and upon readmission on 4/10/24.
Failure to Implement OT Recommendations for ROM in Resident with Contractures
Penalty
Summary
The facility failed to ensure that the Occupational Therapy (OT) recommendation for the Restorative Nurse Program (RNP) for Range of Motion (ROM) was initiated and maintained for a resident with limited ROM. The resident, who had multiple diagnoses including hemiplegia, hemiparesis, and contractures, was observed without a splint and stated she was not receiving therapy. The Restorative CNA confirmed that the resident was not on the RNP and did not have a splint. The Director of Rehabilitation acknowledged that the resident had not been seen by therapy since November 2023 and was not on the therapy caseload or the RNP, which could have led to worsening contractures. The OT discharge summary indicated that the resident was referred to the RNP for positioning and ROM exercises, but there was no documentation to show that these recommendations were followed. The Licensed Practical Nurse/MDS Coordinator, who assisted with the RNP, confirmed that there was no indication in the resident's clinical records that the resident was on the RNP. The Director of Rehabilitation also acknowledged that there was no documentation to indicate that the therapy recommendation for the RNP was followed. The facility did not have a specific policy for contracture management but had documentation to assist with ROM. The failure to follow through with the OT recommendations and the lack of documentation and policy for contracture management led to the deficiency in the resident's care.
Failure to Administer Oxygen Therapy Per Physician Orders
Penalty
Summary
The facility failed to ensure oxygen therapy was administered per physician orders for two residents. Resident #14, who was admitted with diagnoses including COPD and stroke, was observed wearing a nasal cannula attached to an oxygen concentrator set at 6 LPM, despite a physician's order for 10 LPM. The Unit Manager confirmed the discrepancy and adjusted the flow rate to the correct setting. The protocol for ensuring proper oxygen delivery was for the nurse to check the concentrator flow rate at the beginning of each shift, which was not followed in this case. Similarly, Resident #58, who had diagnoses including Alzheimer's disease, dementia, and heart failure, was observed with an oxygen concentrator set at 1.5 LPM, contrary to the physician's order for 2 LPM. The Unit Manager also confirmed this discrepancy and adjusted the flow rate accordingly. The Director of Nursing stated that the expectation was for nurses to follow physician orders and check the concentrator at the beginning of each shift and with each medication administration, which was not adhered to in these instances.
Failure to Administer Medications Timely and Inform Residents
Penalty
Summary
The facility failed to ensure medications were administered within the designated guidelines and per professional standards and practices for two residents. Resident #30, who had diagnoses including poly-osteoarthritis, hypertension, and hyperlipidemia, received her scheduled 9:00 AM medications significantly late on multiple occasions. For instance, on one day, her medications were administered between 11:06 AM and 11:24 AM, and on another day, they were given at 12:21 PM. The Licensed Practical Nurse (LPN) acknowledged the delay and stated that it was challenging to complete medication administration within the allotted time. The Director of Clinical Services (DCS) and the Regional DCS confirmed that the medications were given outside the prescribed parameters. Resident #90, who had diagnoses including atherosclerotic heart disease, atrial fibrillation, and anemia, also experienced late medication administration. On one occasion, his 9:00 AM medications were administered at 12:08 PM. Additionally, the LPN who administered the medications did not inform the resident about the medications being given. The facility's policy stated that medications should be administered within one hour of their prescribed time, which was not adhered to in these cases.
Failure to Sustain Improvement Measures for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure the Quality Assessment & Assurance (QAA) / Quality Assurance and Performance Improvement (QAPI) committee conducted performance improvement activities to sustain prior improvement measures for self-administration of medications. The QAPI plan indicated that the team would identify, collect, and analyze data from different departments, conduct root cause analysis, and develop a Performance Improvement Plan (PIP) with goals, actions, responsible parties, target dates, and status/outcome. However, concerns with self-administration of medications were identified and cited at F554 during the previous recertification survey, and the same concerns were found again during the current survey, indicating noncompliance with F554 due to insufficient auditing and oversight by the QAPI committee. The Administrator acknowledged that the facility constantly educated staff on medications at bedside and that department heads conducted daily room rounds. Despite these measures, medications were still found at bedside without resident assessments for self-administration of medications. The Administrator explained that residents purchased medications on outings or family members brought them in, and department heads were supposed to identify these medications during their rounds. However, the Administrator could not explain why the issue persisted, indicating a need to address the room rounds process to identify and resolve the issues found by the survey team.
Infection Control Deficiencies in Linen Handling and Hand Hygiene
Penalty
Summary
The facility failed to maintain a safe and sanitary environment in handling linens and following appropriate hand hygiene and PPE practices. On 4/17/24, a Laundry Attendant was observed picking up a clean bed sheet that had fallen on the floor, flapping it, folding it, and placing it back on the linen cart with other clean linens. The Laundry Attendant acknowledged the mistake and stated that she was aware that items from the floor should not be placed with clean supplies. The Housekeeping/Laundry Manager confirmed that linens falling on the floor should be considered contaminated and placed in a plastic bag in the soiled utility room. On 4/18/24, a CNA was observed walking out of one resident's room wearing gloves and entering another room without changing gloves or performing hand hygiene. The CNA acknowledged the mistake and stated that she had received infection control education during her orientation. The Infection Preventionist and the Director of Nursing confirmed that these actions could lead to cross-contamination and the spread of germs. The facility's infection control policies emphasize the importance of hand hygiene and proper handling of PPE to prevent the spread of infections.
Failure to Ensure Call Light System in Resident Bathroom
Penalty
Summary
The facility failed to ensure that a resident's bathroom was adequately equipped with a call light system, as observed in the bathroom shared by rooms #125 and #127. During inspections on 4/15/24 and 4/16/24, it was noted that there was no call light system in the bathroom. Resident #19, who used the bathroom independently, confirmed the absence of a call light and mentioned that another resident who could not talk also used the same bathroom. The Maintenance Work Orders binder revealed that there were two work orders for room #125 in March 2024, but none addressed the missing call light system. The Director of Maintenance and the Administrator both acknowledged the absence of the call light system during their inspections and stated that it had not been reported or noticed previously. The Director of Maintenance explained that call lights are crucial for residents to call for assistance, especially in case of falls. However, he was unable to provide evidence of regular call light audits and mentioned that the task was missing from his maintenance electronic records system (TELS). The facility's policy on inoperable call bell systems, reviewed in 2017, mandates that residents must have a system to notify staff when assistance is needed and that the call bell system should be inspected regularly. Despite this policy, the deficiency was not identified or addressed until the surveyors' inspection.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Kissimmee
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Kissimmee Nursing & Rehabilitation Center | 0.1 mi | ★★★★★ | 0 | 0 |
| Terrace Of Kissimmee, The | 0.6 mi | ★★★★★ | 2 | 0 |
| Kissimmee Health And Rehabilitation Center | 1.6 mi | ★★★★★ | 0 | 0 |
| Hunters Creek Nursing And Rehab Center | 3.2 mi | ★★★★★ | 1 | 0 |
| The Good Samaritan Society-kissimmee Village | 4.2 mi | ★★★★★ | 12 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.