Terrace of Kissimmee, The

In the surveyor’s words

From the most serious findings on record at Terrace of Kissimmee, The, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Oct 24, 2024

  Based on interviews, and record review, the facility failed to protect the resident's right to be free from neglect by failing to honor the resident's wishes for life saving measures, by failing to follow physician's order for Full Code and failing to initiate Cardiopulmonary Resuscitation (CPR) for 1 of 6 residents reviewed for Advanced Directives, of a total sample of 8 residents, (#2). On [DATE] at approximately 10:05 PM, resident #2 was found not breathing by Certified Nursing Assistant (CNA) D. The CNA notified Licensed Practical Nurse (LPN) C who evaluated the resident with no vital signs. LPN C did not check the resident's code status nor provide CPR but instead informed the Weekend Supervisor Registered Nurse (RN) E of the situation at approximately 10:08 PM. […]

• Immediate jeopardy, isolatedF678Oct 24, 2024

  Based on interview, and record review, the facility failed to honor the resident's/family's wishes and failed to follow the physician's order to provide basic life support (BLS) and initiate Cardiopulmonary Resuscitation (CPR) for 1 of 6 residents reviewed for Advanced Directives, of a total sample of 8 residents, (#2). On [DATE] at approximately 10:05 PM, resident #2 was found unresponsive in bed, not breathing by Certified Nursing Assistant (CNA) D. The CNA notified Licensed Practical Nurse (LPN) C who evaluated the resident had no vital signs. LPN C did not verify the resident's code status, or initiate CPR and instead asked Registered Nurse (RN) Supervisor E at approximately 10:08 PM to come to the resident's room. […]

• Actual harm, isolatedF689May 20, 2021

  Based on interview and record review, the facility failed to provide individualized interventions and adequate supervision to prevent falls resulting in fractures for 1 of 3 residents reviewed for falls, (#1). Findings: Resident #1 was admitted to the facility on [DATE] with diagnoses of [CONDITION(S)], wedge compression fractures of [MEDICATION(S)] (T) 11-T12 vertebra, first, second and third lumbar vertebrae, dementia, anxiety disorder, and generalized muscle weakness. A review of progress note dated 4/21/21 at 4:46 AM, read This writer was standing at the nurses' station when I saw resident sticking her head outside of her room. I was walking towards her when she took a few steps forward and lost her balance. I observed resident's head hit the tile. […]

• No harm, potential for more than minimal, widespreadF812Apr 17, 2025

  Based on observation, interview, and record review the facility failed to store food in accordance with professional standards for food service safety by failing to label, date, and discard food after an acceptable time period and by failing to air-dry glasses, cups, and trays prior to their use in meal service, in one of one walk-in refrigerator/freezer, one of one dry storage room and one of one kitchen. Findings: On [DATE] at 9:45 AM, during the initial kitchen tour with the Consultant Certified Dietary Manager (CDM) S, there were multiple leftover/previously opened food items found unlabeled and undated in the walk-in refrigerator as listed: four packages of wrapped American Cheese slices, two packages of shredded cheese, a half-pan of what appeared to be chicken breasts floating in… […]

• No harm, potential for more than minimal, patternF867Apr 17, 2025

  Based on interview, and review of facility documentation, the facility failed to ensure implementation of policies to the extent of including thorough monitoring of previously identified areas of concern and adequately tracking performance to ensure prior improvement measures were realized and sustained for two of ten concerns identified during the survey, (F554, and F880). Findings: Review of the facility's undated policy, Quality Assurance and Performance Improvement (QAPI) Program, revealed the purpose of the QAPI Program was to establish data driven, facility wide processes to improve the quality of care, quality of life and clinical outcomes of their residents. The policy included Action Steps to support and enhance the QAPI Program. […]