Inspection·August 14, 2025

F 0656 was to make an accurate and comprehensive assessment of a resident's needs, strengths, goals, life history and preferences, which would be reviewed and revised by the interdisciplinary team regularly. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105431 If continuation sheet Page 2 of 10 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 08/14/2025 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility policy review, the facility failed to provide the necessary assistance with Activities of Daily Living (ADL) for one of three residents reviewed for ADL care, of a total sample of 45 residents, (#75). This failure resulted in resident #75 not receiving timely and adequate support for personal grooming and hygiene, which could contribute to a decline in the resident's physical and psychosocial well-being. Findings: On 8/11/25 at 11:40 AM, resident #75 was awake, lying in his bed. His fingernails on both hands were elongated with brown debris visible under the nails. The resident stated he spoke Creole. He was able to answer yes/no questions appropriately, and able to gesture. Resident #75 indicated he preferred to keep his fingernails long by shaking his head to gesture no and showing his elongated fingernails. On 8/12/25 at 9:25 AM, resident #75's fingernails on both hands continued to be elongated with brown debris visible under the fingernails. The resident permitted photos to be taken of his fingernails. (Photographic evidence obtained) On 8/13/25 at 1:00 PM, resident #75 was in bed, and awake. The fingernails on both hands were elongated with visible brown debris under the nails. On 8/14/25 at 10:00 AM, resident #75 was awake and in bed. His fingernails on both hands remained elongated with brown debris visible under the nails. On 8/14/25 at 10:05 AM, Certified Nurse's Assistant (CNA) B, stated activities personnel provided fingernail care including cleaning and trimming for residents. She conveyed all CNAs including herself could provide fingernail care to residents. CNA B confirmed she was assigned to resident #75 that day but had not ever provided fingernail care to the resident. She said she used assistance from other staff to communicate with the resident in his preferred language (Creole). The CNA explained she provided fingernail care weekly. At that time CNA D entered the resident's room and asked the resident if he'd like to have his fingernails cleaned and trimmed in his preferred language. CNA D stated the resident replied, Yes, I am here for you to help me. I cannot do that myself. On 8/14/25 at 10:15 AM, Licensed Practical Nurse (LPN) C, confirmed she was assigned to care for resident #75 today. She stated the CNAs provided fingernail care including cleaning and trimming to residents, unless they were diabetic then a podiatrist would do it. She denied the podiatrist trimmed residents' fingernails and explained the nurses trimmed the fingernails for diabetic residents. LPN C stated a schedule for when the care would be provided was kept in the chart, but explained if the nails were long or dirty, staff should just provide the care, regardless of the schedule. Review of resident #75's medical record revealed her diagnoses included diabetes mellitus type 2, Alzheimer's Disease, and seizures. Review of the quarterly Minimum Data Set assessment dated [DATE], revealed moderately impaired cognitive function, and no behavioral symptoms present including refusals of care. Review of resident #75's progress notes from 7/22/25 thru 8/14/25 did not reveal any notations of refusal of care of any type. Review of the person-centered care plan initiated 1/30/19 and revised 2/28/22, for resident #75 revealed a focus for risk for self-care deficit in ADLs related to need for assistance with daily care. The care plan indicated resident #75 required some assistance with dressing and bathing due to weakness and cognition and impaired communication (Creole speaking) and he was at risk for decline in functional status. The care plan interventions detailed the resident required assistance of one staff with dressing, hygiene and bathing. On 8/14/25 at 10:52 AM, the Administrator stated the expectation was for fingernails to be cleaned and trimmed per the resident's preference, with care provided by direct care CNAs and Activities staff. The Administrator explained each resident was assessed at admission to determine if they need assistance with the task, and whether the resident allowed it. She expressed staff should try to reapproach at a different time, or with different staff, if a Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105431 If continuation sheet Page 3 of 10 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 08/14/2025 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 0677 Level of Harm - Minimal harm or potential for actual harm resident refused care, and the behavior should be documented in the medical record. The Administrator stated it would be part of the resident's care plan, and refusals of care should also be documented in the Minimum Data Set assessments. A review of the facility policy titled ADL Care and Assistance dated 4/01/22 revealed, the facility's policy was to provide the resident with ADL care and assistance while attempting to maintain the highest practicable level of function for the resident. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105431 If continuation sheet Page 4 of 10 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 08/14/2025 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to follow physician orders for medication administration for 5 of 5 residents reviewed for medication administration, of a total sample of 45 residents, (#112, #3, #94, #5, and #67).Findings:1. Resident #112 was admitted to the facility on [DATE] with diagnoses including esophagitis (inflammation of the esophagus) without bleeding, other psychoactive substance dependence, hypertension, nicotine dependence, chronic pain syndrome, opioid dependency, and anxiety. Review of the resident's care plan initiated 6/26/25 revealed a focus related to antianxiety medication use with an intervention to administer medication as prescribed. During a phone interview with the resident on 8/13/25 at 11:17 AM, he stated he had missed medications while at the facility. Review of resident #112's physician orders revealed an order for Xanax 1 milligram (mg) to be given twice a day for anxiety with a start date of 6/26/25 and end date of 7/10/25. Review of the Electronic Medical Record (EMAR) revealed the following:On 7/07/25 at 9:00 AM, the resident did not receive the morning dose of medications with no progress note documentation as to the reason.On 7/07/25 at 5:00 PM, the resident did not receive the afternoon dose of medications with a progress note which read, ‘pharmacy' as the reason documented.On 7/08/25 at 9:00 AM, the resident did not receive the morning dose of medications with no progress note documentation for the reason the medication was not given.On 7/08/25 at 5:00 PM, the resident did not receive the afternoon dose of medications with no progress note documentation for the reason the medication was not given. On 8/13/25 at 12:24 PM, the DON explained the investigation of resident #112's missed medication was initiated on 7/16/25 when the Department of Children and Families investigator came to the facility in regard to allegations of neglect due to the resident's concerns over not receiving his Xanax. The facility acknowledged at the time the resident missed four doses of the medication due to it needing a new prescription for it to be refilled. Further review of the medical record revealed a physician order for Xanax 1 mg by mouth now to be given three times day for anxiety starting on 7/10/25. Review of the EMAR revealed the following:On 7/16/25 at 9:00 AM, the resident did not receive the medications with no progress note documentation for the reason it was not given.On 7/26/25 at 2:00 PM, the resident did not receive the afternoon dose of medication with no progress note documenting the reason it was not given.On 7/26/25 at 9:00 PM, the resident did not receive the medication, but contained a note that documented, on order for the reason it was not given. A progress note written on 7/26/25 at 10:00 PM, revealed resident #112's Xanax was not available to be administered. The note indicated the pharmacy notified the facility that a new prescription was needed in order for the medication to be refilled. 2. Resident #3 was admitted to the facility on [DATE] with diagnoses including anxiety disorder, polyneuropathy (nerve pain), hypertension, and stroke complications. Resident #3's care plan initiated 3/07/25 revealed a focus for the risk of abnormal bleeding related to the use of anticoagulants with an intervention to administer medications as ordered. The resident also had care plan focus for the potential for adverse side effects related to use of psychotropic medications, potential of complications related to alteration in cardiac function due to diagnosis of hypertension and potential for alteration in comfort related to stroke, generalized discomfort and impaired mobility. The interventions listed included administering medications as ordered. On 8/12/25 at 1:20 PM, resident #3 stated it seemed she had a problem with availability of medication every month, but not always with the same medication being unavailable. The resident reported yesterday she was told the facility was out of her Lyrica medication. Lyrica is a prescription medication used to treat nerve pain for neuropathy and other disorders. Take exactly as prescribed by your physician, at the same (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105431 If continuation sheet Page 5 of 10 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 08/14/2025 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some time each day, Do not stop using Lyrica suddenly, (retrieved on 8/27/25 from www.drugs.com). A self-reported grievance filed on 6/09/25 by resident #3 revealed a concern that Xarelto was not available to be given. Review of the grievance revealed the investigation found the resident was out of the medication which was to be delivered that day. The resolution indicated the medication arrived the next day on 6/10/25 and education was provided to staff, that nurses were to reorder medications within five days of stock depletion, and if the medication was not present, nurses were to call the provider to either place the medication on hold or obtain a substitute. Although this education was noted on the grievance, resident #3 continued to miss doses of her medication due to it not being available per the EMAR. Xarelto is a prescription medication used mainly to prevent blood clots. It blocks the action of substances in the blood to prevent formation of blood clots. Do not stop taking Xarelto without your doctor's advice, it can increase your risk for blood clots or stroke, (retrieved on 8/27/25 from www.drugs.com). Review of the medical record revealed resident #3 had physician orders including Duloxetine HCl delayed release (DR) 20 mg daily for anxiety, Nifedipine extended release (ER) 30 mg daily for hypertension, Rivaroxaban (Xarelto) 10 mg daily for anticoagulation, and Lyrica 75 mg two times a day for neuropathy pain. Review of EMAR for June 2025 revealed the following:On 6/06/25 at 9:00 AM, the resident did not receive her Xarelto 10 mg. There was no progress note documentation for the reason it was not given.On 6/07/25 at 9:00 AM, the resident did not receive her Xarelto 10 mg. There was no progress note documentation for the reason it was not given.On 6/08/25 at 9:00 AM, the resident did not receive her Xarelto 10 mg. There was no progress note documentation for the reason it was not given.On 6/09/25 at 9:00 AM, the resident did not receive her Xarelto 10 mg. There was no progress note documentation for the reason it was not given.On 6/20/25 at 9:00 AM, the resident did not receive her Xarelto 10 mg. There was no progress note documentation for the reason it was not given. Review of the EMAR for August 2025 revealed the following:On 8/02/25 at 9:00 AM, the resident did not receive her Tizanidine 2 mg, Xarelto 10 mg, Duloxetine DR 30 mg nor her Nifedipine ER 30 mg. A progress note for these medications indicated the medications were, on delivery.On 8/02/25 at 2:00 PM, the resident did not receive her Tizanidine 2 mg. A progress note indicated, on delivery.On 8/11/25 at 9:00 AM, the resident did not receive her Lyrica 75 mg. A progress note was documented by the nurse, pharmacy was called, and order will be delivered evening. On 8/11/25 at 2:00 PM, resident #3 did not receive her Lyrica 75 mg. A progress note indicated, medication is a new order, medication will arrive at 4. 3. Resident #94 was admitted to the facility on [DATE] with diagnoses including hypertension, stage 2 chronic kidney disease, hyperlipidemia, osteoarthritis, anxiety, atrial fibrillation, peripheral vascular disease and atherosclerotic heart disease. Review of the resident's care plan initiated 2/06/25 revealed a focus for the potential of complications related to an alteration in cardiac function due to a diagnosis history of hypertension, atrial fibrillation and hyperlipidemia. One of the interventions was to administer medications as ordered and observe for effectiveness. Review of the medical record revealed physician orders for Labetalol HCL 100 mg two times a day for hypertension. Labetalol HCL is a prescription medication used to treat high blood pressure. Use this medication as directed by the physician, do not stop taking Labetalol suddenly, it may make your condition worse, (retrieved on 8/27/25 from www.drugs.com). Review of the EMAR for August 2025 showed the following:On 8/05/25 at 6:00 PM, Labetalol HCL 100 mg was not administered as ordered. There was no progress note documentation for the reason it was not given.On 8/06/25 at 6:00 AM, Labetalol HCL 100 mg was not administered as ordered. A progress note by the nurse indicated, ran out of medication. On 8/07/25 at 6:00 AM, Labetalol HCL 100 mg was not administered as ordered. A progress note by the nurse indicated, ran out of medication. On 8/07/25 at 6:00 PM, Labetalol HCL 100 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105431 If continuation sheet Page 6 of 10 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 08/14/2025 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete mg was not administered as ordered. A progress note documented by the nurse read, waiting for delivery. On 8/08/25 at 6:00 AM, the Labetalol HCL 100 mg was not administered, and a progress note was documented by the nurse, waiting for delivery, e-kit did not have it. 4. Resident #5 was admitted to the facility on [DATE] with diagnoses that included dementia without behaviors, hypothyroidism, paranoid schizophrenia and bipolar disorder. Review of the medical record revealed physician orders for Synthroid 50 micrograms (mcg) daily for hypothyroidism. Synthroid is a prescription medication used to replace the hormone normally produced by the thyroid gland to regulate energy and metabolism. Take this medication exactly as prescribed, (retrieved on 8/27/25 from www.drugs.com). Review of the EMAR for August 2025 showed the following:On 8/02/25 at 6:30 AM, the medication was not administered and a progress note indicated, patient ran out of medication.On 8/03/25 at 6:30 AM, the Synthroid was not administered as ordered. A progress note documented by the nurse indicated, ran out of medication. 5. Resident #67 was admitted to the facility on [DATE] with diagnoses including anxiety, schizoaffective disorder, psychosis not due to substances, Gastro-esophageal Reflux disease (GERD), dementia, seizures, hypertension and depression. Review of resident #67's care plan initiated 8/19/20 revealed foci including potential for complications related to alteration in cardiac function due to diagnosis of hypertension, potential for adverse side effects related to the use of psychiatric medications, potential for injury or complications related to seizures and actual behaviors including combativeness, yelling and being verbally inappropriate. The interventions included administer medications as ordered. Review of the medical record revealed physician orders for Iron 325 mg daily for supplementation; Amlodipine 10 mg daily for hypertension; Cholecalciferol 1000 units (give 2 tabs) daily for bone health; Cyanocobalamin 1000 mcg daily for macrocytic anemia; Pepcid 20mg daily for GERD; Lidocaine patch 4% daily for low back pain; Valproic acid 250 mg/ml, give 10 milliliters (ml) twice daily for mood stabilization; Ativan gel 2 mg/ml three times a day for anxiety and Tylenol 650 mg daily for pain . Review of the EMAR for August 2025 revealed the following:On 8/03/25 at 8:00 AM, resident #67 did not receive her Iron 325 mg. There was no documentation to indicate why it was not administered as ordered.On 8/03/25 at 9:00 AM, resident #67 did not receive her Amlodipine 10mg, Cholecalciferol 2000 units, Cyanocobalamin 1000mcg, Pepcid 20mg, Lidocaine external patch 4%, Valproic acid 10ml, nor her Ativan gel 2 mg/ml. There was no documentation to indicate why the medications were not administered as ordered.On 8/03/25 at 10:00 AM, resident #67 did not receive her Tylenol 650 mg. There was no documentation to indicate why the medication was not administered as ordered.On 8/03/25 at 2:00 PM, resident #67 did not receive her Ativan gel 2 mg/ml. There was no documentation to indicate why it was not administered as ordered. On 8/14/25 at 12:57 PM, the DON said she was unaware residents #3, #5, #67, #94 and #112 had missed doses of medications since the time they became aware of resident #112's neglect allegation for missed medications this past July. She stated regular reordering of medications and audits were the actions initiated following that investigation. She was unable to say why residents missed multiple medication doses due to the drugs not being available, but confirmed she never verified the nurses were reordering and auditing as planned. The DON stated the expectation for staff when a medication was unavailable was to check the emergency medication kit, call the pharmacy and call the physician to ask for a hold order for the medication or an alternative. The facility's policy entitled Medication Administration dated 4/01/22 indicated that medications should be administered in a timely manner and in accordance with the physician's orders. If medications are unavailable at the time of medication administration, the nurse should check the Emergency Drug Kit (EDK) system for availability. If the medication is not available the nurse should notify the physician for new orders and contact the pharmacy, as needed. Event ID: Facility ID: 105431 If continuation sheet Page 7 of 10 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 08/14/2025 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 0778 Help the resident make transportation arrangements to and from radiology services. 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 assist in making transportation arrangements to diagnostic and physician's appointments for 1 out of 1 resident reviewed for choices, of a total sample of 45 residents, (#97).Findings: A review of the electronic medical record revealed resident # 97 was admitted to the facility on [DATE] with diagnoses which included acute embolism and thrombosis (blood clot) of other specified deep vein of the right lower extremity, paraplegia (partial paralysis), hyperlipidemia, and unspecified heart transplant status. Resident #97 's quarterly Minimum Data Set with an assessment reference date of 7/12/25 revealed the resident scored 15 out of 15 on the Brief Interview for Mental Status which indicated he was cognitively intact. A review of resident #97 's plan of care revealed he had the potential for complications related to an alteration in cardiac function due to his diagnoses, heart transplant status initiated on 4/23/25. Interventions included labs and diagnostic tests as ordered; update physician of results initiated 4/23/25. On 8/11/25 at 11:48 AM, resident #97 was in bed, alert and oriented to person, place and time. He stated he had missed several doctor's appointments and an echocardiogram (cardiac test) due to transportation not being arranged. The resident continued that he had appointment cancellations due to the lack of communication between facility staff and the transport coordinator. Review of the medical record progress notes from the B Wing Unit Manager (UM) revealed the following: On 6/11/25 the UM documented, Called resident transplant coordinator on last week, received message of (coordinator), being out on vacation. Attempted to reach on 6/10 to received appointment updated information for resident. Unable to reach. Left voice mail. Called this am 6/11, and was able to reach coordinator, informed to call for updated scheduling information. Unable to get receptionist online. Left message will reattempt call in 1 hour.On 8/01/25 the UM documented, resident states he received call for appointment cancellation of ECHO [echocardiogram]. Nurse attempted to call office to receive follow up time and date for makeup appointment. Message left with answering service. Awaiting response from [name of hospital] transplant office. Transplant coordinator. A review of the medical record progress notes and documents written by the Advance Practice Registered Nurse (APRN) revealed the following excerpts: On 6/21/25 and 7/19/25, the APRN documented, NO acute issues. Per resident, he went to have a bone scan last month and was told by ID [infectious disease] doctor that, everything looks good for Echo/transplant f/u [follow up] on 7/31/25. On 8/12/25 the APRN wrote, Wound care rendered by nurse, r/o [rule out] cellulitis/infection. I called the transplant center to schedule a follow up appointment. Apparently, he had missed 3 f/u visits due to dates not entered to PCC. I left a message to the answering service, Awaiting return call. On 8/13/25 at 3:31 PM, in a joint interview with the Social Worker (SW) and Director of Nursing (DON) they explained the team including the UMs, and Staffing and Transportation Coordinator had an app (application) they used to coordinate the facility's van and arrange transportation. This app was used to manage arrangements to transport residents to and from doctor's appointments or for any other transport within the community. The SW and DON described that residents who relied solely on their insurance for transportation, still had access to the facility's van because sometimes those services were unreliable. The DON and SW acknowledged resident #97 had missed some appointments with his physician at his heart transplant center as well as an echocardiogram appointment that was cancelled because no transportation was arranged. The DON explained she believed the resident had an outside coordinator to arrange transportation; however, she acknowledged the UM, and nurses were responsible for following up to ensure the arrangements were made. The DON stated they dropped the ball on this one. The DON was unsure if resident #97's echocardiogram was ever rescheduled. On 8/13/25 at 4:10 PM, Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105431 If continuation sheet Page 8 of 10 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 08/14/2025 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 0778 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete in a joint interview with the SW and the Transportation Coordinator, the Transportation Coordinator explained she would get the appointment paperwork from nurses or on the resident's return from an appointment. She would then place it in the transport book, and the nurses would log the appointment in the computer. She said she would call the physician's offices and make appointments for residents who were unable to. The Transportation Coordinator described that for residents who made their own appointments but did not have transportation the facility would set transportation up through her. She explained for resident #97, she believed he made his own appointments, and the facility had never taken him anywhere. The SW said that even though the resident made the appointments himself, he communicated to nurse, and the nurse would have to put the appointment into the computer. The SW was unable to find any information that the missed echocardiogram was rescheduled. On 8/13/25 at 4:22 PM, the B Wing UM acknowledged she was aware resident #97 missed his appointments for heart transplant follow up and of the echocardiogram cancellation because transportation was not arranged. The UM stated, he mentioned missing appointments due to transportation and that the transplant center sent him a message that he missed an appointment. She continued to explain that she tried to get in touch with the transplant scheduler but had not rescheduled yet at that time. The UM said the facility's process was to put the appointment in the computer and acknowledged she never followed up with rescheduling the missed appointment after the note written on 6/11/25. On 8/13/2025 at 4:57 PM, resident #97 clarified the only time he went out for an appointment was for a scan on 5/21/25, but not with the heart transplant center nor for the echocardiogram. He continued to explain that at the end of April or May it was the facility's fault he missed his appointment. Resident #97 said he did not arrange transportation to the appointments himself, instead the facility was supposed to arrange them. He explained he got a paper with the information and gave it to facility staff, and they made the arrangements. Resident #97 said the only time he called to reschedule an appointment was the time the nurse could not do it. He said he was able to reschedule the appointment, so he wrote the information on a piece of paper and gave it to the nurse, who told him she would put it in the system, but she never did. The resident recalled he spoke to the SW about his frustration but did not hear anything back from the facility regarding his concerns. Review of the Treatment Administration Record (TAR) for May, June, July and August 2025 revealed no appointments were scheduled except on 5/06/25 for the unrelated scan and follow-up appointments for the scan which took place on 5/12/25 and 5/21/25. The TAR was reviewed for June, July and August 2025 which showed no scheduled appointments for the heart transplant center nor for the echocardiogram. On 8/13/25 at 5:13 PM, the SW confirmed the resident previously reached out to her about his frustrations on 6/15/25 and that he was waiting on the B Wing UM to reschedule the appointment. On 8/14/25 at 11:27 AM, the APRN stated that on 7/31/25 someone called the facility and told them to cancel resident #97's appointment, but she confirmed this was not documented anywhere. She continued to explain she wrote the note on 8/11/25 because the resident told her he missed all of his appointments which is why she felt she had to reach out to the transplant center herself to make the appointment. The APRN confirmed nurses were not entering the appointments into the computer which contributed to resident #97 missing his appointments. On 8/14/25 at 12:44 PM, the DON said there was a breakdown in communication when staff did not enter the dates of appointments as given by the resident. She confirmed staff should have kept calling the transplant center and followed up on rescheduling resident #97's appointments. The Regional Nurse Consultant stated the facility had a Transportation Policy (which was not provided) but explained the policy did not have anything that spoke specifically to scheduling appointments. Event ID: Facility ID: 105431 If continuation sheet Page 9 of 10 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 08/14/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and facility policy review, the facility failed to ensure proper handling and food safety practices when staff failed to sanitize a food thermometer between checking food items, and ice bath calibration. The deficient practice had the potential to affect all residents who received a regular or puree diet by increasing the risk of cross-contamination and foodborne illness. Findings: On 8/13/25 at 11:10 AM, kitchen preparation for the lunch service began with cook G and Dietitian F present. At 11:37 AM, cook G used a food thermometer to check food temperatures of the prepared foods held on the steam table line prior to plating the food for service. The cook did not sanitize the food thermometer prior to placing the tip of the thermometer inside the pureed garlic bread, the regular garlic bread, and then the ziti bake. The cook said she cleans the thermometer between each food items. She acknowledged she did not sanitize the thermometer prior to checking the food items, nor had she cleaned it between the food items. The cook explained it was her practice to clean the thermometer between food items but said, We run out of them [the alcohol wipes] so fast, I'm constantly using them. On 8/13/25 at 11:47 AM, Dietitian F explained the process for checking the temperature of foods on the steam table. She stated, All foods are checked for their temperature before service is started. They are supposed to clean the thermometer with a sanitizing wipe in between each food item, that's the proper way. The Dietitian acknowledged she did not notice when cook G did not sanitize the thermometer between the food items in preparation for the lunch service. On 8/13/2025 at 11:50 AM, Kitchen Supervisor E explained the facility process for checking the temperature of foods on the steam table. She confirmed staff should check each food item, record the reading of the thermometer, and then clean the thermometer with an alcohol wipe between each food item.On 8/13/25 at 5:00 PM, in the kitchen, preparation for the dinner service commenced. Kitchen Supervisor E checked the temperature of a tray of turkey ranch wraps (a cold sandwich item) with a food thermometer. She then calibrated the food thermometer in an ice bath but did not sanitize the thermometer between checking the temperature of the wraps and inserting the thermometer in the ice bath. Kitchen Supervisor E proceeded to use the same un-sanitized thermometer to check the puree turkey wrap (a hot item) temperature without sanitizing the thermometer. On 8/13/25 at 5:15 PM, Kitchen Supervisor E acknowledged she had not sanitized the thermometer between checking the temperature of the cold turkey ranch wrap and the ice bath calibration, then again between the ice bath and checking the temperature of the (hot) puree turkey wrap. Kitchen Supervisor E stated, Oh I thought I did, and acknowledged she did not sanitize the thermometer between the food items and the ice bath calibration. Review of the facility policy, Final Cooking Temperatures, revised 10/01/23, revealed food was to be cooked to specific temperatures and times to mitigate the presence of dangerous microorganisms. The policy continued that food thermometers used to check food temperatures should be clean, sanitized, and calibrated for accuracy. Event ID: Facility ID: 105431 If continuation sheet Page 10 of 10