Terrace Of Kissimmee, The

F 0641

the document attesting to the accuracy of such information. Information in the MDS assessment will consistently reflect information in the progress notes, plans of care, and resident observations/interviews.

Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/23/2025

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 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to communicate with the hospice provider when a change in condition was identified to ensure collaboration on the provision of necessary care and services for 1 of 1 resident reviewed for hospice services, of a total sample of 12 residents, (#2).Findings: Review of resident #2's medical record revealed she was originally admitted to the facility on [DATE REDACTED] and readmitted from an acute care hospital on [DATE REDACTED]. Her diagnoses included seizures, disorders of bone density and structure, anxiety, muscle weakness, and dementia with mood disturbance. Review of resident #2's Progress Notes revealed a nursing note dated 8/15/25 and a Social Services note dated 8/17/25, detailing the resident returned to the facility from the hospital on hospice services. Review of resident #2's comprehensive care plan revealed a hospice care plan initiated on 8/18/25 and revised on 11/24/25. The care plan included an approach that directed nursing staff to observe the resident daily for pain medication effectiveness, nausea/vomiting, appetite, ability to move, and ability to communicate needs, and to notify the nurse, physician, and hospice provider of any noted changes. Review of resident #2's medical record revealed an Event Report dated 11/18/25 that documented a fall that resulted in bleeding from the nose and a skin tear above the right eyebrow. Review of the Observation Detail List Report dated 11/18/25 revealed resident #2 was transferred to the hospital due to the fall. Review of the Resident Incident Report form dated 11/18/25 revealed the immediate actions taken after resident #2's fall were to apply pressure to the nose and notify

the physician and the family. The form did not document that hospice was notified. Review of a nursing Progress Note dated 11/18/25 at 10:31 PM, read, Resident fell off the bed at 10:10 P.M. According to CNA (Certified Nursing Assistant) 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. RN (Registered Nurse) applied pressure to the affected area to stop the bleeding until 911 got to the facility. [Emergency Contact name] was notified of the fall. Risk manager [name] and MD (physician) [last name] were also notified . The note indicated the resident was transported to the hospital by paramedics. Review of the medical record revealed no documentation that the hospice provider was contacted regarding resident #2's change in condition, fall, or transfer to the hospital on [DATE REDACTED]. On 12/23/25 at 1:17 PM, in a telephone interview, the Hospice Team Manager stated there was no record the facility notified hospice of resident #2's fall or hospital transfer. She indicated hospice expected to be notified of any change in a hospice resident's condition. On 12/23/25 at 6:49 PM, the Director of Nursing (DON) stated 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 indicated she was not the DON at the time of the incident and was not aware hospice had not been notified. Review of the Nursing Facility Services Agreement dated 1/01/19 between the hospice provider and the facility revealed, Nursing Facility shall notify Hospice when the Hospice Patient experiences a change of condition and shall notify the Hospice Patient's attending physician and family of significant change in condition. The agreement further detailed

the nursing facility shall immediately notify hospice if a significant change in a hospice patient's physical, mental, or emotional status occurs including the need to transfer a hospice patient from the nursing facility.

Event ID:

Facility ID:

If continuation sheet