Health inspection·March 24, 2022

F 0656 Level of Harm - Minimal harm or potential for actual harm 2a. Daily updates to care plans are added by a member of the IDT [interdisciplinary team] at the time the change is implemented, the intervention is needed, or other care plan revision is indicated. Accuracy of the care plan is validated by the IDT during the daily clinical meeting. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105327 If continuation sheet Page 2 of 9 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 03/24/2022 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to provide needed care and services for treatment of a wound for one resident (#140) of three residents sampled for skin conditions. Residents Affected - Few Findings included: A review of Resident #140's medical record revealed Resident #140 was admitted to the facility on [DATE] with diagnoses of flaccid hemiplegia and peripheral vascular disease. A review of Resident #140's care plan revealed a problem, revised on 10/28/2021, that Resident #140 had potential/actual impairment to skin integrity. Interventions included to monitor/document location, size, and treatment of skin; and report abnormalities, failure to heal, signs and symptoms of infection, and maceration to the resident's physician. An interview was conducted on 03/22/2022 at 10:29 a.m. with Resident #140 in the resident's room. During the interview, Resident #140's top left foot was observed to have two white bandages over it with no date. Resident #140 stated the nurse that worked on 03/20/2022 put the bandages on his left foot because he had scratched the area with his right foot to the point that the skin was opened. During the interview, Staff F, Licensed Practical Nurse (LPN) entered the room to administer Resident #140's medications. Staff F, LPN was not able to state any information related to Resident #140's foot wound and stated she would need to check Resident #140's chart for additional information. A review of Resident #140's Minimum Data Set (MDS) Assessment, dated 03/01/2022, under Section C Cognitive Patterns, revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating Resident #140 was cognitively intact. A review of Resident #140's physician orders for March 2022 did not reveal orders for treatment of the wound to Resident #140's left foot. A follow up interview was conducted on 03/23/2022 at 10:07 a.m. with Resident #140 in the resident's room. During the interview, Resident #140's top left foot was observed to have no dressing to it. Resident #140 stated Staff E, LPN removed the dressing on 03/22/2022 to look at the wound. Resident #140's top left foot was observed to have several small, red colored areas, scabbed over in appearance. An interview was conducted on 03/23/2022 at 2:30 p.m. with Staff E, LPN. Staff E, LPN stated she noticed Resident #140 had a bandage on his left foot on 03/22/2022 and removed the bandage to observe the area. The wound to Resident #140's left foot was no longer open, so a new bandage was not applied. Staff E, LPN reviewed Resident #140's medical record and observed there was no physician order for care of the wound to Resident #140's left foot and no assessment of the wound was documented in the medical record. Staff E, LPN stated the wound to Resident #140's left foot should have been assessed and documented in the medical record. Staff E, LPN also stated a treatment for the wound should have been ordered for Resident #140's wound and the bandage to Resident #140's left foot should have been dated. An interview was conducted on 03/24/2022 at 2:08 p.m. with the Director of Nursing (DON). The DON stated if a new skin alteration is identified by staff, she would expect the nursing staff to observe (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105327 If continuation sheet Page 3 of 9 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 03/24/2022 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the area and notify the resident's physician in order to obtain an order for wound care and treatment. The nurse should also measure the wound and document the status of the wound in the resident's medical record. Any dressing that is applied to the resident should be dated and initialed by the nurse who dressed the wound. The DON stated if a dressing is observed on a resident and it is not dated, the nurse should remove the dressing, observe the wound, and review the resident's record to ensure that wound care orders were in place. A review of the facility policy titled Weekly and PRN (as needed) Skin Check, effective in October 2021, revealed under the section titled Policy that the Weekly and PRN Skin Check is used to document skin condition throughout the Resident stay in the facility. The nurse will conduct weekly skin check and/or a PRN skin check when applicable as a proactive measure to identify impairment or suspected impairment timely to reduce the risk of further decline in skin integrity. The policy also revealed under the section titled Procedure once a week and when an area of skin impairment is reported the skin check should be documented on the Weekly & PRN Skin Check documentation tool. If a new area is identified the appropriate skin grid should be initiated within 8-hours. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105327 If continuation sheet Page 4 of 9 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 03/24/2022 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A review of the admission Record revealed Resident #161 was initially admitted into the facility on [DATE] with diagnoses that included COPD, chronic respiratory failure, respiratory disorders in diseases classified elsewhere, and dependence on supplemental oxygen. Residents Affected - Few Section C - Cognitive Patterns of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #161 had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating moderately impaired. Section O - Special Treatments, Procedures, and Programs of the MDS, dated [DATE], revealed the resident had oxygen therapy while a resident of this facility. A review of the Order Summary Report with active physician orders as of 03/24/2022 revealed the following order: oxygen at 3 liters per minute via nasal cannula continuously for COPD. A review of the progress notes for March 2022 did not reflect Resident #161 was noncompliant with the oxygen orders. A review of the care plan related to the use of oxygen, initiated on 06/26/18, revealed interventions that included administer oxygen as ordered, give medications as ordered by the physician, and report changes in respiratory status to the physician. On 03/22/2022 at 2:38 p.m., Resident #161 was observed sitting in the wheelchair next to her bed finishing up lunch. The resident was not wearing the nasal cannula for oxygen at that time. She stated she took a break from the oxygen because it was hurting her nose. On 03/23/2022 at 10:08 a.m., Resident #161 was observed in bed with her eyes closed wearing a nasal cannula for oxygen. The concentrator was set on 3.5 and the resident confirmed the concentrator was set on 3.5. On 03/24/2022 at 9:57 a.m., Resident #161 was observed in bed and not wearing a nasal cannula. The resident stated she felt better without the oxygen. On 03/24/2022 at 10:06 a.m., Staff G, LPN reported Resident #161 was compliant with wearing the nasal cannula for oxygen, but she takes it off if she wants to. Staff G, LPN, reported she wears it 75 percent of the time. The nurse reported the concentrator should be set at 3 but she had seen Resident #161 adjusting the concentrator. Staff G, LPN, stated Resident #161 does what she wants to do. She reported this should be documented in the resident's medical record and reported to the doctor. On 03/24/2022 at 10:52 a.m., the DON reported physician orders should always be followed. The DON confirmed Resident #161 did not have a care plan in place for being noncompliant with oxygen orders. The DON reported she would do education with the resident and notify the doctor. Based on observations, interviews, and record reviews, the facility failed to provide respiratory care in accordance with professional standards of practice for two residents (#140 and #161) of four residents sampled for respiratory care. Findings included: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105327 If continuation sheet Page 5 of 9 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 03/24/2022 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 0695 Level of Harm - Minimal harm or potential for actual harm 1. A review of Resident #140's medical record revealed Resident #140 was admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease (COPD), acute respiratory failure, and obstructive sleep apnea. A review of Resident #140's physician orders for March 2022 revealed the following orders: Residents Affected - Few - An order, dated 05/20/2021 for continuous oxygen at 3 liters per minute via nasal cannula for every shift related to COPD. - An order, dated 02/10/2022 to change tubing every week on Sunday during the night shift and label tubing with the date when changed. A review of Resident #140's care plan revealed a problem, revised on 02/11/2022, that Resident #140 had oxygen therapy related to shortness of breath. Interventions included to change oxygen tubing and set up weekly and label with date when changed and administer oxygen as ordered. An observation was conducted on 03/22/2022 at 10:29 a.m. of Resident #140 resting in bed in his room. Resident #140's oxygen concentrator was observed in the corner of his room with a plastic bag hanging from it. Inside of the plastic bag was an oxygen cannula. The oxygen cannula and the storage bag did not have dates on them and the bag was observed sitting on the floor of the resident's room. Resident #140 was observed not wearing a nasal cannula and the oxygen concentrator was not running. An observation was conducted on 03/23/2022 at 10:07 a.m. of Resident #140 resting in bed in his room. Resident #140's oxygen concentrator was observed in the corner of his room with a plastic bag hanging from it. Inside of the plastic bag was an oxygen cannula. The oxygen cannula and the storage bag did not have dates on them and the bag was observed sitting on the floor of the resident's room. Resident #140 was observed not wearing a nasal cannula and the oxygen concentrator was not running. An interview was conducted on 03/23/2022 at 2:30 p.m. with Staff E, Licensed Practical Nurse (LPN). Staff E, LPN stated Resident #140 had an order for continuous oxygen via nasal cannula, but the resident often refused the oxygen. All refusals should be signed off by the nurse in the resident's chart. Resident #140 wanted the oxygen order to be changed to as needed but the order was not changed. Staff E, LPN stated the order should have been clarified since Resident #140 did not want the oxygen on continuously. Staff E, LPN also stated oxygen tubing was changed weekly every Sunday on the night shift. Staff E, LPN observed Resident #140's oxygen tubing and verified the tubing and storage bag did not have a date on them and the items were touching the floor. Staff E, LPN stated oxygen tubing and storage bags should be dated and kept off of the floor. If the items are observed on the floor by staff, then the items should be replaced. A review of Resident #140's Medication Administration Record (MAR) for March 2022 revealed Resident #140 refused his order for oxygen at 3 liters per minute via nasal cannula on 03/01, 03/02, 03/09, 03/14, 03/16, and 03/21/2022 during the day shift. No other refusals were documented in the MAR. An interview was conducted on 03/24/2022 at 2:08 p.m. with the Director of Nursing (DON). The DON stated Resident #140 usually wore his oxygen and he had an order for continuous oxygen via nasal cannula. If a resident has an order for continuous oxygen and the resident refused, the refusal should be part of the resident's care plan and documented in the resident's chart. Oxygen tubing and storage bags should be changed out weekly and as needed. Oxygen tubing and storage bags should have the date that they were changed on them. The DON stated if staff observe oxygen tubing or storage bags on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105327 If continuation sheet Page 6 of 9 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 03/24/2022 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 0695 the floor, then it would need to be changed out right away, even if the resident was not using it at the time. Level of Harm - Minimal harm or potential for actual harm A review of the facility policy titled, Oxygen Therapy, with no effective date, revealed under the section titled, Definition of Oxygen that oxygen is a drug which must be ordered by a physician. The policy also revealed under the section titled, Oxygen Devices that nasal cannula's should be changed out every week and as needed. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105327 If continuation sheet Page 7 of 9 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 03/24/2022 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observations, interviews and record review, the facility did not ensure the environment was free from odors in two units (Hall 300 and Hall 200) of four units related to sewer gas smells in Hall 300 and cigarette smoke smell in the Hall 200, for four days (3/21/22, 3/22/22, 3/23/22 and 3/24/22) of a four day survey. Findings included: 1. During a facility tour on 03/21/22 at 10:44 AM, a strong odor of sewer gas was noted in Hall 300. An interview was conducted with Resident #119. Resident #119 sated her room has been smelling like sewage. Resident #119 did not know how long the smell had been going on. Resident #119 stated she does not shower in her bathroom because of the gases. Her roommate stated she thought the sewage smell was from gases coming up the shower drain. On 03/21/22 at 11:26 AM, an interview was conducted with Resident #29. Resident #29 stated the only problem he had was that his bathroom smells like sewage. Resident #29 stated he did not think the facility was in a hurry to fix it. An interview was conducted with Resident #18 on 03/21/22 at 12:19 PM. Resident #18 stated his bathroom smells like sewage. Resident #18 reported this has been going on for more than six weeks. Resident #18 said, It's horrible, the gases make you sleepy. On 03/21/22 at 1:15 PM, An interview was conducted with Resident #143. Resident #143 said, My bathroom smells horrible. It makes the whole room smell like sewage. An interview was conducted on 03/21/22 at 1:24 PM with Resident #149 and a visiting family member. Resident #149 reported smelling gases. Resident #149 said, It's probably from the sewage. It is horrible. It makes you sick. An interview was conducted on 03/22/22 at 10:53 AM with Staff C, Certified Nursing Assistant (CNA). Staff C confirmed the sewage smell has been an on-going issue. Staff C stated the head of housekeeping department had been notified. On 03/23/22 at 12:30 PM an interview was conducted the Regional Environmental Services (EVS) Manager and the facility's EVS manager. The Regional EVS said, The sewer problem is obvious in Hall 300. You can't miss it. The facility's EVS Manager stated there has been an on-going sewage maintenance issue. He stated that residents and staff report smelling gas. The facility's EVS Manager stated the administration was aware of the sewer gas issue. The facility's EVS Manager stated housekeeping did not have anything to do with it and that a follow -up should be done with the Nursing Home Administrator (NHA) or maintenance department. An interview was conducted on 03/23/22 at 1:20 PM with the Director of Maintenance. (DOM) The DOM said, There is a problem in Hall 300. The gases go through the drain and come up to the residents' rooms. The DOM said, I am aware of the concerns. It has been an issue for about six months or so. It comes and goes. The DOM stated they had not received any work orders or reports recently. A follow up interview was conducted with the NHA on 03/23/22 at 1:45 PM. The NHA said, We have four (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105327 If continuation sheet Page 8 of 9 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 03/24/2022 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some gas traps. I am aware that it is leaking gas. I think the problem is a crack in the ground. It has been an issue at least six weeks or so. The NHA stated that he would make a call to schedule a scope procedure for the traps. The NHA said, I know, the residents should be in a comfortable and sanitary environment. 2. During a facility tour of Hallway 200 on 03/21/22 at 9:42 AM, a strong smell of cigarettes was noted inside the building. The smell was in the residents' rooms, hallway, and staff offices in the vicinity. The hallway is adjacent to the courtyard where residents go out to smoke. On 03/22/22 at 1:50 PM, an interview was conducted with Staff D, CNA. Staff D stated the 200 hallway always smells like cigarette smoke. Staff D said, It is not fair for those who do not smoke. Staff D confirmed the residents in this hall complain about it. Staff D stated when the door is opened for smokers, the smoke is trapped inside the building. Staff D stated the problem was lack of ventilation. On 03/23/22 at 12:30 PM, an interview was conducted with the Regional EVS and the facility's EVS manager. They stated the problem with the smoke smell has been ongoing. The facility's EVS manager said, It is pungent. The residents, staff and everyone talks about it. We have had meetings with the NHA trying to address the issue. The facility's EVS Manager stated he has suggested installing smoke eaters. The facility's EVS Manager stated they installed a humidifier in the room before the courtyard, but the problem is still persistent. A follow-up interview was conducted on 03/23/22 at 1:20 PM with the DOM. The DOM stated the administration is aware of the problem of cigarette smells in the rooms near the courtyard entrance. The DOM stated the 200 hallway is affected the most. The DOM stated staff have reported the problem and the administration is addressing it. The DOM did not have a timeline of when they anticipated a resolution. On 03/23/22 at 1:45 PM an interview was conducted with the NHA related to the smoke smell in resident rooms and hallway in hall 200. The NHA said, I know it is a problem and it is not fair for those residents. The NHA stated he has asked social services to speak with all of them [residents in the 200 hall] today and offer them a room switch. The NHA stated they are considering using silicone coding on doors and windows to keep the smoke outside. The NHA stated they will service the air curtains on the courtyard doors. The NHA stated during COVID they switched the entrance to the courtyard and that was where the problem started. The NHA said, We will review all options. Of course, our residents' comfort is our priority. A follow up interview was conducted with the NHA on 03/24/22 2:08 PM. The NHA stated he has plumbers coming to scope, put a camera through the sewer system and down the 300 Hall to rule out cracks in the grease traps. The NHA stated the residents have not complained to him but, a family member said something about it. The NHA confirmed he was aware of the smoke problem in Hall 200. Review of a document titled, Resident Handbook, dated 02/17, Page 5, showed under housekeeping and maintenance services, the housekeeping and maintenance staff keep the facility safe, comfortable, and clean. We consider a pleasant environment important to your well-being. Review of a facility policy titled, Physical Environment, dated January 1, 2020, showed an expectation to ensure a safe, clean, comfortable, and home- life environment is provided for each resident / patient. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105327 If continuation sheet Page 9 of 9