Inspection·March 21, 2024

F 0554 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few in their rooms. She acknowledged that a self-administration evaluation was not conducted for resident #47, and the resident did not have a physician order for self-administration of medications. On 3/19/24 at 10:14 AM, the B Wing Unit Manager (UM) explained medications should not be in a resident's room, unless there was a physician order for self-administration of medications, and an order to keep the medications at the resident's bedside. The B Wing UM stated that nurses were aware of the process. On 3/20/24 at 6:00 PM, the DON explained if a resident wanted to self-administer medications, a selfadministration evaluation needed to be completed, and a physician's order for self-administration of medications obtained. The facility's policy, Self-Administration of Medications issued on 4/01/22 read, As part of the overall evaluation, the staff and practitioner will assess or evaluate resident's mental and physical abilities to determine whether a resident is capable of self-administering medications . Self-administered medications should be stored in a safe and secure place, which is not accessible by other residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105431 If continuation sheet Page 2 of 17 Printed: 05/28/2026 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 105431 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Courtyards of Orlando Care Center and Rehab 1900 Mercy Drive Orlando, FL 32808 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 0568 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to send quarterly personal fund account balance statements to resident's responsible party for 1 of 7 sampled residents reviewed for personal funds, out of a total sample of 45 residents, (#71). Findings: Resident #71 was admitted to the facility on [DATE] and re-admitted on [DATE] for long term care. Her diagnoses included cerebral infarction, attention to gastrostomy, pressure ulcer- sacral region, dementia, epilepsy, seizures, sepsis, hypertensive heart, and chronic kidney disease. A review of the census information revealed resident #71's payor source was Medicaid as of 8/28/23. A review of the medical record revealed admission Minimum Data Set (MDS) assessment dated [DATE] which showed her Brief Interview for Mental Status score of 00 which meant she was severely cognitively impaired. Her quarterly MDS assessments dated 11/15/23 and 2/15/24 showed she was rarely/never understood, had both long term and short-term memory problems, and had severely impaired cognitive skills for daily decision making. On 3/19/24 at 11:35 AM, a phone interview was conducted with resident #71's designated responsible party and Durable Power of Attorney (POA). She acknowledged the resident was a Medicaid recipient. She said she had a trust fund account with the facility's business office but had not received statements of her account balance from the facility business office for greater than 6 months. Review of the electronic medical record (EMR) showed the Durable POA form signed and dated 7/3/2008 in resident #71's chart. The form included the resident representative's mailing address. On 3/19/23 at 3:55 PM, an interview with the Business Office Manager (BOM) revealed she had been working at the facility for 5 years and was in the role of BOM for 3 years. She explained that the resident's trust fund accounts were set up when they became Long Term Care residents, and they got an allowance of $160 per month. She stated, we don't regularly send out statements and only give them out if the balance is over $2000 so the family would know that they need to spend down the money. She added, the statements did not come from me, and she would have to find out if the Medicaid Specialist was sending them out because they were not being generated by the business office over the 3 years that she had been in that role. Review of the Resident Fund Statements dated 9/29/23 and 12/29/23 for resident #71 showed they were addressed to the resident and included the facility address and not the DPOA/resident's representative address. On 3/21/24 at 9:48 AM, a telephone interview was conducted with the [NAME] President of Finance and the Medicaid Specialist was present in person. The staff verified that they did assist resident #71's daughter with the Medicaid application process which became the payer source as of 8/28/23. They acknowledged the Durable POA paperwork with the daughter's address was contained in the EMR scanned items since August 2023 as well. They acknowledged that resident #71 had a personal trust fund (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105431 If continuation sheet Page 3 of 17 Printed: 05/28/2026 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 105431 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Courtyards of Orlando Care Center and Rehab 1900 Mercy Drive Orlando, FL 32808 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 0568 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few account with the facility. They also acknowledged the resident had severe cognitive impairment and had a responsible party/financial and medical POA family member. The facility directly received the resident's monthly Social Security checks for direct payment. They acknowledged that because the resident was not her own decision maker that the quarterly statements should have gone to her responsible party and not the resident. The staff explained they would have to manually go into the Resident Trust management account to edit the address to ensure that it would be mailed to the resident representative at the correct address. Review of the facility's admission paperwork regarding Personal Funds, Trust Account read, The resident may choose to deposit personal funds with Center in a resident trust fund account pursuant to trust fund agreement and beneficiary designation form in accordance with applicable state and federal laws. The Center will not charge additional fees for trust account services .The resident may see records of his/her account through quarterly statements . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105431 If continuation sheet Page 4 of 17 Printed: 05/28/2026 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 105431 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Courtyards of Orlando Care Center and Rehab 1900 Mercy Drive Orlando, FL 32808 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure documentation for code status Do Not Resuscitate (DNR) matched the clinical records for 1 of 1 resident reviewed for Advance Directives, of a total sample of 45 residents, (#47). Findings: Resident #47 was admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, diabetes type II, obstructive sleep apnea, atrial fibrillation, acute on chronic diastolic (congestive) heart failure, hypertension, and major depressive disorder. Review of the resident's clinical records revealed a physician order dated 3/16/24 for Full Code status. The Electronic Medical Record (EMR) banner noted full code status. Scanned documents revealed a canary yellow form State of Florida Do Not Resuscitate Order dated 9/11/23, signed by the resident, and physician on 9/11/23. Review of the DNR Binder located at the nurses' station on the B Wing revealed a State of Florida DNR order for resident #47. On 3/18/24 at 5:43 PM, the Director of Nursing (DON) explained that if a resident was found unresponsive, the nurse would review the resident's code status in the facility's electronic medical record. The resident's clinical records, and the DNR binder were reviewed with the DON. She acknowledged that the documentation was conflicting, since there was an order for full code, and a DNR order in place. The DON stated, if a resident changed his/her mind regarding their code status, an order would be obtained to revoke the DNR order, and the information would be documented in the resident's clinical record. Clinical record review revealed no documentation to indicate the resident revoked her DNR order. This was confirmed by the DON. On 3/18/24 at 5:52 PM, resident # 47 stated she had a DNR order in her clinical records, which would remain in place. On 3/18/24 at 5:53 PM, the B Wing Unit Manager (UM) stated if a resident was found unresponsive, nurses would confirm the resident's code status by checking the electronic medical record, and the DNR binder. She acknowledged that the information in the EMR and the DNR binder were conflicting. The UM stated that when the resident was readmitted to the facility on [DATE], she placed the order for full code status in the resident's EMR based on her review of the Medical Certification For Medicaid Long Term Care Services And Patient Transfer Form (3008) dated 3/16/24. She said she did not clarify the code status with the resident, and stated it was an error on her part. An Advance Directive Note documented by the Social Service Assistant dated 3/18/24 at 5:56 PM indicated the resident's code status was discussed, and the resident wish to stay a DNR. The resident's care plan for advance directives initiated 11/07/23 noted the resident had a DNR in place and could make informed consent regarding her health care decisions. An intervention was to honor the resident's wishes regarding Advanced Directives/Code status. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105431 If continuation sheet Page 5 of 17 Printed: 05/28/2026 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 105431 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Courtyards of Orlando Care Center and Rehab 1900 Mercy Drive Orlando, FL 32808 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete The facility's policy Determination of Code Status issued 4/01/2022 read, The resident's Code Status will be determined by a physician's order and/or validly executed State of Florida DNR order form .and/or documented evidence of the resident wishes being in place .Upon admission the nurse completing the admission assessment will ascertain resident's desired code status (Full Code or DNR) .The electronic record (including electronic chart, point of care kiosk or eMAR (electronic medication administration record)) will serve as the primary source of validation of code status should a resident be found unresponsive. Event ID: Facility ID: 105431 If continuation sheet Page 6 of 17 Printed: 05/28/2026 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 105431 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Courtyards of Orlando Care Center and Rehab 1900 Mercy Drive Orlando, FL 32808 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 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Resident #121 was admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy, dementia, atrial fibrillation, and heart failure. A physician's order dated 6/06/23, read, send the resident to the emergency room for evaluation due to altered mental status. On 3/20/24 at 4:14 PM, the SSD stated the Social Service Department was responsible to submit notification of transfer/discharges to the Ombudsman. She explained the forms were submitted weekly to the Ombudsman, and a copy of the form was placed in a binder at the facility. Clinical record review revealed no documentation or evidence that the transfer/discharge notification of the hospital transfer was submitted to the Ombudsman. On 3/21/24 at 2:42 PM, the SSD stated she was unable to locate any documents to confirm the discharge/transfer notification for resident #121 was submitted to the Ombudsman. The facility's policy Transfer and Discharge issued 4/01/2022 read, If the facility initiates the discharge, a copy of the Notice of intent to Transfer or Discharge should be sent to the Office of the State Long-Term Care Ombudsman In situations where the facility has decided to discharge the resident while the resident is still hospitalized , the facility will send a notice of the discharge notice to a representative of the Office of the State LTC Ombudsman. Based on interview, and record review, the facility failed to provide written Notification of Transfer or Discharge forms to the Ombudsman for 4 of 6 residents reviewed for hospitalizations, out of a total sample of 45 residents, (#42, #79, #18, and #21). Findings: 1. Resident #42 was admitted to the facility on [DATE] with diagnoses to include unspecified dementia, major depressive disorder, end stage renal disease and hypertension. The Minimum Data Set Annual Assessment noted resident #42 scored 3 on the Brief Interview for Mental Status evaluation which indicated the resident's cognition was severely impaired. A Nursing Home to Hospital Transfer Form dated 07/07/2023 revealed resident #42 had generalized weakness, and had a fall. Review of the medical record revealed resident #42 was in the hospital from [DATE] and returned to the facility on [DATE]. On 3/21/2024 at 10:18 AM, the Social Service Director (SSD) was unable to provide documentation of notice to the state Ombudsman of resident #42's emergent transfer to the hospital. The facility was unable to provide documentation of written notice made to the state Ombudsman. 2. Resident # 79 was admitted to the facility on [DATE] with diagnoses that included unspecified (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105431 If continuation sheet Page 7 of 17 Printed: 05/28/2026 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 105431 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Courtyards of Orlando Care Center and Rehab 1900 Mercy Drive Orlando, FL 32808 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 0623 dementia- unspecified severity without behavioral disturbance and hypertension. Level of Harm - Minimal harm or potential for actual harm A progress note dated 01/12/23 revealed resident #79 had swelling on the right side the forehead. The resident had projectile vomiting, abdominal pain and dizziness and was transferred to the hospital. The resident returned to the facility five days later, on 1/17/23. Residents Affected - Some Review of resident #79's medical record revealed a written Notification of Transfer or Discharge form for hospitalization dated 01/12/23 signed by the Nursing Home Administrator/Designee. The notice was not signed as received by the resident or representative nor was there indication of notification to the state Ombudsman's office. On 3/21/2024 at 10:18 AM, the SSD was unable to provide documentation of notice to the state Ombudsman of resident #79's emergent transfer to the hospital. The facility was unable to provide documentation of written notice made to the state Ombudsman. 3. Resident #18 was admitted to the facility on [DATE] with diagnoses including muscle weakness, primary osteoarthritis, atherosclerosis of coronary artery bypass graft(s) without angina pectoris, dementia, other sequelae of cerebral infarction, and Alzheimer's disease. Review of resident #18's medical record revealed she was hospitalized on [DATE] and readmitted to the facility on [DATE] as a result of a displaced fracture of the right femur. The medical record did not contain a copy of the Nursing Home Notice of Transfer and Discharge Notice or evidence of Ombudsman notification of the transfer. On 3/20/24 at 4:13 PM, the SSD stated social services was responsible for notifying the Ombudsman of transfers and discharges. She explained the forms were faxed to the Ombudsman office and a copy of the fax confirmation was kept in the social services office. On 3/21/24 at 10:15 AM, the SSD provided a copy of the Nursing Home Transfer and Discharge Notice. She stated she had missed sending the notice to the Ombudsman. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105431 If continuation sheet Page 8 of 17 Printed: 05/28/2026 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 105431 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Courtyards of Orlando Care Center and Rehab 1900 Mercy Drive Orlando, FL 32808 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure Minimum Data Set (MDS) assessments accurately reflected vision and edentulous (without teeth) status for 1 of 3 residents reviewed for vision and dental services, of a total sample of 45 residents, (#69). Residents Affected - Few Findings: Review of resident #69's medical record revealed he was originally admitted to the facility on [DATE] and readmitted from an acute care hospital on 4/07/22. His diagnoses included legal blindness and type 2 diabetes. Review of resident #69's MDS Annual assessment with Assessment Reference Date (ARD) of 3/05/24 revealed a Brief Interview for Mental Status score of 14 out of 15 which indicated intact cognition. On 3/18/24 at 4:25 PM, resident #69 stated he previously had upper and lower dentures, but he lost them approximately 2 years ago. He stated he was recently measured and was still waiting for his new dentures. During the conversation, his mouth opened to reveal he had no upper or lower teeth. Resident #69 stated he was also waiting for cataract surgery and mentioned he could not see well. Review of resident #69's medical record revealed an admission Nursing Comprehensive Evaluation dated 2/26/22. It showed his visual acuity was severely impaired/blind: can only see shapes/lights or NO vision. It indicated glasses were used. The dental evaluation section included questions about the condition of the natural teeth and if the resident used dentures/partials. These were answered as, All teeth intact, no dental issues. Does not have dentures/partials. Review of resident #69's medical record revealed a Social Services admission Evaluation date 2/28/22. The summary included, Resident reports adequate vision without the use of glasses. Resident has natural teeth with no reports of pain while chewing. Review of resident #69's medical record revealed care plans initiated on 3/07/22 for self-care deficit related to visual limitation, which read legally blind and risk for falls related to alteration in visual function as evidence by legally blind. Review of the Florida Agency for Health Care Administration 5000-3008 Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form signed by the hospital's physician on 4/04/22 revealed resident #69 was blind legally. Review of resident #69's medical record revealed an admission Nursing Comprehensive Evaluation dated 4/07/22. It showed his visual acuity was severely impaired/blind: can only see shapes/lights or NO vision. It indicated no corrective devices were used. The dental evaluation section included questions about the condition of the natural teeth and if the resident used dentures/partials. These were answered as, All teeth intact, no dental issues. Does not have dentures/partials. Review of a hospital Bedside Swallow Assessment note dated 4/05/22 revealed resident #69 was observed eating a turkey sandwich with little difficulty without dentures. The note included the patient was edentulous and he reported eating meals without dentures in place. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105431 If continuation sheet Page 9 of 17 Printed: 05/28/2026 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 105431 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Courtyards of Orlando Care Center and Rehab 1900 Mercy Drive Orlando, FL 32808 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 0641 Level of Harm - Minimal harm or potential for actual harm Review of a dental Screening Report dated 8/04/22 for resident #69 read, Upper and lower edentulous. Patient interested in dentures. Review of a Nutrition Risk Evaluation dated 3/07/23 read, Independent diner, edentulous and interested in dentures - dental following. Residents Affected - Few Review of a dental Screening Report dated 11/16/23 for resident #69 read, Patient has upper and lower edentulous. Patient states he doesn't have dentures . Review of resident #69's MDS Annual assessments with ARD of 3/05/23 and 3/05/24 revealed his dental status was incorrectly assessed. Section L - Oral/Dental Status, Subsection L0200B, was not coded or check-marked to indicate the resident was edentulous. The MDS assessments indicated resident #69 did not have any problems with his teeth. Review of resident #69's care plan for nutrition and hydration initiated on 3/05/22 with target review date of 3/29/24 did not include the resident's edentulous status. Review of resident #69's MDS Annual assessment with ARD of 3/05/23, Quarterly assessment with ARD of 6/05/23 and Quarterly assessment with ARD of 9/05/23 revealed his vision status was incorrectly assessed. Section B - Hearing, Speech, and Vision, Subsection B1000, was coded as adequate. The MDS assessments indicated resident #69 did not have any problems with his vision. On 3/21/24 at 2:23 PM, MDS Coordinator C explained she was responsible for completing sections A, B, GG, H, I, J, L, M, N, O, and P of the MDS assessments and creating or updating residents' care plans. She stated she spoke with residents, collaborated with therapy and other departments such as dietary, activities, and reviewed the admission documents to complete the MDS assessment accurately. She stated all admissions were discussed during clinical meetings and the documentation received was reviewed during that meeting. She explained the Social Services Director also spoke with residents and found out if they needed dental and vision services. She mentioned she reviewed dental evaluation notes for long-term residents to determine if they had any loose teeth or dental issues. She acknowledged during the assessment and conversation with a resident, she would notice if the resident was edentulous. She reviewed resident #69's care plan and said there was no dental care plan, and the nutrition care plan did not mention he was edentulous. She reflected if a resident was edentulous, it would be included in the care plan because that was pertinent information for his care. She stated this was information the staff needed to know although Staff would not go in there; it (the care plan) does not do anything because the Certified Nursing Assistants or nurses do not utilize it at all. She then reviewed section B of the Annual MDS dated [DATE], the Quarterly MDS dated [DATE] and Quarterly MDS dated [DATE] and confirmed they showed resident #69's vision was adequate. She acknowledged this was incorrectly coded on the 3 mentioned MDS assessments because there was documentation that indicated he was legally blind. She also acknowledged Section L of the Annual MDS assessments dated 3/05/23 and 3/05/24 were answered incorrectly when no dental issues was selected. She confirmed she completed the MDS assessment dated [DATE] and could not offer an explanation why section L was incorrectly coded. She validated when the assessment was submitted, she attested the information was accurate. On 3/21/24 at 5:13 PM, the Director of Nursing stated she was aware of the incorrect documentation in resident #69's MDS assessments and stated the dental status was not updated because there were no concerns with his eating. She acknowledged the vision and dental sections were inaccurately coded and did not reflect the resident's vision impairment and edentulous status. She stated the assessment (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105431 If continuation sheet Page 10 of 17 Printed: 05/28/2026 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 105431 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Courtyards of Orlando Care Center and Rehab 1900 Mercy Drive Orlando, FL 32808 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 0641 and care plan should be accurate and resident centered. Level of Harm - Minimal harm or potential for actual harm Review of the Centers for Medicare & Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual Section B: Hearing, Speech, and Vision directed the user to code 1 if vision was impaired, code 2 if moderately impaired and code 4 if severely impaired. Residents Affected - Few Review of the CMS RAI Manual revealed coding instructions for Section L: Oral/Dental Status which directed the user to place a check mark by Subsection L0200B if the resident was edentulous. Review of the facility's policy and procedure titled, Comprehensive Assessments and Care Plans dated 4/01/2022 revealed the intent to compile a comprehensive assessment by obtaining the resident's needs, goals, life history and preferences, using the RAI specified by CMS. It provided a list of areas for the assessment which included vision and dental. The Guidelines read, The facility will conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity. Review of the facility's policy and procedure titled MDS Assessments dated 4/01/2022 read, It will be the policy of this facility to complete MDS assessments in accordance with the RAI manual guidelines. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105431 If continuation sheet Page 11 of 17 Printed: 05/28/2026 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 105431 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Courtyards of Orlando Care Center and Rehab 1900 Mercy Drive Orlando, FL 32808 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 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a midline dressing was changed as per professional guidelines to prevent the potential for infection, and failed to obtain physician's order for a midline dressing for 1 of 1 resident of a total sample of 45 residents, (#107). Residents Affected - Few A midline catheter is a small tube used to give treatments and to take blood samples. The catheter is inserted into a vein in your arm .can stay in place for up to 30 days. (Retrieved on 3/22/24 from drugs.com) Findings: Resident #107 was admitted to the facility on [DATE] with diagnoses which included diabetes type II, anemia in chronic kidney disease, hypertension, Alzheimer's Disease, major depressive disorder, generalized anxiety disorders, and bipolar disorder. Observations on 3/18/24 at 4:17 PM, 3/19/24 at 9:44 AM, and on 3/20/24 at 9:38 AM, showed resident #107 reclining in her bed watching television. A midline was noted to the resident's left upper arm, and the dressing was dated 3/13/24. Resident #107 stated she was no longer receiving any medication via the midline, and shared that staff flushed the midline. On 3/21/24 at 9:56 AM, resident #107 was lying in bed positioned to her left side. The midline dressing to her left upper arm was dated 3/13/24, and the area below the midline was swollen/infiltrated. Review of the resident's physician orders revealed an order for the insertion of the midline on 2/28/24, and orders dated 3/07/24 for staff to check the midline site for signs/symptoms of infection or bleeding, and to flush the midline with 10 milliliters of normal saline every shift. A physician order for dressing change of the midline was not identified. On 3/21/24 at 9:59 AM, the resident's midline was observed with the resident's assigned nurse, Registered Nurse (RN) E. She acknowledged that the date on the midline dressing was 3/13/24, and that the area below the midline was swollen/infiltrated. RN B stated the midline dressing was to be changed every week and as needed. The resident's physician orders were reviewed with the RN, and she verbalized that an order for the midline dressing could not be identified. She stated if an order for the midline dressing was not in place, the nurse should notify the physician, and obtain an order. On 3/21/24 at 10:09 AM, the B Wing Unit Manager (UM) stated a dressing for a midline should be changed every seven (7) days. Observations of the midline dressing dated 3/13/24 was shared with the B Wing UM, she stated the midline dressing should have been changed by the resident's assigned nurse, or the wound care nurse on 3/20/24. The resident's physician orders were reviewed with the UM, who acknowledged that an order for the resident's midline dressing change could not be identified. The resident's midline was observed with the UM, and she confirmed that the date on the dressing was 3/13/24 and acknowledged that the area below the midline was swollen/infiltrated. The UM said nurses knew the resident had a midline, and if there was no order for dressing changes, nurses should notify the physician, and obtain an order. On 3/21/24 at 10:18 AM, the Assistant Director of Nursing/Infection Preventionist stated midline (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105431 If continuation sheet Page 12 of 17 Printed: 05/28/2026 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 105431 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Courtyards of Orlando Care Center and Rehab 1900 Mercy Drive Orlando, FL 32808 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 0694 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few dressings should be changed every 7 days for prevention of infection, and the UMs were supposed to ensure that midline dressings were changed on a weekly basis. On 3/21/24 at 12:59 PM, the Registered Nurse (RN)/Wound Care Nurse recalled he completed the dressing for resident #107's midline on 3/13/24 and stated the dressing should have been changed on 3/20/24. The Wound Care nurse stated he was not aware the resident did not have an order for the dressing change. He said he should have verified the order and if an order was not in place, he should have called the physician to obtain an order. The policy PICC (Peripherally inserted central catheter)/Midline IV (Intravenous) Line issued on 4/01/22 read, Sterile dressing change using transparent dressing is performed: . at least weekly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105431 If continuation sheet Page 13 of 17 Printed: 05/28/2026 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 105431 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Courtyards of Orlando Care Center and Rehab 1900 Mercy Drive Orlando, FL 32808 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to obtain a physician order for Oxygen (O2) therapy for 1 of 1 resident reviewed for respiratory care, of a total sample of 45 residents, (#47). Residents Affected - Few Findings: Resident #47 was admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, diabetes type II, obstructive sleep apnea, atrial fibrillation, acute on chronic diastolic (congestive) heart failure, hypertension, and major depressive disorder. Review of the resident's quarterly Minimum Data Set assessment dated [DATE] revealed the resident's cognition was intact with a Brief Interview for Mental Status (BIMS) score of 14 out of 15. The assessment indicated the resident was on oxygen therapy. Observations on 3/18/24 at 11:52 AM, and on 3/19/24 at 9:50 AM showed resident #47 reclining in bed, with O2 infusing via nasal cannula at 6 liters per minute (LPM). The resident stated she was on 4 to 6 LPM of O2 continuously. In a review of the resident's physician orders, an order for O2 therapy was not identified. On 3/19/24 at 9:57 AM, Licensed Practical Nurse (LPN) A stated she was the resident's assigned nurse. She recalled that during the shift to shift report she received, she was told that resident #47 was on O2, but she was not told the LPM. Observation of the O2 flow rate was conducted with the LPN, she acknowledged the O2 therapy was infusing at 6 LPM. A review of the resident's physician orders conducted with LPN A revealed an order for O2 therapy could not be identified. This was acknowledged by the LPN, and she verbalized she had not reviewed the resident's physician orders, or checked the O2 therapy the resident was receiving. On 3/19/24 at 10:14 AM, and at 10:20 AM, the B Wing Unit Manager (UM) stated resident #47 was readmitted to the facility on [DATE]. The UM explained she completed the readmission process, and entered the resident's orders in the resident's electronic medical record after they were reviewed and verified with the physician. The resident's physician's orders were reviewed with the B Wing UM. She acknowledged that an order for O2 therapy could not be identified for the resident and said, I missed it. The B Wing UM said the expectation was that residents would receive the correct O2 therapy/setting, and if an order for O2 therapy was not identified, nurses should call the physician and obtain orders. On 3/19/24 at 10:22 AM, the Director of Nursing (DON) stated that the Interdisciplinary team (IDT) reviewed the clinical records of all new admissions to the facility on the day following the resident's admission/readmission. She explained if the admission was on a weekend, the clinical records would be reviewed by the Supervisor, or by the IDT on the following Monday. She said the resident's readmission was completed and reviewed by the B Wing UM who was the supervisor on 3/16/24. The DON stated the expectation for O2 therapy, was that nurses should be checking and ensuring that O2 was infusing at the right LPM and follow up with maintenance of the O2 tubing. She said O2 was considered a medication, administered by physician orders, and if the resident did not have an order for the O2 therapy, nurses should notify the physician, and obtain orders. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105431 If continuation sheet Page 14 of 17 Printed: 05/28/2026 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 105431 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Courtyards of Orlando Care Center and Rehab 1900 Mercy Drive Orlando, FL 32808 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 0695 Level of Harm - Minimal harm or potential for actual harm A care plan for oxygen therapy initiated on 9/06/23 with revision on 11/07/23 indicated the resident needed oxygen constantly or intermittently to aid breathing, and an intervention was for oxygen at 6 LPM. The policy Respiratory Care issued on 4/01/2022 read, Verify that there is a physician's order for respiratory procedures or oxygen use. Review the physician's orders for oxygen administration. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105431 If continuation sheet Page 15 of 17 Printed: 05/28/2026 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 105431 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Courtyards of Orlando Care Center and Rehab 1900 Mercy Drive Orlando, FL 32808 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure pharmacy recommendations were acted upon in a timely manner for 1 of 5 residents reviewed for unnecessary medications, of a total sample of 45 residents, (#47). Findings Resident #47 was admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, diabetes type II, atrial fibrillation, acute on chronic diastolic (congestive) heart failure, hypertension, and major depressive disorder. Pharmacy recommendations for resident #47 on 9/18/23 indicated the resident was currently taking Digoxin and recommended that an apical pulse be obtained prior to administration of the medication. The physician/prescriber agreed to the recommendation on 10/16/23. A second pharmacy recommendation dated 12/15/23 addressed the same concern and read, Obtain an apical pulse prior to administration of the medication. The physician/prescriber response dated 1/17/24 was agree. Digoxin is used to treat heart failure and abnormal heart rhythms (arrhythmias). It helps the heart work better and helps control your heart rate (Retrieved 3/27/24 from www.medlineplus.gov). Review of the resident's physician orders revealed an order for Digoxin 125 microgram (mcg) in the morning for heart failure. There was no directive to monitor apical pulse prior to the administration of the medication as recommended by the Consultant Pharmacist on 9/18/23, and on 12/15/23. On 3/20/24 at 1:30 PM, and on 3/21/24 at 9:00 AM, the Director of Nursing (DON) stated pharmacy recommendations were received by her via mail, hand delivered or email. She explained that pharmacy recommendations regarding labs, diagnosis, and apical pulse would be entered in the identified resident's electronic medical record by the Advanced Practice Registered Nurse, DON, or the Unit Managers. The DON said the facility's protocol was that pharmacy recommendations would be addressed and responded to prior to the next monthly pharmacy recommendation. The resident's pharmacy recommendations dated 9/18/23 and 12/15/23, the physician/prescriber's responses to the recommendations dated 10/16/23, and 1/17/24, and the resident's physician orders were reviewed with the DON. She acknowledged the pharmacy recommendations, and physician's responses, and acknowledged there was no documentation for staff to obtain an apical pulse prior to administration of the resident's Digoxin. She stated she was not sure if the directive would be placed on the physician order sheet but would be on the Medication Administration Record (MAR). However, review of the resident's MAR for the period January 2024 through March 2024 revealed no documentation to indicate the resident's apical pulse was monitored prior to administration of the Digoxin, this was acknowledged by the DON. She stated apical pulse should be monitored for the resident prior to administering the Digoxin, because if the apical pulse was below 60 beats per minute, the medication should be held. On 3/21/24 at 11:58 AM, the Medical Director stated resident #47 was recently hospitalized , and was discharged to the facility on the Digoxin. The pharmacy recommendations regarding the Digoxin was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105431 If continuation sheet Page 16 of 17 Printed: 05/28/2026 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 105431 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Courtyards of Orlando Care Center and Rehab 1900 Mercy Drive Orlando, FL 32808 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete shared with the Medical Director. He stated he was not sure about the nursing protocol but had placed some parameters for the Digoxin until the medication could be discussed with the resident's cardiologist. The policy Pharmacist Recommendations issued 4/01/22, read It will be the policy of this facility to provide pharmacist services to meet the needs of the residents through monthly regimen review (MRR) and properly addressing recommendations per federal and state guidelines . The pharmacist must report any irregularities to the attending physician .and the facility's medical director and director of nursing, and these reports must be acted upon as soon as reasonably able, but prior to the following month's MRR. Event ID: Facility ID: 105431 If continuation sheet Page 17 of 17