Terrace Of Kissimmee, The

F-F554 for the recertification survey of 1/13/22.

During this survey, the following deficiencies were again identified,

F-F880. As a result of these repeat citations, it was identified there was insufficient auditing and oversight of the mentioned citations.

On 4/17/25 at 4:57 PM, the Administrator stated during their monthly QAPI meetings they discussed areas in need of improvement. He explained Performance Improvement Projects (PIPs) may be developed and implemented accordingly. He mentioned the length of PIP's depended on how long it took to correct the problem. He stated they performed consistent audits of medication related concerns but had not identified any recent trends of medication variances. He acknowledged the QAPI committee did not adequately implement, monitor, and review the identified areas to prevent repeat non-compliance.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 14 105839 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105839 B. Wing 04/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Terrace of Kissimmee, The 221 Park Place Blvd Kissimmee, FL 34741

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50401 potential for actual harm Based on observation, interview, and record review, the facility failed to provide a system for preventing and Residents Affected - Few controlling infections and communicable diseases for residents by not offering hand hygiene to residents prior to meals and not maintaining a catheter bag dragging on the floor. This had the potential to affect 43 residents eating meals in the dining room, and one of one resident reviewed for urinary tract infections, (#95) of a total sample of 44 residents.

Findings:

1. On 4/14/25 at 12:22 PM, during dining observation, 43 residents in the main dining room and the small room off the main dining room, were observed waiting for lunch to be served. At 12:38 PM, the first of three carts with meal trays were delivered from the kitchen and were served to residents. None of the residents were offered hand hygiene before the meal.

On 4/15/25 at 12:35 PM, 39 residents were observed waiting for their lunch meal in the main dining room. Five visitors and three residents confirmed they had not been offered hand hygiene before the meal nor had

they previously been offered hand hygiene before meals that they could recall.

On 4/15/25 at 1:08 PM, Certified Nursing Assistant (CNA) F assisted a resident with their meal and acknowledged she had not offered hand hygiene to the resident before they ate. The CNA stated hand sanitizer was available if they found a resident needed it, but was unsure if the residents were provided any hand hygiene before coming to the dining room to eat.

On 4/16/25 at 12:50 PM, 36 residents were in the main dining room either eating or awaiting their meal to be served. A few minutes later at 1:15 PM, CNA G assisted a resident with his meal and explained they used to offer hand hygiene to residents in the dining room, but not as a hard rule. She said over time, the staff forgot to ask residents if they wanted to clean their hands. She stated it was important for the residents to have clean hands because many of them touched their food with their hands which could have a lot of germs on them. She added they had disinfectant in the cabinets in the dining room if a resident needed it, but did not say why it wasn't offered to the residents.

On 4/17/25 at 3:08 PM, the Infection Control nurse, stated she realized this week, on Monday, 4/14/25, the facility did not provide hand hygiene to residents prior to meals. She added, she was surprised about that and explained her goal was to provide individualized packets of hand wipes to residents prior to meals so

they could clean their hands when they wanted to.

The facility's policy entitled Standard Precautions, dated 2024, contained procedures to limit or stop the spread of transmissible infectious agents. It indicated facility personnel assisted residents with hand hygiene

before meals, after toileting, and when indicated.

51234

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 14 105839 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105839 B. Wing 04/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Terrace of Kissimmee, The 221 Park Place Blvd Kissimmee, FL 34741

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 2. Resident #95 was admitted on [DATE REDACTED] with diagnoses that included lower urinary tract symptoms after prostate removal surgery, unspecified dementia with unspecified severity, and need for assistance with Level of Harm - Minimal harm or personal care. He had a physician's order dated 4/02/25 for a urinary catheter due to prostate diagnoses. potential for actual harm

On 4/14/25 at 10:26 AM, resident #95 was seated in his wheelchair, the bottom of his urinary catheter Residents Affected - Few drainage bag was dragging along the facility's floor as he was pushed in his wheelchair by a staff member.

On 4/14/25 at 12:55 PM, resident #95 was seated in his wheelchair in the facility's dining room. The bottom portion of the urine drainage bag of his catheter was lying on the ground under his wheelchair. Multiple staff were present in the dining room including the facility's Infection Preventionist. No one noticed or picked up

the bag from the floor at that time.

On 4/14/25 at 4:00 PM, resident #95's urine collection bag and the tubing scraped the right wheel of his wheelchair as he self propelled himself down the hallway from the nursing station to his room.

On 4/17/25 at 10:10 AM, the Director of Nursing and the Regional Nurse Consultant confirmed that urinary catheter tubing and collection bags should not touch the floor nor the wheels of wheelchairs to prevent potential infection.

Review of the facility's undated policy entitled Urinary Tract Infections (Catheter-Associated), Guidelines for Preventing, noted the urinary catheter drainage bag should not be placed on the floor.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 14 105839