Inspection·August 19, 2024

F 0569 Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a refund, and a final accounting of the resident's funds deposited with the facility within 30 days of the resident's discharge, for 1 of 3 residents sampled for personal funds, (#1). Residents Affected - Few Resident #1 was admitted to the facility on [DATE] and discharged from the facility to the community on 6/27/24. Review of the facility's admission Agreement signed by resident #1's financial power of attorney on 1/13/22 revealed the facility would refund any deposits held by them within thirty days from the resident's date of discharge. Review of the facility's Policy and Procedure Manual in the section regarding Resident Personal Funds, issued 4/01/22 and revised 1/01/24, under the Procedure section item 6. Within thirty (30) days of a resident's discharge or death, the facility will refund the resident's personal funds and provide a final accounting of those funds to the resident, the resident's representative or to the resident's estate, as applicable. In a telephone interview on 8/19/24 at 8:31 AM, resident #1's financial power of attorney said she had received one refund check for $3,266 from the facility since resident #1's discharge over 30 days after resident #1's discharge. She said she was told the facility held funds and there was still an outstanding refund of $813.00 due. The financial power of attorney said she had requested an itemized statement of how resident #1's funds had been disbursed since resident #1's original admission on [DATE] but had yet to receive the statement. On 08/19/24 at 12:41 PM, the Business Office Manager she said she believed resident #1's financial power of attorney was still owed $813.00. She verified the resident was discharged from the facility 06/27/2024. The Business Office Manager explained the money was overdue by 23 days beyond the 30 days from Resident #1's facility discharge. In a telephone interview on 8/19/24 at approximately 12:45 PM, the Accounts Receivable Specialist of the facility's contracted Accounting Group verified Resident #1 was discharged on 6/27/24. She verified the facility owed Resident #1's financial power of attorney a refund from Resident #1's facility held account related to July 2024 and August 2024. She said it usually took about 30 days to provide a refund from a resident's date of discharge. She verified the refund was currently late over 30 days since resident #1's discharge and a full refund had not yet been issued to resident #1's financial power of attorney. She said she would contact her colleague in Accounts Payable who had the (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 105431 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 08/19/2024 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)