Tag 0755 · Severity E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies · Deficient, Provider has date of correction 2025-09-141900 Mercy Drive, Orlando, FL 32808
(407) 299-5404 · Fl SNF Trust
| Ownership | For profit - Limited Liability company | Certified beds | 120 |
|---|---|---|---|
| Estimated occupancy | 96.0% | Latest inspection | 2025-08-14 |
| Metric | Facility | County | Florida |
|---|---|---|---|
| Overall rating | 2 of 5 | 3 of 5 | 3 of 5 |
| Health-inspection score | 31.0 points | 50.9 points | 38.5 points |
| Total nurse staffing | 3.55 hours/day | 3.66 hours/day | 3.63 hours/day |
| RN staffing | 0.29 hours/day | 0.66 hours/day | 0.62 hours/day |
| Staff turnover | 51.6% | 41.7% | 41.8% |
| Latest health deficiencies | 5 deficiencies | 4.5 deficiencies | 6 deficiencies |
Comparisons describe CMS data; they are not recommendations.
Immediate-jeopardy citations: 0
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies · Deficient, Provider has date of correction 2025-09-14Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction 2025-09-14Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction 2025-09-14Provide care and assistance to perform activities of daily living for any resident who is unable.
Quality of Life and Care Deficiencies · Deficient, Provider has date of correction 2025-09-14Help the resident make transportation arrangements to and from radiology services.
Administration Deficiencies · Deficient, Provider has date of correction 2025-09-14Immediate-jeopardy citations: 0
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Resident Rights Deficiencies · Deficient, Provider has date of correction 2024-04-21Allow residents to self-administer drugs if determined clinically appropriate.
Resident Rights Deficiencies · Deficient, Provider has date of correction 2024-04-21Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Resident Rights Deficiencies · Deficient, Provider has date of correction 2024-04-21Honor 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.
Resident Rights Deficiencies · Deficient, Provider has date of correction 2024-04-21Ensure each resident receives an accurate assessment.
Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction 2024-04-21Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Quality of Life and Care Deficiencies · Deficient, Provider has date of correction 2024-04-21Provide safe and appropriate respiratory care for a resident when needed.
Quality of Life and Care Deficiencies · Deficient, Provider has date of correction 2024-04-21Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Pharmacy Service Deficiencies · Deficient, Provider has date of correction 2024-04-21Immediate-jeopardy citations: 0
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Quality of Life and Care Deficiencies · Deficient, Provider has date of correction 2022-06-20Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies · Deficient, Provider has date of correction 2022-06-20Ensure each resident receives an accurate assessment.
Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction 2022-06-20Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction 2022-06-20Provide care and assistance to perform activities of daily living for any resident who is unable.
Quality of Life and Care Deficiencies · Deficient, Provider has date of correction 2022-06-20Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies · Deficient, Provider has date of correction 2022-06-20Provide or obtain dental services for each resident.
Quality of Life and Care Deficiencies · Deficient, Provider has date of correction 2022-06-20Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction 2022-06-20Reported averages, not a real-time staffing schedule.
These group measures do not predict an individual resident’s experience.
How many RNs are typically on site during days, nights, and weekends?
Suggested because of: rn staffingWhat is driving staff turnover, and what is being done to retain nurses and aides?
Suggested because of: staff turnoverWhat fall-prevention program is used, and how are families notified after a fall?
Suggested because of: falls major injuryHow does the care team prevent and treat pressure injuries?
Suggested because of: pressure ulcersHow will the care plan be developed, reviewed, and shared with our family?
Suggested because of: general care planning| Reported measure | Value |
|---|---|
| Nurse aide hours | 2.36407 |
| Lpn hours | 0.89433 |
| Rn hours | 0.29322 |
| Reported total hours | 3.55163 |
| Weekend total hours | 3.18282 |
| Weekend rn hours | 0.18047 |
| Adjusted total hours | 4.421 |
| Total turnover percent | 51.6 |
| Rn turnover percent | 76.9 |
| Administrators left | 0 |
Hours are per resident per day; turnover values are percentages. Missing values are not zero.
No matching penalties in the supplied CMS records.
Totals reflect the supplied CMS records, not a lifetime total.
Health counts describe the latest rating cycle. Fire counts cover supplied fire-safety records.
FL counts scope/severity G–L as serious deficiencies. Immediate jeopardy is J–L; these are not interchangeable.
0
| Name | Role | Share |
|---|---|---|
| COURTYARDS NURSING HOLDCO LLC | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% |
| FL MASTER OPCO HOLDCO II LLC | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED |
| FL SNF TRUST I | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED |
| FL SNF TRUST II | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED |
| CRUZ-PIZARRO, NAIHOMI | W-2 MANAGING EMPLOYEE | NOT APPLICABLE |
| ELLENBOGEN, MOSS | CORPORATE OFFICER | NOT APPLICABLE |
Educational information, not medical or legal advice. Data & methodology