Health inspection·January 8, 2021

F 0759 pacemaker. Level of Harm - Minimal harm or potential for actual harm Resident #151 had orders that included but were not limited to: ASA chewable tablet: give 81 mg by mouth one time a day dated 12/16/2020 Residents Affected - Few Calcitriol capsule 0.25mcg: give 1 capsule by mouth one time a day for vitamin deficiency dated 12/16/2020 Carvedilol tablet 12.5mg: give 1 tablet by mouth one time a day for hypertension dated 12/15/2020 Isosorbide mononitrate tablet: give 30mg by mouth one time a day for unstable angina dated 12/16/2020 Januvia tablet 100mg: give 1 tablet by mouth one time a day for type 2 diabetes Lasix tablet 40mg: give 40 by mouth one time a day for heart failure dated 12/31/2020 Lisinopril tablet 5mg: give 1 tablet by mouth one time a day for essential hypertension dated 12/22/2020 Potassium chloride ER tablet extended release 10meq: give 10 meq by mouth two times a day for hypokalemia dated 1/5/2021 Vitamin D tablet: give 2000IU by mouth one time a day for vitamin deficiency dated 12/16/2020 Zinc sulfate tablet: give 200mg by mouth one time a day for anemia dated 12/25/2020 On 1/8/2021 at 1:44 PM in an interview with the ADON (assistant director of nursing) she said that this was unacceptable. The expectation is that the medication should have been passed within an hour of the time ordered. Also, if a medication was given late, the nurse should have called the doctor and let them know that it was outside the window and asked them if they want to give the medication at that time. The nurse should have also called the POA (power of attorney) and let them know that the meds are late, and then put a note in the resident's chart documenting those conversations. Review of the facility's policy and procedure titled medication administration General guidelines dated 12/12 under the subtitle medication administration #14 showed Medications are administered within 60 minutes of scheduled time .routine medications are administered according to the established medication administration schedule for the nursing care center. Review of the facility's medication administration times reveals that 9 AM is the morning medication administration time. The next administration time of the day is 1 PM. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105327 If continuation sheet Page 2 of 7 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 105327 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/08/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Casa Mora Rehabilitation and Extended Care 1902 59th St W Bradenton, FL 34209 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to maintain drugs and biologicals used in the facility in a safe and secure manner in one of eight medication carts. Findings included: On 1/7/21 at 11:08 a.m. a medication cart was observed in the hallway outside of room [ROOM NUMBER]. Five residents were observed sitting in the hallway at the time about two doors away waiting to go outside to the smoking area. One bottle of Novolin R insulin belonging to Resident #42, an insulin syringe and one bottle of Erythromycin eye ointment belonging to Resident #20 were noted to be on top of the medication cart unsecured. Photographic evidence obtained. No nursing staff were observed near the cart at the time of the observations. On 1/7/21 at 11:14 a.m. Staff H, Licensed Practical Nurse (LPN) approached the medication cart. An interview was conducted with Staff H, LPN. The nurse indicated the medication cart was assigned to her for the day. Staff H, LPN stated she was in room [ROOM NUMBER] giving medications to a resident. room [ROOM NUMBER] was noted to be four rooms away from the location of the cart. The nurse confirmed all medications should always be secured inside the locked medication cart . Staff H, LPN stated she should not have left the medications on top of the cart. Staff H, LPN then proceeded to place the medications inside the cart and lock the cart. A review of the medication orders for Resident #42 revealed a current active order for Novolin R Solution inject as prescriber per sliding scale. A review of the medication orders for Resident #20 revealed a current active order for Erythromycin Ointment 5 milligrams/gram instill one application in right eye at bedtime for eye treatment. An interview was conducted with the Consulting Pharmacist on 1/8/21 at 12:46 p.m. The Pharmacist confirmed that all medications are always expected to be secured and should not be out of the sight of the nurse for safety purposes. A review of the policy entitled Medication Storage/Storage of Medications dated 09/18 revealed the following: Policy: Medications and biologicals are stored properly, following manufacturer's or provider pharmacy recommendations, to maintain their integrity and to support safe effective drug administration. The medication supply shall be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Procedures: 3) In order to limit access to prescription medications, only licensed nurses, pharmacy staff, and those lawfully authorized to administer medications (such as medication aide) are allowed access to medication carts. Medication rooms, cabinets and medication supplies should remain locked when not in use or attended by persons with authorized access. On 1/8/21 at 1:53 p.m. an interview was conducted with the Assistant Director of Nursing (ADON). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105327 If continuation sheet Page 3 of 7 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 105327 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/08/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Casa Mora Rehabilitation and Extended Care 1902 59th St W Bradenton, FL 34209 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 0761 The ADON stated the expectation for nursing was to keep all medications secured inside of the locked medication cart at all time. 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: 105327 If continuation sheet Page 4 of 7 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 105327 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/08/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Casa Mora Rehabilitation and Extended Care 1902 59th St W Bradenton, FL 34209 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 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, staff interviews and kitchen records, the facility did not ensure it maintained a High Wash temperature dish machine according to specifications during one of five days observed (1/4/2021) and thirty of thirty-four days reviewed regarding not reaching the required temperature of 160 degrees F for the wash cycle. Findings included: On 1/4/2021 at 10:03 a.m. a tour of the kitchen was conducted with the Certified Dietary Manager (CDM). The CDM indicated that they had just completed washing dishes with the High Temperature Dishwashing machine, from the breakfast meal service. The dish machine was visibly on with a staff member, kitchen aide (Employee C.) removing a crate of clean dishes on the clean side of the dish machine. Employee C. was asked if she normally operated the machine and she said that she does not operate it routinely. Employee C. was asked if she knew what type of dish cleaning machine it was. She did not know. Further, she was asked if she knew what the wash and rinse cycle temperatures should reach during wash and rinse cycle. The CDM spoke for her and said, The wash temperature should be 140 degrees F. and above and the rinse temperature should be 180 and above. The CDM confirmed again that the dish machine was a high temp machine. Employee C. and the CDM were asked when the last time the dish machine company was out to do maintenance. Employee C. said, he was just out here. She did not know exactly when but did confirm it was within the last couple of weeks. The CDM clarified that the dish machine maintenance company was out to fix a clogged chemical soap line but did not have any other concerns with the machine at that time. Employee C. and the CDM were asked if the dish machine needed to be primed a few times prior to it running at optimal temps. The CDM did confirm that the machine has to be primed and with a few cycles ran, prior to washing crates of dishes, etc. She and Employee C. both confirmed that the machine had been primed prior to the start of dish cleaning. At that point, there were no more dishes to be washed as they had already been washed. However, the CDM and Employee C. were both asked to run an empty crate through the machine so temperature observations could be made. At 10:10 a.m. Employee C. ran an empty crate through the machine. During this first observation, the wash temperature reached 158 degrees F. The rinse temperature reached over 180 degrees F. A second observation was made at 10:12 a.m. with the wash temperature reaching 150 degrees F. and with the wash temperature reaching over 180 degrees F. A third observation was made and the dish machine was observed with a wash temperature reaching 151 degrees F. and with the rinse temperature reaching well over 180 degrees F. Employee C. took out her electronic phone device to take a picture of the machine's specification plate, which was located down below the machine table on the right side. Employee C. presented a photo of the specification plate and read the following: (Left side of the specification plate) Hot water sanitizing 160 degrees F. Minimum Wash Tank Temperature, 180 degrees F. Minimum Final Rinse Temperature, 180 degrees F. Inlet Water Temperature. (Right side of the specification plate) Chemical Sanitizing 140 degrees F. Minimum Wash Tank Temperature, 120 degrees F. Minimum Final (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105327 If continuation sheet Page 5 of 7 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 105327 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/08/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Casa Mora Rehabilitation and Extended Care 1902 59th St W Bradenton, FL 34209 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 Rinse Temperature, 140 degrees F. Inlet Water Temperature, 50 ppm Minimum Chlorine Required. Level of Harm - Minimal harm or potential for actual harm Employee C. and the CDM confirmed now that they had been using the Chemical Sanitizing temps and not the Hot water sanitizing temps. It was confirmed that the Kitchen staff had been following Low Temp Chemical Sanitizing temperature specifications rather than following the High Temp Hot water sanitizing temperatures specifications. Photographic evidence of the dish machine's specification plate was taken. Residents Affected - Some The CDM was requested to provide the documented dish machine temperature logs for the past two months (12/2020 and 1/2021) for review. The 12/2020 dish machine temperature log revealed the following documented temperatures of below 160 degrees: 12/2020 Breakfast Cycle (12/1/2020 - 12/31/2020), Lunch Cycle (12/1/2020 - 12/2/2020, 12/4/2020 12/31/2020), Dinner Cycle (12/1/2020 - 12/16/2020, 12/18/2020 - 12/25/2020, 12/27/2020 - 12/28/2020, and 12/30/2020 - 12/31/2020). There were only four days documented that the dish machine wash cycle reached 160 degrees F. and above. The 1/2021 dish machine temperature log revealed the following documented temperatures of below 160 degrees: 1/2021 Breakfast Cycle (1/2/2021 and 1/4/2021), Lunch Cycle (1/1/2021, 1/2/2021), Dinner Cycle (1/1/2021, 1/2/2021, and 1/3/2021). All days reviewed had errant wash temperatures. Review of both 12/2020 and 1/2021 DISHMACHINE LOG revealed, For High Temperature Machine: (Refer to machine data plate for temperature requirements), Temperature Requirements: Wash - 160 degrees F., Rinse - 180 degrees F., Final Rinse - 180 degrees F. Further, the log revealed, *Always defer to manufacturer's guidelines regarding temperatures and correct chemical concentration for use. Further interview with the CDM revealed that it was the staff's responsibility to log temperatures for each meal, and each day, and it was her responsibility to review the log daily. The CDM revealed that she was fairly new to the facility and had been the CDM for about three weeks. The CDM confirmed the machine as per today's observation/demonstration, was not running at optimal temperatures according to the guideline and machine specifications plate. The CDM further revealed that the kitchen staff have been trained on how to run and monitor the dish machine but did not have any documents showing completion the training. On 1/5/2021 at 8:00 a.m. the Nursing Home Administrator reported that the dish machine maintenance company came out to the facility the night before (1/4/2021) and found that the wash temperatures were not rising to the specified temperature and hooked up chemical sanitizer to the machine and switched the machine from High temp to a Low temp functioning machine. This was verified through an additional kitchen tour at 10:00 a.m. and further confirmed by the CDM. On 1/5/2021 the Nursing Home Administrator provided the Cleaning and Sanitation policy and procedure with effective/review date of 9/2020. The policy showed, The facility promotes a clean and sanitary environment for its employees, residents and visitors. The entire Food and Nutrition Services team maintains clean and sanitary kitchen (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105327 If continuation sheet Page 6 of 7 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 105327 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/08/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Casa Mora Rehabilitation and Extended Care 1902 59th St W Bradenton, FL 34209 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 facilities and equipment. Walls, floors, ceiling, equipment and utensils are clean, sanitized and in good working order. Employees are provided with personal protective equipment (PPE) such as gloves, goggles and splash aprons, as appropriate when handling hazardous detergents and chemicals. Local, State and Federal regulations are followed to assure a safe and sanitary Nutrition Services Department. The procedure section of the policy, #7, revealed: Follow appropriate procedures for washing and sanitizing kitchen equipment. #8 revealed: Wash dishes in: High temperature dish machine per manufacturers guideline plate or at 150 - 165 degrees F. wash and 180 degrees F final rinse (or in accordance with State regulations). #9 revealed: Record dish machine temperatures and chemical saturation PPM three times daily using the Dish Machine Temperature Log to ensure dishes are sanitized. On 1/5/2021 at 8:30 a.m. an interview with the Nursing Home Administrator revealed that they follow the policy but confirmed that the dish machine wash and rinse specifications as indicated on the machine, should be followed and is more accurate. He further provided a communication documented from the dish machine maintenance company, dated 3/17/2020 which revealed in part, High Temperature Dish Machine Programs, (company name) current practice for NSF-compliant high temperature dish machines are in alignment with these CDC recommendations. (company name)'s high temperature dish machines maintain a suitable alkaline detergent at 1000 ppm minimum in the wash step and a consistent elevated temperature of 180 degrees F during the sanitizing cycle. However, there was not a problem with the wash detergent cycle or the high temp rinse cycle. The problem with the machine observations and review of the log revealed the wash cycle did not meet the required temperatures as per the machine specification plate. This was confirmed by both the Certified Dietary Manager, Employee C. and the Nursing Home Administrator. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105327 If continuation sheet Page 7 of 7