Terrace of Kissimmee Infection Control Failures FL
KISSIMMEE, FL - A state inspection at The Terrace of Kissimmee nursing home revealed concerning lapses in infection prevention protocols, including a complete absence of hand hygiene procedures before meals for dozens of residents and improper catheter care that allowed medical equipment to drag across facility floors.
Widespread Hand Hygiene Failures Exposed During Meal Service
During a multi-day observation period in April 2025, state inspectors documented a systemic failure to provide any form of hand sanitization to residents before meals. The violations affected up to 43 residents who regularly ate in the facility's dining areas.
On April 14, inspectors observed 43 residents waiting for lunch in the main dining room and an adjacent smaller room. When meal service began at 12:38 PM, staff served food directly from kitchen carts without offering residents any opportunity to clean their hands. The pattern continued throughout the inspection period, with similar observations documented on April 15 when 39 residents received meals without hand hygiene, and again on April 16 with 36 residents.
The scope of the problem became clear when inspectors interviewed multiple sources. Five visitors and three residents confirmed during the April 15 observation that they had not been offered hand sanitization before that meal, nor could they recall being offered hand hygiene before previous meals. A certified nursing assistant acknowledged to inspectors that she had not offered hand hygiene to a resident she was assisting with feeding, stating that while hand sanitizer was available "if they found a resident needed it," she was unsure whether residents received any hand cleaning before being brought to the dining room.
Staff Awareness Without Action Points to Systemic Breakdown
Perhaps most troubling was staff's acknowledgment that they understood the importance of the missing protocols. One CNA told inspectors on April 16 that the facility "used to offer hand hygiene to residents in the dining room, but not as a hard rule." She explained that over time, staff simply forgot to ask residents if they wanted to clean their hands, despite recognizing that proper hand hygiene was important because many residents touched their food directly with hands that "could have a lot of germs on them."
The facility's own Infection Control nurse admitted she only became aware of the hand hygiene gap on April 14, the first day of the inspection. She expressed surprise at the discovery and indicated plans to provide individual hand wipe packets to residents before meals. However, this acknowledgment came only after inspectors had already documented multiple instances of the violation.
The facility's written policy, titled "Standard Precautions" and dated 2024, clearly required staff to assist residents with hand hygiene before meals, after toileting, and whenever indicated. The complete disconnect between written policy and actual practice demonstrated a fundamental breakdown in training, supervision, and quality assurance systems.
Catheter Mismanagement Creates Additional Infection Risks
Inspectors also documented serious breaches in catheter care for a resident with complex urinary tract issues. Resident #95, who had been admitted with lower urinary tract symptoms following prostate removal surgery and required catheter care due to his medical condition, was observed multiple times with his catheter drainage bag dragging along facility floors.
On April 14 at 10:26 AM, the resident's catheter bag dragged along the floor as a staff member pushed his wheelchair through the facility. Later that same day at 12:55 PM, the drainage bag was observed lying on the dining room floor beneath his wheelchair while multiple staff members, including the facility's Infection Preventionist, were present but failed to notice or address the situation.
The problem persisted throughout the day. At 4:00 PM, as the resident propelled himself down the hallway, both the collection bag and tubing scraped against his wheelchair's right wheel. These observations directly violated the facility's own policy on "Urinary Tract Infections (Catheter-Associated)," which explicitly stated that drainage bags should never be placed on the floor.
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
TERRACE OF KISSIMMEE, THE in KISSIMMEE, FL was cited for violations during a health inspection on April 17, 2025.
The violations affected up to 43 residents who regularly ate in the facility's dining areas.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.