Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Kissimmee Health And Rehabilitation Center during CMS and state inspections, most recent first.
MDS assessments were not accurately completed for two residents. One resident receiving hospice services had a hospice certification stating a life expectancy of 6 months or less, but the MDS prognosis item was marked No. Another resident had an order for Hydrocortisone 2.5% cream to both arms and legs, and the TAR showed it was applied, but the MDS did not capture the ointment/medication treatment in Section M.
A resident with mood disorder, psychotic disorder, and ID had an inaccurate PASRR Level I on admission and no new PASRR was submitted after later behavioral changes, suicidal ideations, and psych med adjustments. The record showed psychosis, hallucinations, depression, 1:1 observation, and medication changes, while staff acknowledged the revised PASRR was not electronically submitted to the State.
Failure to revise care plan for neck brace use: A resident with ESRD, DM, and a cervical spine fx after falls was ordered to wear a neck brace at all times, but staff observed him without the brace and he said he did not like wearing it while eating. The care plan included assistance with the collar, yet the facility could not provide documentation of refusal, and the DON stated refusals should be documented and the MD notified.
A resident with dementia, HIV, diabetes, and dependent ADL needs had ongoing pruritus, scratching, and skin lesions, but ordered skin treatment was not consistently provided as ordered and the MAR showed medication documentation gaps. Staff observed persistent itching, red areas, and open bumps, yet physician notification, treatment effectiveness review, and documentation were incomplete. The DON confirmed there was no evidence of recent MD notification, and the physician later noted the resident’s excoriated, dry skin and ordered a change in treatment after the resident continued to scratch.
Medication administration and disposal practices were not followed for two residents. An RN documented meds after the fact instead of at the time of administration, gave some meds in ways and at times that differed from the MAR without documentation or MD notification, and another RN discarded unused meds into an open trash bin on the med cart before restarting the pass. The DON stated meds should be documented immediately and never thrown in regular trash.
Failure to perform hand hygiene during medication administration. An RN entered a resident's room, donned gloves, took BP, removed the gloves, and left without hand hygiene, then prepared oral meds without hand hygiene and later administered them. The RN acknowledged skipping hand hygiene steps, and the IP and DON stated hand hygiene was required before glove use, after glove removal, before resident contact, and before preparing medications.
The facility failed to follow their grievance process for two residents, leading to deficiencies in addressing their concerns. One resident's fall was not documented, and her son was not informed, while another resident's meal tray was periodically missing, and his requests for certain CNAs were not honored. The facility did not log or follow up on grievances as required by their policy.
MDS Assessments Did Not Accurately Reflect Hospice Prognosis and Skin Treatment
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected a resident’s prognosis of life for a resident receiving hospice services. Resident #11 had diagnoses including Alzheimer’s disease, dementia, and heart disease, and the medical record included a hospice certification form stating that the physician believed the resident had a life expectancy of 6 months or less if the disease took its natural course. However, the resident’s quarterly MDS assessment with an ARD of 3/19/26 answered “No” to the question asking whether the resident had a condition or chronic disease that may result in a life expectancy of less than 6 months. The facility also failed to accurately capture a skin treatment on another resident’s MDS. Resident #54 had diagnoses including dementia, HIV, heart disease, and type 2 diabetes, and had a physician order for Hydrocortisone External Cream 2.5% to be applied to both arms and legs topically two times daily. The TAR showed the cream was applied daily during April 2026, but the resident’s quarterly MDS assessment with an ARD of 4/14/26 did not select the treatment category for application of ointments/medications other than to feet in Section M. The MDS Coordinator stated she was responsible for completing the assessments, acknowledged the hospice prognosis item for resident #11 was answered incorrectly, and confirmed the hydrocortisone treatment for resident #54 should have been captured on the MDS.
PASRR Screening Not Updated for Changed Psychiatric Condition
Penalty
Summary
The facility failed to resubmit an accurate PASRR Level I screening for a resident with diagnoses including mood disorder, psychotic disorder, and intellectual disability, and failed to submit a new PASRR after the resident’s condition changed. The resident’s record showed psychotropic medication use, moderate cognitive impairment on the annual MDS, depressive symptoms, and behavioral symptoms including screaming and disruptive sounds. The resident also had care plan interventions related to psychosocial well-being, behavioral concerns, and adverse effects from psychotropic medications. The resident’s record contained an initial Florida PASRR Level I screen that left the mental illness section blank and indicated no diagnosis or suspicion of SMI or ID, with Level II review not required. A second PASRR form completed by the DON later identified psychotic disorder and persistent mood disorder, but again indicated no diagnosis or suspicion of SMI or ID and no Level II review required. Psychiatry documentation showed the resident was admitted with mood disorder and psychosis and was treated with Depakote and Risperidone, later had hallucinations, and subsequently developed suicidal ideations that led to 1:1 observation, medication changes, and ongoing behavioral monitoring. Interdisciplinary notes documented suicidal ideations, 1:1 supervision, later discontinuation of 1:1, and continued safety checks. The record did not show a new PASRR Level I being completed or submitted after the resident’s missing SMI diagnoses were identified or after the resident’s behavioral changes, suicidal ideations, and psychiatric medication adjustments. Facility staff stated they knew a new PASRR Level I was required when diagnoses or psychotropic medications changed, but acknowledged that no revised PASRR had been electronically submitted to the State.
Failure to Revise Care Plan for Neck Brace Use
Penalty
Summary
The facility failed to revise the comprehensive person-centered care plan for 1 of 23 residents reviewed, Resident #3. Resident #3 was admitted with diagnoses of end stage renal disease, diabetes, and stroke, and the MDS assessment showed a BIMS score of 15 out of 15, indicating he was cognitively intact. The record showed he fell on one occasion and again on 12/24/25, and an AHCA Transfer form dated 12/24/26 documented an unwitnessed fall in which he hit his head and was transferred to the hospital. A physician progress note dated 2/17/26 documented that Resident #3 had a cervical spine fracture, refused surgery, and was ordered to wear a neck brace at all times. The resident’s care plan included an intervention dated 1/07/26 directing staff to assist him with his neck collar, but on 5/27/26 he was observed in the common area without the neck brace and stated he did not like to wear it while eating. The Administrator stated he sometimes took the collar off, and the DON stated that if the resident did not want to wear the neck brace, the doctor should be notified and the refusal documented. The facility was unable to provide documentation that the resident refused the neck collar, and the MDS Coordinator stated the expectation was that care plans should be updated to include interventions and goals for safety.
Failure to Provide Ordered Skin Treatment and Document Ongoing Pruritus
Penalty
Summary
The facility failed to provide appropriate assessment, treatment, and implementation of ordered interventions for a resident with dementia, HIV, major depressive disorder, heart disease, and type 2 diabetes who was dependent on staff for most ADLs and was incontinent of bowel and bladder. The resident had a history of itching, scratching, and skin breakdown, including old scabs on both arms and legs, a prior skin tear from scratching, and ongoing complaints of generalized pruritus. A physician order for Hydrocortisone cream was obtained after a change in condition note documented the skin concerns, and later Benadryl was ordered for itching. Despite the ongoing skin complaints, the treatment was not carried out as ordered. The TAR showed the Hydrocortisone cream was documented as applied daily rather than twice daily as ordered, and the resident told surveyors on multiple occasions that he had not received the cream that day and continued to itch all over. Multiple small red areas, scratch marks, and open bumps were observed on the resident’s arms, legs, thighs, chest, and under his arm, and the CNA reported the resident frequently scratched to the point that sheets had to be changed because he bled. The CNA also stated the resident had open small bumps on his back and thighs and repeatedly requested cream application. The record also showed gaps in communication, assessment, and documentation. The DON stated she was not aware of the resident’s skin condition and confirmed there was no evidence of recent physician notification regarding the continued itching. Weekly skin evaluations repeatedly noted ongoing itching and continued treatment, but there was no evidence the condition was discussed at the interdisciplinary care meeting. The wound nurse acknowledged the resident continued to complain of itching with visible red marks and that she did not contact the physician or review treatment effectiveness during her shift. The UM and RN D stated Benadryl was administered without verifying or documenting the order, and the physician stated that if it is not documented, it is not done. A dermatology note later documented generalized pruritus with diffuse erythematous eruption and concern for bacterial and fungal skin infections related to the resident’s immunocompromised HIV status.
Medication Administration and Disposal Errors
Penalty
Summary
Pharmaceutical services were not provided in accordance with physician orders and medication administration standards for one resident during a medication pass observation. RN E prepared and administered the resident’s 9:00 AM medications, but the MAR showed additional medications scheduled for that time that were not prepared during the observed pass, and Hydralazine 10 mg was scheduled for 8:00 AM yet was documented later as administered at 10:55 AM. The medications observed being given at 10:16 AM were documented at 10:56 AM, and RN E stated she did not always document medications immediately after administration because she sometimes ran late and later documented them all at the same time. During the same observation, RN E stated she gave Eldertonic earlier because it was an appetite stimulant, opened a Turmeric capsule and mixed it into the resident’s breakfast pudding because the resident preferred it that way, and administered the House Supplement after the medication pass because the resident did not like taking it with medications. The medical record contained no documentation of these medication administration preferences, and there was no evidence the physician was notified about alternative administration practices or times that differed from the physician’s orders. The Staff Educator stated nurses were expected to document medications at the time of administration. A second medication pass observation showed improper handling of unused medications for another resident. RN D prepared oral medications and, after counting the pills, found the number in the cup did not match the medications observed. She attempted to reconcile the discrepancy, then discarded the medications into a small open trash bin attached to the medication cart and started over. She later added Tylenol 325 mg because the resident complained of pain, administered the medications, and exited the room. RN D stated she was supposed to discard medications in a different container and not in the trash bin, but could not locate the proper disposal bottle and could not explain why medications should not be discarded in the trash. The DON stated medications should never be discarded in regular trash because individuals passing by could retrieve them.
Failure to Perform Hand Hygiene During Medication Administration
Penalty
Summary
The facility failed to follow appropriate hand hygiene during medication administration for one of four nurses reviewed, Registered Nurse E. On 5/26/26 at 10:02 AM, RN E entered resident #47's room, obtained gloves, donned them, took the resident's blood pressure, removed the gloves, and exited the room without performing hand hygiene. At 10:06 AM, RN E then obtained three medication cups and prepared oral medications without performing hand hygiene. After preparing the medications, RN E entered resident #47's room at 10:16 AM and administered the medications. When questioned at 10:19 AM, RN E stated hand hygiene should be done before and after medication administration and acknowledged skipping steps, including hand hygiene before preparing and before administering the medications. The Infection Preventionist stated nurses were expected to perform hand hygiene before donning gloves, before entering a resident's room, after removing gloves, and before medication preparation. The DON also stated nurses were expected to perform hand hygiene every time they had resident contact and before preparing medications. Facility policies for Medication Administration and Hand Hygiene both required hand hygiene prior to administering or preparing medications and stated glove use did not replace hand hygiene.
Failure to Follow Grievance Process for Residents
Penalty
Summary
The facility failed to follow their grievance process for two residents, leading to deficiencies in addressing their concerns. Resident #2, who had moderate cognitive impairment, was admitted to the facility and later transferred to a hospital without the facility documenting a fall she had sustained. Her son, who is her responsible party, was not informed about the fall and had to find out from the hospital staff. Despite requesting a meeting with the Interdisciplinary Team (IDT) to discuss his concerns, no follow-up was made by the Director of Nursing (DON) for over two weeks, and no grievance was logged for Resident #2. Resident #4, who is cognitively intact, reported that his meal tray was periodically missing, particularly during dinner. He expressed that the kitchen staff was not including his meal tray on purpose and that he had stopped complaining because nothing was done. He had also requested certain Certified Nursing Assistants (CNAs) not be assigned to his care, but his requests were not consistently honored. On one occasion, he called the police due to his concerns about food and care, but the weekend supervisor did not complete a grievance form because Resident #4 refused to speak to her. The Administrator and DON were aware of the incident but did not follow up with Resident #4 or log a grievance. The facility's policy requires that grievances be documented and addressed promptly, but this was not done for either resident. The Administrator and DON acknowledged that grievances should have been logged and followed up on, but this did not occur. The failure to document and address the grievances led to a lack of resolution for the residents' concerns, violating their right to voice grievances without discrimination or reprisal.
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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) |
|---|---|---|---|---|
| Terrace Of Kissimmee, The | 1.1 mi | ★★★★★ | 2 | 0 |
| Aviata At Kissimmee Gardens | 1.6 mi | ★★★★★ | 6 | 0 |
| Kissimmee Nursing & Rehabilitation Center | 1.6 mi | ★★★★★ | 0 | 0 |
| The Good Samaritan Society-kissimmee Village | 3.2 mi | ★★★★★ | 12 | 0 |
| Hunters Creek Nursing And Rehab Center | 4.7 mi | ★★★★★ | 1 | 0 |
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