Below average — CMS composite of the measures below.
The next survey window likely opens around November 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 The Good Samaritan Society-kissimmee Village during CMS and state inspections, most recent first.
Food safety and sanitation deficiencies were observed in the kitchen and tray line. A dietary aide with a beard was working without a beard guard, dishes were floating in sanitizer instead of being fully submerged, a heavily carbon-buildup frying pan was found on a clean rack, and the juice dispenser nozzle contained beige and pink sludge with no clear cleaning history. During lunch service, a dietary aide initially checked meatloaf temperature incorrectly by probing multiple pieces; when checked properly, one slice measured 127.9 degrees Fahrenheit, below the required hot-holding temperature.
Incorrect Mashed Potato Portioning: The facility failed to follow its menu for garlic mashed potato portion size. A lunch menu called for a number 8 scoop to provide a 4-ounce portion, but during tray line observation staff used a number 10 scoop instead, resulting in a 3.2-ounce portion. Staff present could not explain why the wrong scoop was used, despite oversight by the kitchen manager and RD.
Inaccurate MDS coding led to two residents being assessed as receiving services such as dialysis, hospice, trach care, radiation, and O2 therapy without supporting physician orders, care plans, or documentation in the medical record. The MDS Coordinator reviewed the Section O entries and confirmed the coding was incorrect and did not reflect the residents' actual status or services received.
PASARR Level I screenings were not updated for two residents with evolving mental health diagnoses. One resident’s PASARR did not include MI despite later records showing dementia, mood disorder, schizoaffective disorder, depression, and psychotic disorder, along with behaviors such as yelling, threats, and physical outbursts. Another resident’s PASARR identified depressive disorder, but after bipolar disorder was added, the screening was not revised. An RN stated both PASARRs needed updating.
Failure to Provide Ongoing Activity Program: Three residents with severe cognitive impairment and Hospice status were observed sitting near Nurse’s Station 3 with Christmas music playing and no staff engagement or organized activity. Their care plans identified individualized activity preferences such as music, bingo, outdoor strolls, sensory items, and group activities, but observations and activity logs showed limited participation and repeated periods with no meaningful activity provided.
Medication Administration Error Rate Exceeded: The facility failed to keep medication administration errors below 5%, with an 8% error rate identified for one resident. An RN administered ordered morphine sulfate and lorazepam incorrectly by pouring the liquid from medication cups into the resident's mouth instead of giving them sublingually as ordered. The hospice nurse confirmed the medications were not properly given under the tongue, and the RN acknowledged she used the wrong method and had not notified supervision that she lacked the needed supplies.
A resident with multiple fractures and an artificial joint had grievances filed regarding staff conduct and billing issues. The facility failed to obtain statements from all staff involved in a customer service complaint and did not document or investigate a billing grievance raised by the resident's representative. Facility policy required thorough investigation and documentation of all grievances, which was not followed.
Food Safety and Temperature Control Deficiencies
Penalty
Summary
The facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards when surveyors observed multiple kitchen sanitation and food safety issues. In the dishwashing room, a dietary aide with a beard was putting away dome pellet covers without wearing a beard guard, and he stated his beard guard had fallen off but did not explain why he had not put on a new one. In the three-compartment sink, dishes were floating in sanitizer water, and the Registered Dietitian confirmed the dishes needed to be completely submerged. On a clean storage rack, an 8-inch frying pan had significant carbon buildup, making it difficult to determine whether it was stainless steel or a non-stick pan with a disintegrating coating. The General Manager discarded the pan after the RD said it would be replaced. Surveyors also observed the facility’s bag-in-the-box juice and beverage dispenser with a dispensing gun and nozzle that were not clean and sanitary. When the nozzle was removed, beige and pink sludge was seen inside the nozzle and dispensing gun, and staff, including the General Manager and RD, could not explain when the equipment had last been cleaned and sanitized. In addition, during lunch tray line observation, a dietary aide checked the hot holding temperature of homemade meatloaf on the steam table. She initially inserted the thermometer through several pieces of meatloaf and stated the temperature was above 135 degrees Fahrenheit, but when instructed to check only one slice, the internal temperature was 127.9 degrees Fahrenheit. The aide stated the holding temperature was too low.
Incorrect Mashed Potato Portioning
Penalty
Summary
The facility failed to follow the menu for garlic mashed potato portion size. The menu for lunch on 12/11/25 specified garlic mashed potatoes, and the diet spreadsheet directed staff to use a number 8 scoop, which would provide a 4-ounce portion. During observation of the lunch tray line at 11:15 AM, after staff completed hot holding temperature checks on the steam table, serving utensils were placed near each food item and meals were plated. Staff used a number 10 scoop for the garlic mashed potatoes instead of the required number 8 scoop, resulting in a 3.2-ounce portion that was contrary to the facility's menu. The staff present could not explain why the wrong size scoop was used, despite oversight by the kitchen manager and registered dietitian.
Inaccurate MDS Coding for Special Treatments and Procedures
Penalty
Summary
Each resident received an inaccurate MDS assessment that did not reflect their actual status, needs, or documented services. Resident #10, admitted with diagnoses including dementia, Alzheimer's disease, mild cognitive impairment, anxiety, adjustment disorder, and COPD, had a quarterly MDS that coded hospice care, dialysis, tracheostomy care, mechanical ventilator, radiation, and oxygen therapy. However, the medical record contained no physician orders or care plans for dialysis, hospice, radiation, oxygen therapy, or tracheostomy care, and there was no documentation other than the MDS indicating that these services were provided. Resident #119, admitted and later readmitted with diagnoses including type 2 diabetes, anemia, hyperlipidemia, and CKD stage 3, had a significant change MDS that coded renal insufficiency and dialysis while in the facility. The medical record contained no physician orders for dialysis, no care plan for dialysis services or treatment, and no documentation showing that dialysis services or treatment were provided. The MDS Coordinator reviewed the Section O coding for both residents and verified that it was incorrect and did not accurately reflect each resident's status, but could not recall why the assessments were miscoded.
PASARR screenings were not updated for residents with changing mental health diagnoses
Penalty
Summary
The facility failed to complete a new Preadmission Screening and Resident Review (PASARR) Level I screening for 2 of 2 residents reviewed for PASARR, residents #107 and #11. For resident #107, the record showed an initial PASARR Level I form dated 1/03/23 that did not include a Mental Illness diagnosis, even though the resident’s record later documented diagnoses including Alzheimer’s disease, dementia, mood disorder, schizoaffective disorder, major depression, altered mental status, cognitive communication deficit, and psychotic disorder. The resident’s MDS quarterly assessment showed severe cognitive impairment, and the order summary listed Depakote, Remeron, and Trazodone for mood disorder and depression. The care plan described behaviors related to dementia, including being argumentative, making threats, yelling, physical outbursts, and imitating others. For resident #11, the facility completed a PASARR on 6/17/25 and identified depressive disorder as a form of mental illness, but when bipolar disorder was added to the diagnosis list on or about 8/27/25, the PASARR was not updated. RN X stated on 12/11/25 that she was responsible for the residents’ PASARRs and that both residents’ PASARRs needed to be updated to reflect anxiety for resident #107 and bipolar disorder for resident #11. The record also included psychiatric notes for resident #107 showing treatment for anxiety, depression, dementia, mood disorder, and schizoaffective disorder, with staff reporting yelling, screaming, and crying all day.
Failure to Provide Ongoing Activity Program
Penalty
Summary
The facility failed to provide an ongoing activity program for 3 of 3 residents reviewed for activities, including residents #5, #8, and #135. Each of these residents had severe cognitive impairment and were documented as needing staff assistance for activity participation. Resident #135 was admitted with unspecified dementia, depression, and hypothyroidism, was later placed on Hospice, and had activity preferences that included music, group activities, and outside visits. Her care plan identified a need for cognitive and sensory stimulation, social activities, and staff assistance to attend scheduled activities. Resident #135’s activity log for the first 11 days of December showed only single daily sensory stimulation activities on some days, including television, radio/iPod, and sitting outside, with two days showing no activities. During multiple observations over several days, she was repeatedly found sitting at the #3 Nurse’s Station with other residents, with Christmas music playing nearby, but with no staff interaction or organized activity observed. She was also observed in the dining area alone or with other residents while CNA staff stood in the hallway conversing, and no activity was taking place. The Activities Director stated sensory stimulation could include aroma therapy, hand massage, foam puzzles, music therapy, sensory blankets, butterfly garden, and sitting outside, and said residents at #3 Nurse’s Station were usually included in activities in the morning and afternoon because they were more awake. Resident #5 was admitted with sequelae of cerebral infarction, hemiplegia, hemiparesis, adjustment disorder, anxiety, and Hospice status. Her MDS showed severely impaired cognition, and her activity preferences included music, favorite activities, and going outside for fresh air. Her care plan noted preferences for classic/Christian music, outdoor strolls, bingo, and TV, later updated to merengue, bachata, and R&B music. She was observed sitting in a wheelchair near Nurse’s Station 3 with Christmas music playing and no staff present to engage the residents. Resident #8, who had Alzheimer’s disease, COPD, schizoaffective disorder, dementia, and Hospice status, also had severely impaired cognition and a care plan calling for participation in activities of choice several times weekly. His preferred activities included upbeat Spanish music, singing, horse videos, garden strolls, rummaging through sensory boxes, and sensory items. He was observed sitting in his chair near Nurse’s Station 3 with other residents, while Christmas music played continuously and no staff engaged the residents. The Activities Director stated she could not determine whether he liked Christmas music and said more activity staff were needed when asked why residents were not receiving activities aligned with their care plans.
Medication Administration Error Rate Exceeded
Penalty
Summary
Medication administration error rates were not kept below 5 percent. Based on observation, interview, and record review, the facility failed to prevent a medication administration error rate of 5% or greater for 1 of 13 residents sampled for medication administration, resident #87. Surveyors identified 2 medication errors in 25 opportunities, resulting in an 8% error rate. Resident #87 was admitted with diagnoses including dementia, insomnia, anxiety, depression, restlessness and agitation, moderate protein-calorie malnutrition, and generalized muscle weakness. He had been receiving hospice services since 8/22/25 and was on crisis care at the time of the observation. During medication administration, RN A prepared Morphine Sulfate liquid and Lorazepam liquid and poured both from medication cups into the resident's mouth while he was lying in bed with his eyes closed in a semi-reclined position. It could not be determined whether he swallowed the medications or held them in his mouth. The active physician orders required both medications to be given sublingually. The hospice nurse confirmed the medications had not been properly administered under the tongue as ordered, and RN A acknowledged the medications were administered incorrectly and that she had used medication cups instead of administering them sublingually. RN A stated she had not notified her supervisor or DON that she did not have the needed supplies to administer the medications per order, and the DON stated the nurse was new to the facility and should have asked a supervisor.
Failure to Thoroughly Investigate and Document Resident Grievances
Penalty
Summary
The facility failed to appropriately record and investigate grievances to ensure timely resolution for one resident. The resident, who was cognitively intact and had a history of fractures and an artificial ankle joint, had two grievances filed on her behalf. While the first grievance was addressed with solutions offered, the second grievance regarding customer service by a CNA and a nurse was not thoroughly investigated. The investigation included a statement from the CNA but omitted a statement from the nurse involved. The DON, responsible for the investigation, confirmed that she did not interview the nurse, focusing only on the CNA's actions, and acknowledged that the investigation was incomplete as not all parties were given the opportunity to provide input. Additionally, the resident's son reported that the facility did not respond to his complaint about a bill received after his mother's discharge. The BOM confirmed that there was a lack of collaboration between the business office and Social Services regarding the resident's coverage status, which led to unresolved billing concerns. The Administrator acknowledged that a grievance form was not initiated for the billing complaint, despite policy requiring all grievances to be documented and investigated. The facility's policy emphasized prompt efforts to resolve grievances and thorough investigations involving all relevant parties, which was not followed in these instances.
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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 Health And Rehabilitation Center | 3.2 mi | ★★★★★ | 0 | 0 |
| Terrace Of Kissimmee, The | 4 mi | ★★★★★ | 2 | 0 |
| Aviata At Kissimmee Gardens | 4.2 mi | ★★★★★ | 6 | 0 |
| Kissimmee Nursing & Rehabilitation Center | 4.2 mi | ★★★★★ | 0 | 0 |
| Hunters Creek Nursing And Rehab Center | 7.2 mi | ★★★★★ | 1 | 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.