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.
Medical Implications of Infection Control Failures
Hand hygiene before meals represents one of the most fundamental infection prevention measures in healthcare settings. The human hands carry approximately 150 different species of bacteria at any given time, with counts ranging from 10,000 to 10 million organisms per square centimeter of skin. In nursing home populations, where residents often have compromised immune systems, chronic medical conditions, and frequent exposure to healthcare environments, the transmission of pathogens through contaminated hands poses significant health risks.
When residents consume food with unwashed hands, they directly introduce potential pathogens into their digestive systems. Common infections that spread through this route include norovirus, which causes severe gastrointestinal illness; Clostridium difficile, a bacteria that causes life-threatening diarrhea; and various respiratory pathogens that residents may have picked up from touching contaminated surfaces. For elderly residents with weakened immune systems, these infections can lead to serious complications including dehydration, malnutrition from inability to eat, and in severe cases, sepsis and death.
The catheter care violations present equally serious risks. Urinary tract infections (UTIs) are already the most common healthcare-associated infection in long-term care facilities, accounting for approximately 30-40% of all infections in these settings. When catheter bags contact floor surfaces, they become contaminated with environmental bacteria. These organisms can then migrate up the catheter tubing through capillary action or when the bag is lifted, potentially introducing bacteria directly into the resident's bladder. For a resident like #95, who already had compromised urinary function following prostate surgery, such contamination significantly increases the risk of developing catheter-associated urinary tract infections (CAUTIs).
CAUTIs in elderly nursing home residents frequently progress to more serious conditions. The infection can ascend from the bladder to the kidneys, causing pyelonephritis, or enter the bloodstream, resulting in urosepsis. Studies show that nursing home residents who develop CAUTIs have mortality rates between 10-30%, with even higher rates among those with multiple comorbidities.
Industry Standards and Expected Protocols
According to Centers for Disease Control and Prevention guidelines, healthcare facilities should implement hand hygiene protocols that include either alcohol-based hand sanitizer containing at least 60% alcohol or soap and water washing for at least 20 seconds. In nursing home settings where many residents have cognitive impairment or physical limitations, staff must actively facilitate this process rather than assuming residents will independently maintain hand hygiene.
Best practices dictate that hand hygiene should be incorporated into the meal service routine as automatically as setting the table or serving food. Many facilities successfully implement systems where hand wipes are distributed as residents enter dining areas, or portable hand sanitizer stations are brought directly to residents who eat in their rooms. Some facilities make hand hygiene a social activity, with staff leading residents through the process as a group before meals begin.
For catheter care, professional standards require maintaining a closed drainage system with the collection bag always positioned below the level of the bladder but never touching the floor. The bag should be secured to the wheelchair frame or the resident's leg using appropriate holders that prevent both floor contact and tension on the catheter itself. Staff should receive training on proper positioning during transfers and movement, with regular monitoring to ensure compliance.
Additional Issues Identified
The inspection also revealed problems with the facility's Quality Assurance and Performance Improvement (QAPI) program. The Administrator acknowledged that while the QAPI committee discussed areas needing improvement during monthly meetings and occasionally developed Performance Improvement Projects, they had failed to identify recent trends in medication variances despite performing what they described as "consistent audits." The committee's inability to adequately implement, monitor, and review identified problem areas had resulted in repeat citations, indicating systemic oversight failures that extended beyond the specific infection control violations observed.
Pattern of Systemic Failure
The violations at The Terrace of Kissimmee reflect more than isolated incidents or individual staff mistakes. The widespread nature of the hand hygiene failures, affecting dozens of residents over multiple days and involving numerous staff members, indicates a complete breakdown of fundamental care protocols. When combined with the catheter care violations observed in plain sight of multiple staff members including the Infection Preventionist, and the admitted failures of the quality assurance program to identify and address these issues, a picture emerges of a facility that has lost sight of basic infection prevention standards.
The fact that staff understood the importance of these measures but failed to implement them suggests problems with leadership, accountability, and organizational culture that extend well beyond the specific violations documented. Without comprehensive changes to training, supervision, and quality monitoring systems, residents remain at unnecessary risk for preventable infections that could have serious or even fatal consequences.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Terrace of Kissimmee, The from 2025-04-17 including all violations, facility responses, and corrective action plans.
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