The November 18 fall at The Terrace of Kissimmee left the resident bleeding from her nose and with a skin tear above her right eyebrow. A certified nursing assistant reported seeing the woman roll over the side rails and hit her nose on the floor at 10:10 PM.
Staff applied pressure to stop the bleeding and called 911. They notified the resident's family, the facility's risk manager, and her physician. But they never called hospice.
The resident had been receiving hospice services since August, when she returned from a hospital stay. Her diagnoses included seizures, bone density disorders, anxiety, muscle weakness, and dementia with mood disturbance.
Federal inspectors found the facility violated its own care agreement with the hospice provider. The resident's comprehensive care plan specifically directed nursing staff to notify hospice of any changes in her condition. The facility's 2019 contract with the hospice company required immediate notification when a hospice patient experiences "a change of condition" or needs to be transferred.
"Hospice expected to be notified of any change in a hospice resident's condition," the Hospice Team Manager told inspectors during a December 23 telephone interview. She confirmed there was no record the facility had contacted them about the fall or hospital transfer.
The Director of Nursing acknowledged the failure during the inspection. "The hospice provider should have been informed of resident #2's fall and transfer to the hospital and that such notification should have been documented in the medical record," she stated. The director said she wasn't working at the facility when the incident occurred and was unaware hospice hadn't been notified.
The incident report completed after the fall documented the immediate actions taken: applying pressure to the bleeding nose and notifying the physician and family. It made no mention of contacting hospice.
A nursing progress note from that night described the sequence of events: "Resident fell off the bed at 10:10 P.M. According to CNA report, resident was in bed when she noticed that resident rolled over the side rails and fell. Resident hit her nose on the floor. Resident was bleeding from the nose."
The note indicated paramedics transported the resident to the hospital. But medical records contained no documentation that hospice was ever contacted about the change in condition, fall, or hospital transfer.
The facility's agreement with the hospice provider spelled out clear expectations. The nursing home was required to notify hospice when any hospice patient experienced a change of condition and to immediately contact hospice if a significant change in physical, mental, or emotional status occurred, including any need for transfer.
The resident's care plan had been updated as recently as November 24, just six days after the fall. It directed staff to observe her daily for pain medication effectiveness, nausea, appetite, mobility, and communication needs. Any noted changes were supposed to trigger notifications to the nurse, physician, and hospice provider.
The resident had originally been admitted to The Terrace of Kissimmee earlier in the year before being readmitted from an acute care hospital in August on hospice services. Her hospice care plan was initiated August 18 and revised November 24.
The communication breakdown meant the hospice team remained unaware their patient had suffered a traumatic fall, required emergency medical attention, and been hospitalized. The failure violated both the facility's written agreement with the hospice provider and the resident's individualized care plan.
Federal inspectors cited the facility for failing to arrange proper hospice services, finding the violation caused minimal harm with potential for actual harm to the resident.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Terrace of Kissimmee, The from 2025-12-23 including all violations, facility responses, and corrective action plans.