Cycle 1
Health 2025-08-14 · Fire 2025-08-14
5 health deficiencies
Top issue: Administration (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Orlando, FL
Courtyards Of Orlando Care Center And Rehab
2-star overall rating with 3-star inspections with $15,764 in total fines with 5 recent health deficiencies
1900 Mercy Drive, Orlando, FL
(407) 299-5404
Overall
2 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
116
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Gold Fl Trust Ii
Operator or chain grouping
Approved since
1983-07-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
46 facilities
Chain averages 3 overall / 3 health / 3 staffing / 5 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.23
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.96
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
2.28
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
3.48
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.19
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
3.15
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.12
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.27
CMS adjusted RN staffing hours
Adjusted total hours
4.05
CMS adjusted total nurse staffing hours
Case-mix index
1.17
Higher values indicate more complex resident acuity
RN turnover
72%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
54%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,437
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
20.39
Composite VBP score used to determine payment impact.
Payment multiplier
0.9824
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 19.34% · Performance 21.88% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
1.97
Baseline 5.77% · Performance 7.25% · Measure score 1.97 · Achievement 1.97 · Improvement 0
Total nurse turnover
2.95
Baseline 55.74% · Performance 51.64% · Measure score 2.95 · Achievement 2.95 · Improvement 0.83
Adjusted total nurse staffing
3.24
Baseline 3.79 hours · Performance 4 hours · Measure score 3.24 · Achievement 3.24 · Improvement 0.54
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.27% |
10.72%
1.5 pts worse
|
No Different than the National Rate · Eligible stays 56 · Observed rate 17.86% · Lower 95% interval 8.57% |
| Discharge to community | 34.96% |
50.57%
15.6 pts worse
|
No Different than the National Rate · Eligible stays 27 · Observed rate 14.81% · Lower 95% interval 19.54% |
| Medicare spending per beneficiary | 1.12 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 96.91% |
95.27%
1.6 pts better
|
Numerator 94 · Denominator 97 |
| Falls with major injury | 1.03% |
0.77%
0.3 pts worse
|
Numerator 1 · Denominator 97 |
| Discharge self-care score | 84.13% |
53.69%
30.4 pts better
|
Numerator 53 · Denominator 63 |
| Discharge mobility score | 76.19% |
50.94%
25.2 pts better
|
Numerator 48 · Denominator 63 |
| Pressure ulcers or injuries, new or worsened | 3.09% |
2.29%
0.8 pts worse
|
Numerator 3 · Denominator 97 · Adjusted rate 2.68% |
| Healthcare-associated infections requiring hospitalization | 7.25% |
7.12%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 31 · Observed rate 12.9% · Lower 95% interval 4.37% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 192 |
| Staff flu vaccination coverage | 56.21% |
42%
14.2 pts better
|
Numerator 86 · Denominator 153 |
| Discharge function score | 85.71% |
56.45%
29.3 pts better
|
Numerator 54 · Denominator 63 |
| Transfer of health information to provider | 77.78% |
95.95%
18.2 pts worse
|
Numerator 35 · Denominator 45 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 5.66% |
25.2%
19.5 pts worse
|
Numerator 3 · Denominator 53 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.0 |
2.1
0.9 pts worse
|
1.9
1.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.0 · Observed 3.2 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.4 |
1.2
0.2 pts worse
|
1.8
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.5 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.8% |
97.8%
2 pts better
|
93.4%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 99.1% · 4Q avg 99.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
99.2%
0.8 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.8% |
2.6%
1.2 pts worse
|
3.3%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 3.8% · Q3 4.8% · Q4 3.8% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.8% |
3.7%
1.9 pts better
|
11.4%
9.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 2.1% · Q3 1.1% · Q4 1.1% · 4Q avg 1.8% |
| Percentage of long-stay residents who lose too much weight | 10.7% |
5.9%
4.8 pts worse
|
5.4%
5.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 13.8% · Q3 13.0% · Q4 8.5% · 4Q avg 10.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 9.6% |
15.7%
6.1 pts better
|
19.6%
10 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.2% · Q2 7.2% · Q3 13.5% · Q4 9.4% · 4Q avg 9.6% |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 3.9% |
11.7%
7.8 pts better
|
16.3%
12.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 4.0% · Q3 4.1% · Q4 1.9% · 4Q avg 3.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.9% |
9.8%
3.9 pts better
|
14.9%
9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 3.4% · Q3 9.0% · Q4 3.4% · 4Q avg 5.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.4%
0.4 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
0.8%
0.8 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 2.3% |
12.5%
10.2 pts better
|
19.8%
17.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 1.9% · Q3 1.8% · Q4 1.7% · 4Q avg 2.3% |
| Percentage of long-stay residents with pressure ulcers | 5.4% |
5.1%
0.3 pts worse
|
5.1%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 4.6% · Q3 5.2% · Q4 6.7% · 4Q avg 5.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.7% |
94.3%
4.4 pts better
|
81.7%
17 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 98.8% · Q3 98.8% · Q4 97.5% · 4Q avg 98.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.9% |
9.3%
2.6 pts worse
|
12.0%
0.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.9% · Observed 14.5% · Expected 13.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.2% |
1.5%
1.7 pts worse
|
1.6%
1.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 0.0% · Q3 2.3% · Q4 5.1% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.8% |
94.7%
4.1 pts better
|
79.7%
19.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.7% |
26.2%
4.5 pts better
|
23.9%
2.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.7% · Observed 25.8% · Expected 28.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-21 · Fire 2024-03-21
9 health deficiencies
Top issue: Resident Rights (5 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-05-19 · Fire 2022-05-19
11 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-08-14
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-09-14
E · Potential for more than minimal harm
2025-08-14
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-09-14
D · Potential for more than minimal harm
2025-08-14
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-09-14
D · Potential for more than minimal harm
2025-08-14
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-09-14
D · Potential for more than minimal harm
2025-08-14
F778 · Administration Deficiencies
Health
Help the resident make transportation arrangements to and from radiology services.
Corrected 2025-09-14
D · Potential for more than minimal harm
2024-08-19
F569 · Resident Rights Deficiencies
Health
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Corrected 2024-09-05
E · Potential for more than minimal harm
2024-03-21
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-04-21
D · Potential for more than minimal harm
2024-03-21
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-04-21
D · Potential for more than minimal harm
2024-03-21
F568 · Resident Rights Deficiencies
Health
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Corrected 2024-04-21
D · Potential for more than minimal harm
2024-03-21
F578 · Resident Rights Deficiencies
Health
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.
Corrected 2024-04-21
D · Potential for more than minimal harm
2024-03-21
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-04-21
D · Potential for more than minimal harm
2024-03-21
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2024-04-21
D · Potential for more than minimal harm
2024-03-21
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-04-21
D · Potential for more than minimal harm
2024-03-21
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2024-04-21
K · Immediate jeopardy
2023-05-26
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-05-08
K · Immediate jeopardy
2023-05-26
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-05-08
K · Immediate jeopardy
2023-05-26
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2023-05-08
E · Potential for more than minimal harm
2022-05-19
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2022-06-20
E · Potential for more than minimal harm
2022-05-19
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2022-06-20
D · Potential for more than minimal harm
2022-05-19
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-06-20
D · Potential for more than minimal harm
2022-05-19
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-06-20
D · Potential for more than minimal harm
2022-05-19
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-06-20
D · Potential for more than minimal harm
2022-05-19
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-06-20
D · Potential for more than minimal harm
2022-05-19
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2022-06-20
D · Potential for more than minimal harm
2022-05-19
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2022-06-20
Penalties and ownership
What sits behind the stars
$4,593
2023-05-26
Fine
Fine · fine $4,593
Fine
$4,600
2023-05-26
Fine
Fine · fine $4,600
Fine
$6,571
2023-05-26
Fine
Fine · fine $6,571
Fine
Ownership
Courtyards Nursing Holdco LLC
5% Or Greater Direct Ownership Interest · Organization
Cruz-Pizarro, Naihomi
W-2 Managing Employee · Individual
Ellenbogen, Moss
Corporate Officer · Individual
Fl Master Opco Holdco Ii LLC
5% Or Greater Indirect Ownership Interest · Organization
Fl SNF Trust I
5% Or Greater Indirect Ownership Interest · Organization
Fl SNF Trust Ii
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Other facilities in reach
#1
Guardian Care Nursing & Rehabilitation Center
Orlando, FL
3-star overall rating with 2-star inspections with $15,737 in total fines with 12 recent health deficiencies
#2
Aviata At Rosewood
Orlando, FL
2-star overall rating with 2-star inspections with 6 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Metro West Nursing And Rehab Center
Orlando, FL
3-star overall rating with 3-star inspections with 6 recent health deficiencies
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