Kissimmee Nursing & Rehabilitation Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600Jun 9, 2023

  Based on interview and record review, the facility failed to protect the resident's right to be free from neglect. This neglect was evident when the facility failed to develop and implement protocols to ensure residents received necessary wound care and services through consistent in-house assessment of pressure injuries and oversight of contracted wound care practitioners; and nursing staff neglected to report abnormal findings and obtain appropriate treatments for 1 of 6 residents reviewed for acquired pressure injuries, out of a total sample of 10 residents, (#2). These failures contributed to resident #2's pressure injuries, a severe infection, and his subsequent death. […]

• Immediate jeopardy, isolatedF686Jun 9, 2023

  Based on observation, interview and record review, the facility failed to prevent the development and worsening of pressure injuries; failed to provide wound care services consistent with professional standards of practice; and failed to identify and treat signs and symptoms of wound infection for 2 of 6 residents reviewed for acquired pressure injuries, out of a total sample of 10 residents, (#2 and #4). These failures contributed to resident #2's pressure injuries, a severe infection, and his subsequent death. Resident #2 suffered a life threatening illness, pain, discomfort, permanent disfigurement, and impairment as his wounds worsened until his death. On [DATE], ten days after admission to the facility, a nurse identified pressure injuries on resident #2's heels. […]

• Actual harm, isolatedF686Oct 14, 2021

  Based on observation, interview, and record review, the facility failed to provide care and services to prevent development of a pressure ulcer and promote healing of a newly identified area of skin breakdown for 1 of 4 residents reviewed for pressure ulcers, of a total sample of 40 residents, (#96). The facility's failure to implement preventative interventions consistent with the resident's risk for skin breakdown, and failure to initiate treatment according to accepted standards of practice resulted in actual harm, development of a stage 3 sacral pressure ulcer. […]

• No harm, potential for more than minimal, patternF686Jun 13, 2024

  Based on observation, interview, and record review, the facility failed to provide the necessary treatment and services to promote healing and prevent worsening of existing pressure ulcers for 3 of 13 residents reviewed for pressure ulcers, of a total sample of 20 residents, (#3, #9, and #17). Findings: According to the National Pressure Ulcer Advisory Panel (NPUAP), There are Stage 1 to 4 pressure ulcers, unstageable and suspected deep tissue injury (SDTI) .Stage 2 has partial thickness loss of dermis presenting as a shallow open ulcer with red/pink wound bed, without slough .Stage 3 has full thickness skin loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed . […]

• No harm, potential for more than minimal, patternF812Aug 10, 2023

  Based on observation, interview and record review, the facility failed to maintain safe and sanitary conditions for food storage in 2 of 2 nutrition stations, (Specialized Subacute Unit and General and Restorative Unit). Findings: On 8/10/23 at 10:30 AM, during a tour of the Specialized Subacute Unit (SSU) nutrition station with the SSU Unit Manager (UM), the following concerns were identified: * The countertop sink was leaking underneath the cabinet into bath basin and overflowing pink colored water noted to be eroding cabinet. The cabinet had brownish/black substance noted in the corners. […]