Kissimmee Health and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Kissimmee Health and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jun 20, 2021

  Based on observation, interview and record review, the facility failed to prevent a physically and cognitively impaired resident from exiting the facility, failed to conduct accurate elopement risk evaluations, and failed to implement appropriate interventions to address wandering risk for 1 of 5 residents reviewed for elopement, out of a total sample of 5 residents (#1). These failures contributed to the elopement of resident #1 and placed him at risk for serious injury/impairment/death. […]

• No harm, potential for more than minimal, widespreadF732May 29, 2025

  Based on observation, and interviews, the facility failed to post a complete Nurse Staffing report in a place readily accessible to residents, staff, and visitors. Findings: On 5/27/25 at 2:30 PM, the Nurse Staffing sheet was posted on the wall in the hall leading from the lobby to the resident rooms. It was about six feet from the floor and out of view of the residents. Review of the posting revealed it did not include the facility census as required. On 5/28/25 at 2:00 PM, a facility visitor stated she was not aware of the facility staff posting on the wall. […]

• No harm, potential for more than minimal, widespreadF801May 29, 2025

  Based on observation, interview, and record review, the facility failed to ensure qualified staff had the appropriate competencies and skill sets to carry out management and oversight of the food and nutrition services as demonstrated by numerous irregularities including labeling/dating food, training to staff on food safety and preparation, and logs for the dish machine, which had the potential to affect all 53 of 53 residents residing and eating at the facility. Findings: On [DATE] at 9:38 AM, during the initial kitchen tour with the Certified Dietary Manager (CDM), multiple food items in the walk-in refrigerator, freezer and dry storage room had unlabeled, undated, expired, and improperly stored food items. […]

• No harm, potential for more than minimal, widespreadF812May 29, 2025

  Based on observation, interview, and record review, the facility failed to label and date stored food in accordance with professional standards for food safety, failed to ensure the dish machine was operated at proper temperatures and sanitizer was dispensed at proper concentrations, and failed to ensure nutritional supplements and residents' food brought in from family were dated and discarded when expired to prevent foodborne illness. These deficiencies had the potential to affect all the 53 residents residing and eating at the facility. Findings: 1. […]

• No harm, potential for more than minimal, patternF867May 29, 2025

  Based on interview, and record review, the facility failed to ensure the Quality Assessment & Assurance (QAA) / Quality Assurance and Performance Improvement (QAPI) committee conducted performance improvement activities to ensure prior improvement measures were sustained. Findings: Review of the facility's QAPI Plan dated 1/18/24, revealed it was designed to be ongoing and comprehensive. The plan detailed the facility used a systematic approach to determine when in-depth analysis was needed to fully understand the problem, its causes and implications of change. The facility used a thorough and highly organized/structured approach to determine the root cause of identified problems. […]