Cycle 1
Health 2025-02-28 · Fire 2025-02-28
13 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Kissimmee, FL
Kissimmee Nursing & Rehabilitation Center
3-star overall rating with 2-star inspections with $329,259 in total fines with 13 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
2511 John Young Parkway North, Kissimmee, FL
(407) 931-3336
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
115
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Harborview Health Systems
Operator or chain grouping
Approved since
1999-08-25
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
21 facilities
Chain averages 2 overall / 2 health / 3 staffing / 2 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.01
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.55
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
2.25
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
3.81
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.56
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
3.42
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.88
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.12
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
1.12
CMS adjusted RN staffing hours
Adjusted total hours
4.23
CMS adjusted total nurse staffing hours
Case-mix index
1.23
Higher values indicate more complex resident acuity
RN turnover
30%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
32%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,444
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
32.82
Composite VBP score used to determine payment impact.
Payment multiplier
0.9873
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0.02
Baseline 22.92% · Performance 22.62% · Measure score 0.02 · Achievement 0 · Improvement 0.02
Healthcare-associated infections
2.81
Baseline 11.15% · Performance 9.11% · Measure score 2.81 · Achievement 0 · Improvement 2.81
Total nurse turnover
6.85
Baseline 83.33% · Performance 40.37% · Measure score 6.85 · Achievement 5.70 · Improvement 6.85
Adjusted total nurse staffing
3.45
Baseline 4.09 hours · Performance 4.06 hours · Measure score 3.45 · Achievement 3.45 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.99% |
10.72%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 85 · Observed rate 15.29% · Lower 95% interval 7.93% |
| Discharge to community | 29.1% |
50.57%
21.5 pts worse
|
Worse than the National Rate · Eligible stays 60 · Observed rate 13.33% · Lower 95% interval 18.07% |
| Medicare spending per beneficiary | 1.08 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 93.44% |
95.27%
1.8 pts worse
|
Numerator 57 · Denominator 61 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 61 |
| Discharge self-care score | 34.62% |
53.69%
19.1 pts worse
|
Numerator 9 · Denominator 26 |
| Discharge mobility score | 38.46% |
50.94%
12.5 pts worse
|
Numerator 10 · Denominator 26 |
| Pressure ulcers or injuries, new or worsened | 4.92% |
2.29%
2.6 pts worse
|
Numerator 3 · Denominator 61 · Adjusted rate 3.74% |
| Healthcare-associated infections requiring hospitalization | 9.11% |
7.12%
2 pts worse
|
No Different than the National Rate · Eligible stays 40 · Observed rate 25% · Lower 95% interval 6.17% |
| Staff COVID-19 vaccination coverage | 55.3% |
8.2%
47.1 pts better
|
Numerator 73 · Denominator 132 |
| Staff flu vaccination coverage | 70.49% |
42%
28.5 pts better
|
Numerator 129 · Denominator 183 |
| Discharge function score | 42.31% |
56.45%
14.1 pts worse
|
Numerator 11 · Denominator 26 |
| Transfer of health information to provider | 77.42% |
95.95%
18.5 pts worse
|
Numerator 24 · Denominator 31 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 0% |
25.2%
25.2 pts worse
|
Numerator 0 · Denominator 24 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.6 |
2.1
0.5 pts worse
|
1.9
0.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.6 · Observed 2.3 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.6 |
1.2
0.4 pts worse
|
1.8
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.3 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.2% |
97.8%
0.4 pts better
|
93.4%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 96.8% · Q2 97.0% · Q3 99.0% · Q4 100.0% · 4Q avg 98.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
99.2%
0.8 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.8% |
2.6%
1.2 pts worse
|
3.3%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 3.0% · Q3 4.9% · Q4 5.0% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.3% |
3.7%
3.4 pts better
|
11.4%
11.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.1% · 4Q avg 0.3% |
| Percentage of long-stay residents who lose too much weight | 7.9% |
5.9%
2 pts worse
|
5.4%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.3% · Q2 8.1% · Q3 11.6% · Q4 4.5% · 4Q avg 7.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.6% |
15.7%
2.9 pts worse
|
19.6%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.2% · Q2 18.9% · Q3 17.8% · Q4 17.6% · 4Q avg 18.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 5.3% |
9.8%
4.5 pts better
|
16.7%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 7.2% · Q3 4.2% · Q4 4.2% · 4Q avg 5.3% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 10.0% |
11.7%
1.7 pts better
|
16.3%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.2% · Q2 21.1% · Q3 0.0% · Q4 11.1% · 4Q avg 10.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.5% |
9.8%
0.3 pts better
|
14.9%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.0% · Q2 9.8% · Q3 14.0% · Q4 4.9% · 4Q avg 9.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.2% |
0.4%
0.2 pts better
|
1.0%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.8% · Q3 0.0% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.3% |
0.8%
0.5 pts better
|
1.7%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 12.6% |
12.5%
0.1 pts worse
|
19.8%
7.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 22.2% · Q2 9.8% · Q3 12.0% · Q4 6.9% · 4Q avg 12.6% |
| Percentage of long-stay residents with pressure ulcers | 5.4% |
5.1%
0.3 pts worse
|
5.1%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 6.6% · Q3 5.3% · Q4 5.4% · 4Q avg 5.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 87.3% |
94.3%
7 pts worse
|
81.7%
5.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 76.9% · Q2 84.3% · Q3 91.3% · Q4 98.3% · 4Q avg 87.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.2% |
9.3%
0.9 pts worse
|
12.0%
1.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.2% · Observed 12.5% · Expected 13.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.4% |
1.5%
1.1 pts better
|
1.6%
1.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 89.1% |
94.7%
5.6 pts worse
|
79.7%
9.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 89.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 32.9% |
26.2%
6.7 pts worse
|
23.9%
9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 32.9% · Observed 37.5% · Expected 27.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-08-10 · Fire 2023-08-10
9 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cycle 3
Health 2021-10-14 · Fire 2021-10-14
5 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
1 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-02-28
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-03-28
F · Potential for more than minimal harm
2023-08-10
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-09-15
F · Potential for more than minimal harm
2021-10-14
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2021-11-25
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-02-28
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-03-28
D · Potential for more than minimal harm
2025-02-28
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2025-03-28
D · Potential for more than minimal harm
2025-02-28
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-03-28
D · Potential for more than minimal harm
2025-02-28
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-03-28
D · Potential for more than minimal harm
2025-02-28
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-03-28
D · Potential for more than minimal harm
2025-02-28
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-03-28
D · Potential for more than minimal harm
2025-02-28
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-03-28
D · Potential for more than minimal harm
2025-02-28
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2025-03-28
D · Potential for more than minimal harm
2025-02-28
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-03-28
D · Potential for more than minimal harm
2025-02-28
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-03-28
D · Potential for more than minimal harm
2025-02-28
F849 · Administration Deficiencies
Health
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.
Corrected 2025-03-28
D · Potential for more than minimal harm
2025-02-28
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-28
D · Potential for more than minimal harm
2025-02-28
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2025-03-28
D · Potential for more than minimal harm
2024-06-26
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-07-19
E · Potential for more than minimal harm
2024-06-13
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-07-07
E · Potential for more than minimal harm
2023-08-10
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-09-15
D · Potential for more than minimal harm
2023-08-10
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2023-09-15
D · Potential for more than minimal harm
2023-08-10
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2023-09-15
D · Potential for more than minimal harm
2023-08-10
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2023-09-15
D · Potential for more than minimal harm
2023-08-10
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-09-15
D · Potential for more than minimal harm
2023-08-10
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2023-09-15
D · Potential for more than minimal harm
2023-08-10
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2023-09-15
J · Immediate jeopardy
2023-06-09
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-07-07
J · Immediate jeopardy
2023-06-09
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-07-07
D · Potential for more than minimal harm
2023-06-09
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-07-07
G · Actual harm
2021-10-14
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2021-11-14
E · Potential for more than minimal harm
2021-10-14
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2021-11-14
Penalties and ownership
What sits behind the stars
$326,085
2023-06-09
Fine
Fine · fine $326,085
Fine
$3,174
2023-06-05
Fine
Fine · fine $3,174
Fine
Ownership
Harborview Kissimmee Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
Chappel, Christopher
Operational/Managerial Control · Individual
Cl 2022 Irrv Tr
5% Or Greater Indirect Ownership Interest · Organization
De 2021 Irrv Tr
5% Or Greater Indirect Ownership Interest · Organization
Fl 7 Nursing And Rehab Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Leibowitz, Chaim
Operational/Managerial Control · Individual
Vaughan, Christa
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Aviata At Kissimmee Gardens
Kissimmee, FL
4-star overall rating with 3-star inspections with 12 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Terrace Of Kissimmee, The
Kissimmee, FL
1-star overall rating with 1-star inspections with $38,724 in total fines with 11 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Kissimmee Health And Rehabilitation Center
Kissimmee, FL
3-star overall rating with 2-star inspections with 6 recent health deficiencies
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