Health inspection·September 11, 2025

F 0578 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some indicated No with a checkmark-Living Will- indicated No with a checkmark-DO NOT Resuscitate (DNR)indicated Yes with an X and No with a checkmark. The Yes was also circled and there was a line from the circle across the No and error written beside it. -DO NOT Intubate- indicated No with a checkmark-DO NOT Hospitalize- indicated No with a checkmark-No Artificial Feeding- indicated No with a checkmark-Hospiceindicated No with a checkmarkReview of Resident #2's medical record did not reveal a signed DNR Form DH1896. Review of Florida Statutes Chapter 401, Medical Telecommunications and transportation, section 401.45 (3)(a) regarding DNR Form DH1896 showed: Resuscitation may be withheld or withdrawn from a patient by an emergency medical technician or paramedic if evidence of an order not to resuscitate by the patient's physician or physician assistant is presented to the emergency medical technician or paramedic. An order not to resuscitate, to be valid, must be on the form adopted by rule of the department. The form must be signed by the patient's physician or physician assistant and by the patient or, if the patient is incapacitated, the patient's health care surrogate or proxy as provided in chapter 765, court-appointed guardian as provided in chapter 744, or attorney in fact under a durable power of attorney as provided in chapter 709. The court-appointed guardian or attorney in fact must have been delegated authority to make health care decisions on behalf of the patient. (https://www.leg.state.fl.us/statutes/index.cfm?App_mode=Display_Statute&URL=0400-0499/0401/Sections/0401.45.html# Accessed on [DATE])An interview was conducted on [DATE] at 2:34 p.m. with Staff N, Registered Nurse (RN)/Unit Manager (UM). Staff N said when Resident #2 returned from the hospital in [DATE] he completed the admission process. Staff N said Resident #2 was discussed in the morning meeting prior to returning and it was mentioned the resident would be returning to the facility with a DNR status. Staff N said when the resident returned the AHCA 5000-3008 showed the resident was now a DNR. Staff N said he called the provider and received a verbal order for DNR. Staff N said then social services should have called to verify the family approved of the DNR status and the correct power of attorney (POA) or healthcare proxy (HCP) is in place. Staff N said after social services confirms the information, they initiate the DNR Form DH1896 from and get it signed by the resident or resident representative and the provider. Staff N said once the DNR Form DH1896 was completed and signed it was placed in front of the resident hard chart. Staff N said when there is a code called for a resident the first thing staff grab is the resident's hard chart. He said the nurse can double check code status in the computer but the one that matters to us is the chart. Staff N said if a resident with a DNR went out to the hospital the nurse or UM gave a copy of the signed DNR Form DH1896 to EMS as well as letting them know during report the resident had a code status of DNR. Staff N reviewed Resident #2's AHCA 5000-3008 from [DATE]. Staff N said looked at Section H, Advanced Care Planning, and said it was interpreted as DNR initially being marked as No and error was written beside that. He said then Yes was marked indicating the resident was DNR. Staff N said a signed DNR Form DH1896 not come with Resident #2 was from the hospital and he did not remember a completed, signed DNR Form DH1896 from ever being returned to the unit to be placed in the resident's hard chart. Staff N said the process was that when a patient returned from the hospital their chart was brought to the morning clinical meeting and it was reviewed by staff including nursing and social services. Staff N said resident's code status was discussed and social services would then procced with getting the paperwork completed. Staff N said he was working the day Resident #2 went out and Staff Q, RN/UM asked me to see the resident. Staff N said Resident #2 was not looking good and 911 was called. Staff N said he was at the nurses' station completing paperwork and he was not aware of what happened while EMS was in the facility. Review of video footage from the facility's front entrance, dated [DATE], showed two paramedics pushing a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105327 If continuation sheet Page 2 of 31 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 09/11/2025 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 0578 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some stretcher carrying Resident #2. One paramedic was pulling the stretcher from the front. The second paramedic was walking alongside the stretcher with one hand on the center of Resident #2 chest doing one handed chest compressions while moving the patient from the facility to the ambulance outside the front door of the facility. An interview was conducted on [DATE] at 12:38 p.m. with Staff M, Registered Nurse (RN). Staff M said he was the nurse for Resident #2 the day the resident went out to the hospital. Staff M said the resident's vital signs were out of whack and the resident was not doing well. Staff M said 911 was called and Emergency Medical Services (EMS) came and took the resident. Staff M said Resident #2 was a DNR but he doesn't recall if the facility had the DNR Form DH1896 or if the paramedics were told. Staff M said normally the yellow DNR paper is in front of the resident's hard chart, often more than one copy. He said one copy would be sent with EMS if a resident with a DNR order was sent out and if there were not two copies in the chart, a copy would be made for EMS. Staff M said if a resident wanted to change their code status to DNR the provider would give the order, and they would sign the DNR Form DH1896 because they were in the building all the time. A follow-up interview on [DATE] at 1:34 p.m. with Staff M, RN. He said they did not visualize them [EMS] doing CPR. Staff M said when EMS arrived the resident was still alive, he gave report and backed up and the resident was put on a stretcher. Staff M said he knew the resident was a DNR but the Staff Q, RN/Unit Manager (UM) got the paperwork together. An interview was conducted on [DATE] at 12:57 p.m. with Staff Q, RN/UM. Staff Q said on [DATE] Resident #2's rate was elevated; the resident was suctioned the provider was called. Staff Q said Resident #2's heart rate continued to go higher, and the doctor said to send the resident to the hospital, therefore, 911 was called. Staff Q said paramedics came and not to my knowledge did they do CPR. Staff Q said he knew Resident #2 was a DNR but don't believe we had that [signed DNR Form DH1896]. Staff Q said the paperwork he gave the paramedic was the bed hold, AHCA form, medication list, orders, and facesheet. Staff Q said Resident #2 had gone out to the hospital in July and when the resident returned, he was a DNR. Staff Q said he did not know why the signed DNR Form DH1896 was not in the resident's chart and maybe it had still been in the process of being signed. An interview was conducted on [DATE] at 3:51 p.m. with the Risk Manager. The Risk Manager said Staff M, RN was doing rounds on [DATE] and found Resident #2 to be tachycardic (fast heart rate) and diaphoretic (excessive sweating). She said the doctor was notified and 911 was called to send the resident out. The Risk Manager said EMS was provided with a copy of the doctor's order, but the facility did not have the signed DNR Form DH1896. She said there was a breakdown in the process which is why they did not have the signed DNR Form DH1896. The Risk Manager said when a resident wanted to change from full code status to not resuscitate the order is printed, signed and placed in front of the resident's hard chart. She said the full code paperwork that would have previously been in the hard chart was removed to avoid confusion. She said the DNR Form DH1896 was completed, signed, then put in front of the chart also. The Risk Manager said the signed DNR Form DH1896 was given to EMS if a resident with DNR status goes to the hospital. She confirmed if EMS did not have the signed DNR Form DH1896 they do a full code on the resident. The Risk Manager said the reason there was a problem with Resident #2 was social services and the unit manager had the change of code status on their morning meeting homework sheets when the resident was readmitted to the facility, but the paperwork did not get completed that day and it was never transcribed to the next day's morning meeting homework sheet. An interview was conducted on [DATE] at 2:20 p.m. with Staff L, Social Services (SS). Staff L said if a resident wanted to have a DNR code status social services would have had them sign the DNR Form DH1896, if they are their own responsible party. Staff L said if the resident was unable to sign the social services would have called the resident's power or attorney and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105327 If continuation sheet Page 3 of 31 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 09/11/2025 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 0578 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some have them sign the paperwork, either by coming in, by email, by fax, or whatever needed to be done to get the DNR Form DH1896 from signed immediately. Staff L said Resident #2 returned to the facility in [DATE] with a new code status of DNR. Staff L said social services should have reached out to the family to verify the DNR status and get the paperwork completed. Staff L said I don't know that they did reach out to Resident #2's family to verify the code status and get the DNR Form DH1896 signed. When asked if Staff L saw a completed, sign DNR Form DH1896 for Resident #2, she stated, Correct To my knowledge I have never seen one. Staff L said she could not speak for nursing, but she did not reach out to Resident #2's family to confirm DNR status or get the paperwork completed. Staff L said after Resident #2 left the facility she heard about the facility not having Resident #2's signed DNR Form DH1896 form for EMS and CPR being done on the resident. An interview was conducted on [DATE] at 1:25 p.m. with Staff J, Physician Assistant (PA). Staff J said he was called on [DATE] about Resident #2 being in distress and being sent to the hospital. Staff J said there had been several discussions with Resident #2's family about code status and possible hospice prior to going out to the hospital in [DATE]. Staff J said Resident #2 went out with a full code status and returned to the facility on [DATE] with a DNR code status. He said they were told the family made the decision to change the code status while the resident was in the hospital. Staff J said typically when a resident changed to a DNR status the nurse would have given him the DNR Form DH1896 to sign. Staff J said he routinely signed the DNR Form DH1896 forms but had not signed one for Resident #2. Staff J said he was told on [DATE] Resident #2 was being evaluated by EMS and lost a heart rate, and EMS started a code while in the facility. 2)Review of admission Records showed Resident #12 was admitted to the facility on [DATE] with diagnoses including wedge compression fracture of T5-T6 vertebra, encephalopathy, muscle wasting and atrophy and protein calorie malnutrition.Review of Resident #12's provider orders showed: -Full Resuscitation Start: [DATE]. Discontinued [DATE]-Do Not Resuscitate Start: [DATE]. Review of Resident #12's medical record revealed a printed and signed order for Full Code on the first page. The second page of the hard chart revealed a completed, signed DNR Form DH1896, dated [DATE]. An interview was conducted on [DATE] at 4:39 p.m. with Staff R, RN. Staff R said when a code was called staff pulled the residents chart to look for code status. Staff R was observed looking at Resident #12's hard chart. Staff R opened the chart and said, [Resident #12] is a full code. The front page was then flipped over and Staff R said, [Resident #12] has a signed DNR? Staff R said, it shouldn't be like that 3) Review of admission Records showed Resident #13 was admitted on [DATE] with diagnoses including altered mental status and urinary tract infection. Review of Resident #13's admission Assessment showed the resident was oriented to person, place, time and situation. Review of Resident #13's provider orders showed: -Do Not Resuscitate Start [DATE]. Review of Resident #13's medical record revealed a DNR Form DH1896 form signed by the provider, however, it had not been signed by the resident/resident representative. The resident's provider signed the form on [DATE]. An interview was conducted on [DATE] at 4:32 p.m. with the Risk Manager, Director of Nursing (DON) and Nursing Home Administrator (NHA). The DON said the facility should have had the completed, signed DNR Form DH1896, but the facility staff did not do CPR on Resident #2. The DON said they went by the [DATE] AHCA 5000-3008 to see that Resident #2 was a DNR status. She said, this is like our physician order form. The DON said they did not get any other information or DNR paperwork from the hospital, they just went by the AHCA 5000-3008 The DON said social services tried to call the family but did not get a response. She confirmed there was no documentation social services had reached out to the family to confirm Resident #2's updated code status. The NHA said Staff J, PA would have been the provider to sign the DNR Form DH1896 for Resident #2. The Risk Manager and DON reviewed the medical record of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105327 If continuation sheet Page 4 of 31 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 09/11/2025 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 0578 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Resident #12. When the front of the chart was opened the DON said Resident #12 was a full code she then flipped the page and confirmed there was a signed DNR for the resident. The DON and Risk Manager said the hard chart should not have both a full code order and signed DNR order in the chart and confirmed it would lead to confusion. Upon review of the resident's medical record, they confirmed Resident #12 did have a DNR order and stated the full code order should have been removed from the hard chart when the resident changed their code status to DNR. The DON and Risk Manager reviewed Resident #13's DNR Form DH1896 and confirmed it was not signed by the resident. They both agreed the DNR form would not be valid since it was not signed. The DON said Resident #13 is her own responsible party and should have been asked to sign the DNR Form DH1896 upon admission. Review of a facility policy titled Advanced Medical Directives, effective [DATE], showed the following: PolicyAt the time of admission, Admissions shall furnish residents, family members, and/or the resident representative(s) with information regarding Advanced Medical Directives.The resident and/or resident representative shall be asked to provide Social Services with a copy of the resident's current Advanced Medical Directives. Social Services will place the Advanced Medical Directives in the resident's medical record and ensure that the presence, or absence, of Advanced Medical Directives is documented in the resident record.Completion of an Advanced Medical Directive is not a requirement for admission or continued stay in the facility. After admission to the facility, the Director of Social Services will assist in providing further guidance and/or information on Health Care Advanced Directives as required or requested.Procedure1. Verify that information about Advanced Medical Directives was provided to the resident and/or family / resident representative at the time of admission.2. Evaluate factors that may affect the resident capacity to communicate a decision.Notify Physician of any concerns. Consider vision/hearing/cognitive deficits Obtain language preference and utilize translation/interpreter as needed3. Provide culturally appropriate discussion/education for the resident and/or responsible party.4. Obtain any current Advanced Directives from the resident and/or family/resident representative. Read the content to understand the resident's wishes and place the document in the medical record.5. Document the Advanced Medical Directives that are current and in place on the medical record.6. Enter the information on the Advanced Directives/DNR Log upon admission, quarterly, with change in condition, and / or change in Advanced Medical Directive status.7. Update medical record with new or revised Advanced Medical Directives as indicated.8. When a resident rescinds or changes his/her Advanced Medical Directives, have the resident draw a line through the old document, note rescinded/changed, then sign and note date rescinded/changed. Remove the old document from the record and return it to medical records for filing in closed chart. Place updated document in the record and document in the medical record.DNRHow Implemented: An order by the physician that, should the resident's heart stop and/or should respirations cease, CPR is not to initiated. Specific to CPR initiation; does not address other life support measures. Considerations Signed by resident or authorized healthcare decision-maker if resident lacks capacity Means only that CPR will not be initiated; treatable conditions will still be treated Without a DNR order, CPR will be initiated State specific documentation may also be required e.g. yellow form (FL) for EMS The facility's immediate actions to remove the Immediate Jeopardy included: A whole house audit was completed on [DATE] regarding advance directives and two identified variances were corrected. One code status was updated in the medical record, and it is clear to staff of the resident wishes and one next of kin validated the resident's advance directives with a signature on [DATE]. The Regional Nurse Consultant educated the clinical management team at 100% [DATE] to the Code Status Response Policy. Licensed Nurses were educated by the Director of Nursing and the facility clinical administration team on Code Status Response Policy at 97% by (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105327 If continuation sheet Page 5 of 31 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 09/11/2025 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 0578 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete [DATE]. The morning clinical worksheet was updated on [DATE]. ADHOC Quality Assurance meeting was conducted today [DATE] to review the removal plan including the medical director. Verification of the facility's removal plan was conducted by the survey team on [DATE].- Interviews were conducted with forty-three nurses and CNAs who worked across all shifts, the Director of Nursing, the Assistant Director of Nursing, the Nursing Home Administrator, and the Social Services team. The staff members were able to state that they had been trained and were knowledgeable about the new policies and procedures initiated by the facility.- A review of in-service documentation revealed 100% of staff had acknowledged education and training related to procedures for residents' code status, code drills, and advanced directives process. Based on verification of the facility's Immediate Jeopardy removal plan the immediate jeopardy was determined to be removed on [DATE] and the non-compliance was reduced to a scope and severity of E. Event ID: Facility ID: 105327 If continuation sheet Page 6 of 31 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 09/11/2025 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 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to follow the established facility grievance policies and procedures related to investigation and follow-up for resident grievances for five residents (#16, #17, #18, #19, and #20) out of six residents sampled. Findings included:An interview was conducted on 09/09/2025 at 11:15 a.m. with Resident #18. The resident stated he had several grievances filed with the facility and the facility had not followed up with him on most of them. He stated a grievance where he had been awoken by a Certified Nursing Assistant (CNA) making noises in the hall was never addressed by the facility, as well as a grievance about some missing items. An interview was conducted 09/09/2025 at 2:30 p.m. with Residents #16 and #17. They stated there was a joint grievance regarding staff not passing out waters, and regarding the staff being on their personal phones during resident care. Both Resident #16 and #17 voiced no one has discussed their grievances with them and both of their complaints were still ongoing issues and had not been resolved. An interview was conducted on 09/10/2025 11:00 a.m. with Resident #20. The resident stated no one had ever resolved her grievances from July 2025 and no one had followed up on the grievances. The resident stated no staff had come to talk to her about the grievance or informed her of any plans to resolve it. An interview was conducted 09/10/2025 11:07 a.m. with Resident #19. The resident did not want to discuss the specifics of his grievance, however, he did voiced his issues had not been resolved and verified no one had followed up with him regarding his grievance. An interview was conducted with Staff L, Social Services, on 09/10/2025 at 11:34 a.m. Staff L explained the grievance process for the facility. Staff L stated it would depend on the specific situation as to who would follow up with residents and confirmed that no one specific person followed up with the residents to make sure they understood their grievances were either being worked on or completed and signed off. A review of the facility policy titled Grievance/Concern Management, dated May 2025, revealed the following: POLICY :Residents and their representative have the right to present concerns on behalf of themselves, and/ or others to the staff and/ or administrator of the facility, to governmental officials, or to any other person. The concern may be filed verbally or in writing, and the reporter may request to remain anonymous.Residents and their representative have the right to recommend changes in policies and services, and to join with other residents or individuals within or outside the facility to work for improvements in resident care, free from restraint, interference, coercion, discrimination, or reprisal.These rights include access to the State of Florida Long-[NAME] Care Ombudsman and advocates and the right to be a member of, to be active in, and to associate with, advocacy or special interest groups.These rights also include the right to prompt efforts by the facility to resolve resident concerns, including concerns/grievances with respect to the behavior of other residents. PROCEDURE:1. At, during, or after admission, staff will provide:a. An explanation of the facility concern processb. A copy of the concern / grievance formc. An explanation of where concern forms are located, and that staff will provide a form should it be requestedd. Guidance on assistance available to residents or their representatives who are unable to complete the form unassistede. The names, job titles, and telephone numbers of employees responsible for implementing the facility's concern procedure. This information is found in the admission Booklet and includes the address and toll-free telephone numbers and email addresses for the Ombudsman and the Agency and other survey agencies.f. Outside resources available to the resident: -Ombudsman-Department of Health-Facility specific options such as a toll-free number for reporting concerns2. The facility will prominently display a poster that includes the following:a. The contact (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105327 If continuation sheet Page 7 of 31 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 09/11/2025 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 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete information of the Grievance Official to include his / her name, business address (mailing and email address), and business phone number,b. A reasonable expected time for completing a review of the concern,c. The right to obtain a written decision regarding the concern,d. Reference to independent entities with whom concerns may be filed.3. Residents and their representatives who are unable to complete a written concern will be assisted by staff to prepare and submit the form.4. The NH.A is responsible for oversight of the concern process.5. The Social Services representatives/ Grievance Official in collaboration with the NH.A will be responsible for assigning the concern to the appropriate department for investigation. Social Services will monitor and document resident / representative satisfaction upon completion of the investigation and the summary of findings / conclusion.6. Social Service Director in collaboration with the NH.A will be the Grievance Official at the facility7. The facility leadership team will review and discuss concerns and the progress of an investigation(s) and resolution(s). 8. The department involved will document the concern and record the resident/ resident representative's satisfaction with the resolution to the concern.9. The Resident Council will be reminded of the name and location of the grievance officer; how to file a concern; that they may file verbally or in writing and may file anonymously. This reminder will include where they can find the poster with the number where they can make an anonymous report of a concern. The concern process will be reviewed at a minimum annually with the Resident Council.10. Concern forms are confidential, protected Quality Assessment, Assurance and Compliance documents and are not copied.11. Concerns are tracked, trended, and reported in the monthly Quality Assessment, Assurance and Compliance Committee Meeting.12. Retain grievance concern report and logs for three (3) years. Others will be shredded.13. Complete a concern report investigation with summary and conclusion.14. Social Services staff will provide information regarding compliance line information for unresolved concerns. Event ID: Facility ID: 105327 If continuation sheet Page 8 of 31 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 09/11/2025 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, the facility failed to report an incident of elopement related to lack of supervision for one Resident (#1) out of four residents reviewed for elopement. Findings included: A review of Resident #1's admission record revealed an admission date of 1/19/24 with diagnoses to include encephalopathy, unspecified, generalized anxiety disorder, mild cognitive impairment of uncertain or unknown etiology, syncope and collapse, and alcohol use, unspecified. A review of Resident #1‘s quarterly Minimum Data Set (MDS), dated [DATE], under section C-Cognitive Patterns, revealed a Brief Interview for Mental Status (BIMS) score of 12, indicating moderately impaired cognition. Section GG - Functional Abilities, revealed the resident used a walker for mobility and ambulated independently. Section P, Restraints and Alarms, revealed a wander/elopement alarm was used daily. A review of Resident #1's quarterly MDS, dated [DATE], revealed the same information was marked in sections C, GG, and P as in the assessment date of 7/26/25. A review of Resident #1's order summary report, to include completed and discontinued orders, revealed the following:- LOA [leave of absence] with escort for impaired cognition/elopement risk, with an order date of 1/29/24.- Electronic Wander Bracelet: Apply electronic wander bracelet to the L [left] ankle due to elopement risk, with a start date of 1/22/24 and discontinued 6/6/25.- Electronic Wander Bracelet: Check function with the transponder daily on night shift. Replace electronic wander bracelet if not working correctly. every night shift for poor safety awareness, with a start date of 1/22/24 and discontinued 9/3/25.- Electronic Wander Bracelet: Apply electronic wander bracelet to the L ankle due to elopement risk exp [expiration] 3/22/27 every day shift until 03/19/2027 23:59 change the wanderguard, with an order date of 6/6/25 and discontinued 9/3/25. - CBC [complete blood count] with diff [differential], CMP [comprehensive metabolic panel] and UA&PCR [urinalysis and polymerase chain reaction test] one time only for Behaviors for 1 Day. with a start date of 7/7/25 and end date of 7/8/25. A review of Resident #1's care plan revealed the following:- COGNITION: [resident name] has impaired cognitive function/dementia or impaired thought processes r/t [related to] Impaired decision making Date Initiated: 08/01/2025 Revision on: 08/01/2025, with interventions to include, Report to Nurse any changes in cognitive function, specifically changes in: . memory . confusion . Date Initiated: 08/01/2025.- FALL: [resident name] is at Risk for falls or fall related injury because of: Deconditioning, hx [history] of falls Date Initiated: 01/21/2024 Revision on: 01/29/2024 . - ELOPEMENT RISK: [resident name] is at risk for elopement The resident has cognitive impairment and is independently mobile Date Initiated: 01/23/2024 Revision on: 01/29/2024., with a goal to include the following, [resident name] will not exit the facility without staff knowledge, or appropriate supervision Date Initiated: 01/23/2024 Revision on: 07/29/2025., and with interventions to include the following, . Apply electronic wander bracelet due to elopement risk Date Initiated: 02/09/2024 . Obtain an order for LOA with escort Date Initiated: 02/09/2024 . A review of Resident #1's progress notes revealed the following: - 2/8/24 social services note, SW [Social Worker] was made aware that [resident name] continues to ambulate throughout the facility and has been noted to go to the door and look out the glass. He continues to have a wander guard to ankle. He told SW that he wanted to be discharged to [address] where he was going to reside with his [family member]. SW contacted [family member] at [phone number] . SW was told that [address] was an address where [resident] resided at in [state] and that resident's [family member] had passed away in [year]. She further explained that resident did not have a home in [state] and has been staying at a homeless shelter prior to being admitted to the hospital and subsequently [facility name]. She further stated that when talking to her [family member] he has told her (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105327 If continuation sheet Page 9 of 31 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 09/11/2025 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few that he has been staying at a motel and that he was wanting to leave to go to the bar and was planning on returning to the motel. SW met with resident following this conversation and conducted a BIMS [Brief Interview for Mental Status] assessment which indicated that [resident name] score was at this time an 11. During conversation it was also determined that he thought that he was in [state] at this time and had forgotten he was now in [state]. He asked why he could not just walk out the facility and stated that he would make his way there. It was discussed that in order to discharge from the facility it would have to be a safe and appropriate discharge and walking out of facility with no predetermined location would not be safe.- 7/7/25 general progress note, Resident observed with behaviors of going to other residents rooms and followed staff easy to redirect by staff.PA [Physician Assistant] made aware. New order received for labs. POA [power of attorney] notified.- 7/9/25 general progress note CBC,CMP results reviewed by PA with no new order at this time.UA result reviewed resident start Bactrim. POA notified.- 7/26/25 change in condition (CIC) evaluation completed at 22:01, . The Change In Condition/s reported on this CIC Evaluation are/were: Behavioral symptoms (e.g. [example] agitation, psychosis) . Mental Status Evaluation: Increased confusion (e.g. disorientation) Other symptoms or signs of delirium (e.g. inability to pay attention, disorganized thinking) . Behavioral Status Evaluation: Other behavioral symptoms . Nursing observations, evaluation, and recommendations are: . wander guard in place and intact and functioning properly. B. New Testing Orders: - Blood Tests Urinalysis or culture . - 7/26/25 post event note, . The following event has occurred: Patient left facility without the proper sign out process . The resident is cognitively impaired, and evaluation of facial expression indicates there is no pain. - 7/27/25 general progress note, 1:1 [one to one] care s/p [status post] elopement continues, patient is cooperative with no signs or symptoms of distress.7/28/25 general progress note, Clarification: Unauthorized leave/behavior. - 7/28/25 psychotropic medication note, . Medication Type: . Antianxiety Targeted Behaviors: What behaviors is the resident demonstrating that warrants the use of the psychotropic medication(s)? . Wandering . Care Plan Update (Elopement Risk): FOCUS: Elopement Risk - Resident is at risk for elopement GOAL: The resident will not exit the facility without staff knowledge, or appropriate supervision INTERVENTION: Apply electronic wander bracelet due to elopement risk INTERVENTION: Verify the location of the electronic wander bracelet during routine care . - 8/8/25 psychiatry progress note, Date of Service: 2025-07-26 . The patient is seen today at the request of staff after he went outside, he stated that he took a walk and went to the hospital that is across the street from the facility. He was returned unharmed to the facility by law enforcement . he stated that he was just going out for a walk because he was going to a reunion with some friends. The patient has a BIMS of 12 and is doing well and shows no signs or symptoms of any abuse, neglect and no psychosocial distress or injuries noted. History of Present Illness: This patient was admitted to the facility on [DATE] due to encephalopathy with no known allergies. Patient has a medical history of anxiety, alcohol use . Medical necessity/Reason for encounter for today? S visit: . Reportable Incident . A review of Resident #1's evaluations revealed the following:- 2/9/24 elopement risk, A. Evaluation 1. Does the resident have a diagnosis of dementia, or is the resident cognitively impaired or confused AND Is the resident independently mobile either by ambulation or in a wheelchair? 1. Yes . 2. Does the resident exhibit any if the following elopement risk factors? (Select all that apply) . 5. Wandering . - 7/26/25 BIMS evaluation, . Score: 10 . Category: Moderate Impairment . - 7/26/25 elopement risk, A. Evaluation 1. Does the resident have a diagnosis of dementia, or is the resident cognitively impaired or confused AND Is the resident independently mobile either by ambulation or in a wheelchair? 1. Yes . 2. Does the resident exhibit any if the following elopement risk factors? (Select all that apply) . 3. Desires to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105327 If continuation sheet Page 10 of 31 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 09/11/2025 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few leave facility; verbalizes desires to leave facility such as I don't want to stay here, how do I get out of here, I'm looking for my [family member] etc. 5. Wandering . 10. Attempting to tailgate behind staff, visitors, and/or other residents . A review of the abuse/neglect log revealed Resident #1's elopement was not documented in July 2025. A review of the incident and accident report from 7/8/25 to 9/8/25 revealed Resident #1's elopement was not documented. On 9/8/25 at 9:17 a.m., an observation of Resident #1 revealed he was laying down in bed. Resident #1 did not have a wander monitoring device on. He said he has never tried to leave the facility and could not recall a time when he successfully did. Resident #1 stated, Staff don't let me leave. He stated if he tried to leave, Everyone in the world comes to get me. He said he recalled being in another room before. Resident #1 said he was not sure why there was a room change. He stated he walked around a lot. On 9/8/25 at 11:25 a.m., an interview was conducted with Staff F, Registered Nurse (RN) Supervisor. He confirmed he was the supervisor on duty when Resident #1 left the faciity on 7/26/25. He said a Certified Nursing Assistant (CNA), Staff G, opened the door for Resident #10 who had signed out on LOA. Staff F, RN Supervisor said Staff G, CNA did not see Resident #1 follow Resident #10 out the door. He said Resident #10 called him and said Resident #1 followed him outside. Staff F, RN Supervisor said Resident #10 called the facility approximately five minutes after leaving the facility. He said a code silver was called and a head count was completed in which they discovered Resident #1 was missing. He stated, Staff looked everywhere. Staff F, RN Supervisor said Resident #1 was found by the hospital and police brought him back to the facility. He said he thought the resident was out of the facility for approximately 30 minutes. Staff F, RN Supervisor said the wander exit alarm was functioning and he did not know who shut it off. He stated, It alarmed when the resident came back into the facility. He said Resident #1 told him he went to see if he could get a drink at the bar. Staff F, RN Supervisor said Resident #1 was put on 1 to 1 supervision after the event. He said Resident #1 is now in the memory care unit because they do not want to repeat what happened. He stated, We don't have the manpower to keep him on 1 to 1. Staff F, RN Supervisor said Resident #1 being in the memory care unit is safer and more appropriate. On 9/8/25 at 11:51 a.m., an interview was conducted with Resident #10. He said on 7/26/25 he was trying to leave the facility to take the bus and Resident #1 was by the front door. Resident #10 said he was signing out at the front desk when Resident #1 approached him about the door code. He said he told Resident #1 he did not know the code. He said he went to Staff G, CNA to ask him to open the door and also attempted to warn him about Resident #1 trying to exit. Resident #10 said Staff G, CNA opened the front door remotely from the unit, he heard the wander guard alarm go off and then went left towards the bus stop. He said he recalled three or four staff members who came out while he was waiting at the bus stop and then saw them return inside the facility. He said he never called the facility or saw where Resident #1 went. He stated, When I leave, I don't worry about what happens. Resident #10 stated when he returned from LOA, I got cornered by staff. He stated they asked him, Why did you let him [Resident #1] through. He said the police brought Resident #1 back to the facility. He said facility staff never asked him for a statement. Resident #10 stated, I never signed anything. On 9/8/25 at 3:30 p.m., an interview was conducted with the Nursing Home Administrator (NHA) and Director of Nursing (DON). The DON said Resident #1 exited the facility on 7/26/25 at 5:00 p.m. The DON said code silver was completed, and it was determined he was out of facility for two and a half to three hours. She said he was evaluated when he returned to the facility, and he was alert and oriented to person, place, time, and event (x4). The DON said she interviewed the resident when he returned, and he knew what he was doing as he told them he planned to go across the street to get a drink. The DON confirmed he had an electronic monitoring bracelet on when he left, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105327 If continuation sheet Page 11 of 31 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 09/11/2025 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and it was functioning. The DON said Resident #1 has had an electronic monitoring bracelet for as long as she's been at the facility. The NHA said the alarm did go off at that time he left, and confirmed staff did not respond to the alarm. She said the alarm was shut off and it was unclear who did it at that time. She said they were not sure if a staff member turned off the alarm. The NHA said they heard a resident had shut it off, not knowing how they would know the code. She stated there were no staff present by the front door where Resident #1 exited. The NHA said Staff G, CNA confirmed he opened the door for Resident #10 but said he did not hear the alarm. She said there are cameras on the unit and Staff G, CNA must have opened the door remotely and did not see Resident #1 leave. The DON said Resident #1's assigned nurse told the supervisor she had just seen him eating dinner, then he wasn't there. The DON said Resident #1 had no exit seeking behaviors. The NHA said the capability of remotely opening the front door was removed after Resident #1 exited the facility. She said currently staff have to walk to the front door to let residents out. The NHA stated they did not report this because, It was an unauthorized exit. He didn't ask to go out. She said Resident #1 did not follow the LOA process. The DON stated, He was alert and oriented, had a plan, able to navigate himself here. She said Resident #1 was already on his way to the facility and he brought himself back. The NHA and DON said they did not feel he was in harm's way. The NHA said the criteria did not make Resident #1 an elopement risk. On 9/9/25 at 1:31 p.m., a phone interview was conducted with Staff J, Physician Assistant (PA). He said Resident #1 had eloped. He said another resident let him out of the building, he was found by police and brought back to the facility. On 9/11/25 at 12:15 p.m., an interview was conducted with Staff I, CNA. She said Resident #1 was in the front/reception earlier in the day on 7/26/25. Staff I, CNA said he tried to leave through the front door earlier that day. She stated, We sent him back to nursing staff. She said she called the nurse to let them know he was exit-seeking. She said around the time residents are finished with dinner, the lobby is cleared, and no residents are present. She stated, I warned the nursing staff about him before I left. Staff I, CNA said she noticed his patterns had changed. She said he was usually with another resident walking around the facility, but around that time of the incident, he was wandering by himself. Staff I, CNA said she asked Resident #1 why he tried to leave and where he was going. She stated, He said he wanted to go get a few drinks across the street. Staff I, CNA said he seemed confused as he mentioned he wanted to go see his family member. She stated, I don't know if his [family member] was still alive and I asked social services about that. A review of the facility's policy titled, Abuse Prevention Program, dated November 2024, revealed the following: The facility has designated and implemented processes, which strive to reduce the risk of abuse, neglect, exploitation, mistreatment, and misappropriation of resident's property. These policies guide the identification, management, and reporting suspected, or alleged, abuse, neglect, mistreatment, and exploitation. It is expected that these policies will assist the facility with reducing the risk of abuse, neglect, exploitation, and misappropriation of resident's property through education of staff and residents, as well as early identification of staff burn out, or resident behavior which may increase the likelihood of such events. Neglect . Failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress . Alleged Violation . A situation or occurrence that is observed or reported by staff, resident, relative, visitor of others but has not yet been investigated, and if verified, could be noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property. The Administrator, DON, and/or designated individual are responsible for the investigation and reporting of suspected, or alleged, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105327 If continuation sheet Page 12 of 31 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 09/11/2025 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 0609 abuse, neglect, and exploitation and misappropriation. 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 13 of 31 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 09/11/2025 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 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure Advance Directives were honored and properly documented in the medical record for three residents (#2, #12, and #13) out of three residents reviewed for code status. Resident #2 received cardiopulmonary resuscitation (CPR), despite his preference to be a Do Not Resuscitate (DNR) code status, after he was found unresponsive by staff on [DATE]. Staff failed to inform the Emergency Response Team (EMT) of the DNR code status and CPR was begun at the facility and conducted during transport and care in the emergency room (ER). This failure created a situation that resulted in a worsened condition and the likelihood for serious injury or death to Residents #2 and resulted in the determination of Immediate Jeopardy on [DATE]. The findings of Immediate Jeopardy were determined to be removed on [DATE] and the severity and scope was reduced to an E.Findings included: 1)Review of the Emergency Medical Systems (EMS) run report for Resident #2, dated [DATE], showed:Dispatch to rehab facility for [Resident #2] reported to have pink fluid coming from his tracheostomy tube. Upon arrival facility staff were in the hallways and reported that the patient (pt) is not doing well and appeared visibly shaken. Staff were unable to provide a time of onset.Upon entering the room, the patient (pt) was found in a semi-Fowler's position in bed. He was responsive to pain the patient was on blow by humified oxygen. There were thick secretions coming from the pt's tracheostomy tube. Breathing was labored. Lung sounds revealed bilateral rhonchi. Rapid pulse was thready and regular. Skin was normal color, hot and dry. 50 milliliters (ml) of emesis was suctioned from the pt's tracheostomy. Vitals revealed hypoxia. A blood pressure was unable to be palpated or auscultated. The pt was moved on to the stretcher. Prior to moving the pt to the unit [ambulance] his breathing changed from labored to agonal and pulses were no longer present. Cardiopulmonary resuscitation (CPR) was initiated with pulseless electrical activity (PEA) noted as [unreadable]. The pt was moved to the unit.In the unit the pt had an additional 100 ml of emesis suctioned from his tracheostomy. The [NAME] device was used for continuous compressions. The tracheostomy tube (uncuffed) was removed and replaced with a 6.0 ET (endotracheal) tube. He was placed on the ventilator. At the next rhythm check the pt's rhythm was slow PEA that quickly became asystole. CPR was resumed. An Intraosseous Intravenous access (IO) was established and the pt was given 1 milligram (mg) of Epinephrine.Enroute to the hospital CPR was continued with no changes in rhythm. A blood glucose level of 138 milligrams (mg)/deciliter (dL) was obtained. The pt was given 1 mg of epinephrine prior to transferring the pt inside the ED.At the hospital pt care was transferred to the nurse where CPR continued. Review of Resident #2's hospital record, dated [DATE], showed: History of Present Illness (HPI)[Age and gender] with history of anoxic brain injury from prior stroke, tracheal tube, PEG (percutaneous endoscopic gastrostomy) tube, BIBEMS (brought in by emergency medical service) after being found pulseless at this facility. Upon EMS arrival they found him/her in PEA with pink frothy sputum coming out of his/her tracheal tube, they switched out for endotracheal tube. Patient has some point was found to be asystole. Compression were continued until he arrived to the emergency department. He received several rounds of epinephrine and was coded for 30 minutes prior to arrival and transfer to emergency department care. Patient presented from local nursing facility as a pre-hospital cardiac arrest. Report from medics was that they were called because the patient was hypoxic and having significant drainage from his trach. When they arrived, the patient was saturating [oxygen saturation] in the 70s, They said that they suctioned the trach and were getting significant output. They report that it was pink and thick in color. Because of the amount of suctioning they were having to do they were concerned that the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105327 If continuation sheet Page 14 of 31 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 09/11/2025 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 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some trach may have been clogged. Shortly after their arrival the patient went to a cardiac arrest, PEA was the initial rhythm. ACLS (Advanced Cardiac Life Support) protocol was followed. They opted to remove the trach, place a 6-0 endotracheal Lube within the Tracheostomy and then bag the patient. They were able to get improvement in his oxygenation to the 90s with bagging the patient but patient remained between PEA and asystole on pulse checks during transport. ACLS have been ongoing for least 30 minutes on patient arrival. Paramedics report that the patient's blood sugar was in the 130s. He had received 2 rounds of epinephrine prior to arrival. Patient arrived here with a [NAME] device providing chest compressions. Endotracheal tube was within the tracheostomy, and the patient had equal bilateral breath sounds. Additional intraosseous access was obtained and ACLS was continued. He received additional doses of epinephrine including a dirty epi drip and Levophed infusion. He also received bicarb, calcium and magnesium. We did obtain ROSC (return of spontaneous circulation) twice however each was brief. Labs were pulled from the I0 and did not result until after the patient had expired. During the code possible causes of asystole were reviewed, including hypoxia (100% oxygen via endotracheal tube through trach w equal bilateral breath sounds), hypothermia, hypo/hyperkalemia, hypomagnesemia, hydrogen ion acidosis (calcium given for membrane stabilization, sodium bicarb given for acidemia), hypovolemia (IV fluids running). Trauma (none reported, no evidence of on physical exam), toxins (no history), tension pneumothorax (bilateral breath sounds present), cardiac tamponade (no pericardial effusion noted on ultrasound), acute myocardial infarction and pulmonary embolism. Cannot rule our acute myocardial infarction or pulmonary embolus as causes in this patient's course and they may likely provide most reasonable etiology. Despite our efforts patient unfortunately expired, Patient had no spontaneous respirations, heart sounds, response to any stimulus including noxious stimuli. Patient's pupils were fixed and dilated at 8 mm and with no response to light, no corneal reflexes, no gag reflex, and no oculocephalic reflex. Patient was pronounced at 11:26 AM.Prior to the patient's arrival to the emergency department, we were given a heads-up radio call by EMS. I met with my nursing staff and discussed the radio call information with them. I assigned positions and rolls for the cardiac arrest. I instructed them that we will be using closed loop communication.Upon patient arrival via EMS, the patient was moved to trauma bay for initial examination and resuscitation as per ACLS guidelines. Patient was transferred to ER stretcher where patient was immediately placed on cardiac monitor/defibrillator, 02 sat, ET C02 (end tidal carbon dioxide) waveform (the breath-to-breath concentration of carbon dioxide in exhaled air) capnography , and assessed by nursing staff while simultaneously attempting to place two large bore IV lines. Patient arrived on an auto pulse device, and with an endotracheal tube inStat respiratory therapist was paged prior to patient arrival.Patient is in active cardiac arrest and patient's endotracheal tube was suctioned, easily bagged, with bilateral breath sounds. patient has symmetrical chest expansion, no chest crepitus, bilateral breath sounds, and color capnography changes indicating intubation.Continues waveform capnography is continued. Glucose within normal limits. At 1st pulse check at 10:47 a.m. patient was found to be asystole, chest compressions were resumed, and IO was inserted into the left tibia due to difficulty establishing further IV access. Epi was given every 4 minutes with pull check every 2 minutes. Patient was given calcium bicarbonate and magnesium. On all subsequent pulse checks patient was found to be in pulseless electrical activity. At 11:00 a.m. ROSC was achieved, patient started on no epi drip. At 11:07 a.m. patient was found to be in asystole again; epinephrine was given and ACLS was resumed. After multiple rounds of pulseless electrical activity ROSC was achieved at 11:13 a.m. Patient again went into pulseless electrical activity at 11:22 a.m., The ETC02 has remained at < 10 mmHg, patient expired at 11:26 p.m.Review of admission Records showed Resident #2 was admitted on [DATE] (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105327 If continuation sheet Page 15 of 31 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 09/11/2025 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 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some and re-admitted on [DATE] with diagnoses including anoxic brain damage, persistent vegetative state, seizures, acute and chronic respiratory failure, tracheostomy status, gastrostomy status, and cardiac arrest due to underlying conditionsReview of Resident #2's physician orders showed:-Do Not Resuscitate (DNR) Start: [DATE].-Full Resuscitation Discontinued: [DATE] Start: [DATE]Review of Resident #2 Medical Certification for Medicaid Long-Term Care and Services and Patient Transfer Form (AHCA 5000-3008) from hospital discharge, dated [DATE], showed the resident had a Do Not Resuscitate order. Section H, Advanced Care Planning, listed the following:-Advanced Directives- indicated No with a checkmark-Living Will- indicated No with a checkmark-DO NOT Resuscitate (DNR)- indicated Yes with an X and No with a checkmark. The Yes was also circled and there was a line from the circle across the No and error written beside it.-DO NOT Intubate- indicated No with a checkmark-DO NOT Hospitalize- indicated No with a checkmark-No Artificial Feeding- indicated No with a checkmark-Hospice- indicated No with a checkmarkReview of Resident #2's medical record did not reveal a signed DNR Form DH1896.Review of Florida Statutes Chapter 401, Medical Telecommunications and transportation, section 401.45 (3)(a) regarding DNR Form DH1896 showed:Resuscitation may be withheld or withdrawn from a patient by an emergency medical technician or paramedic if evidence of an order not to resuscitate by the patient's physician or physician assistant is presented to the emergency medical technician or paramedic. An order not to resuscitate, to be valid, must be on the form adopted by rule of the department. The form must be signed by the patient's physician or physician assistant and by the patient or, if the patient is incapacitated, the patient's health care surrogate or proxy as provided in chapter 765, court-appointed guardian as provided in chapter 744, or attorney in fact under a durable power of attorney as provided in chapter 709. The court-appointed guardian or attorney in fact must have been delegated authority to make health care decisions on behalf of the patient.https://www.leg.state.fl.us/statutes/index.cfm?App_mode=Display_Statute&URL=0400-0499/0401/Sections/0401.45 Accessed on [DATE])An interview was conducted on [DATE] at 2:34 p.m. with Staff N, Registered Nurse (RN)/Unit Manager (UM) Staff N said when Resident #2 returned from the hospital in [DATE] he completed the admission process. Staff N said Resident #2 was discussed in the morning meeting prior to returning and it was mentioned the resident would be returning to the facility with a DNR status. Staff N said when the resident returned the AHCA 5000-3008 showed the resident was now a DNR. Staff N said he called the provider and received a verbal order for DNR. Staff N said then social services should have called to verify the family approved of the DNR status and the correct power of attorney (POA) or healthcare proxy (HCP) is in place. Staff N said after social services confirms the information, they initiate the DNR Form DH1896 from and get it signed by the resident or resident representative and the provider. Staff N said once the DNR Form DH1896 was completed and signed it was placed in front of the resident hard chart. Staff N said when there is a code called for a resident the first thing staff grab is the resident's hard chart. He said the nurse can double check code status in the computer but the one that matters to us is the chart. Staff N said if a resident with a DNR went out to the hospital the nurse or UM gave a copy of the signed DNR Form DH1896 to EMS as well as letting them know during report the resident had a code status of DNR. Staff N reviewed Resident #2's AHCA 5000-3008 from [DATE]. Staff N said looked at Section H, Advanced Care Planning, and said it was interpreted as DNR initially being marked as No and error was written beside that. He said then Yes was marked indicating the resident was DNR. Staff N said a signed DNR Form DH1896 not come with Resident #2 was from the hospital and he didn't remember a completed, signed DNR Form DH1896 from ever being returned to the unit to be placed in the resident's hard chart. Staff N said the process was that when a patient returned from the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105327 If continuation sheet Page 16 of 31 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 09/11/2025 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 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some hospital their chart was brought to the morning clinical meeting and it was reviewed by staff including nursing and social services. Staff N said resident's code status was discussed and social services would then procced with getting the paperwork completed. Staff N said he was working the day Resident #2 went out and Staff Q, RN/UM asked me to see the resident. Staff N said Resident #2 was not looking good and 911 was called. Staff N said he was at the nurses' station completing paperwork and he was not aware of what happened while EMS was in the facility. Review of video footage from the facility's front entrance, dated [DATE], showed two paramedics pushing a stretcher carrying Resident #2. One paramedic was pulling the stretcher from the front. The second paramedic was walking alongside the stretcher with one hand on the center of Resident #2 chest doing one handed chest compressions while moving the patient from the facility to the ambulance outside the front door of the facility. An interview was conducted on [DATE] at 12:38 p.m. with Staff M, Registered Nurse (RN). Staff M said he was the nurse for Resident #2 the day the resident went out to the hospital. Staff M said the resident's vital signs were out of whack and the resident was not doing well. Staff M said 911 was called and Emergency Medical Services (EMS) came and took the resident. Staff M said Resident #2 was a DNR but he doesn't recall if the facility had the DNR Form DH1896 or if the paramedics were told. Staff M said normally the yellow DNR paper is in front of the resident's hard chart, often more than one copy. He said one copy would be sent with EMS if a resident with a DNR order was sent out and if there weren't two copies in the chart, a copy would be made for EMS. Staff M said if a resident wanted to change their code status to DNR the provider would give the order, and they would sign the DNR Form DH1896 because they were in the building all the time. A follow-up interview on [DATE] at 1:34 p.m. with Staff M, RN. He said they did not visualize them [EMS] doing CPR. Staff M said when EMS arrived the resident was still alive, he gave report and backed up and the resident was put on a stretcher. Staff M said he knew the resident was a DNR but the Staff Q, RN/Unit Manager (UM) got the paperwork together. An interview was conducted on [DATE] at 12:57 p.m. with Staff Q, RN/UM. Staff Q said on [DATE] Resident #2's rate was elevated; the resident was suctioned the provider was called. Staff Q said Resident #2's heart rate continued to go higher, and the Dr said to send the resident to the hospital, therefore, 911 was called. Staff Q said paramedics came and not to my knowledge did they do CPR. Staff Q said he knew Resident #2 was a DNR but don't believe we had that [signed DNR Form DH1896]. Staff Q said the paperwork he gave the paramedic was the bed hold, AHCA form, medication list, orders, and face sheet. Staff Q said Resident #2 had gone out to the hospital in July and when the resident returned, he was a DNR. Staff Q said he did not know why the signed DNR Form DH1896 was not in the resident's chart and maybe it had still been in the process of being signed. An interview was conducted on [DATE] at 3:51 p.m. with the Risk Manager. The Risk Manager said Staff M, RN was doing rounds on [DATE] and found Resident #2 to be tachycardic (fast heart rate) and diaphoretic (excessive sweating). She said the doctor was notified and 911 was called to send the resident out. The Risk Manager said EMS was provided with a copy of the doctor's order, but the facility did not have the signed DNR Form DH1896. She said there was a breakdown in the process which is why they did not have the signed DNR Form DH1896. The Risk Manager said when a resident wanted to change from full code status to not resuscitate the order is printed, signed and placed in front of the resident's hard chart. She said the full code paperwork that would have previously been in the hard chart was removed to avoid confusion. She said the DNR Form DH1896 was completed, signed, then put in front of the chart also. The Risk Manager said the signed DNR Form DH1896 was given to EMS if a resident with DNR status goes to the hospital. She confirmed if EMS did not have the signed DNR Form DH1896 they do a full code on the resident. The Risk Manager said the reason there was a problem with Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105327 If continuation sheet Page 17 of 31 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 09/11/2025 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 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some #2 was social services and the unit manager had the change of code status on their morning meeting homework sheets when the resident was readmitted to the facility, but the paperwork did not get completed that day and it was never transcribed to the next day's morning meeting homework sheet. An interview was conducted on [DATE] at 2:20 p.m. with Staff L, Social Services (SS). Staff L said if a resident wanted to have a DNR code status social services would have had them sign the DNR Form DH1896, if they are their own responsible party. Staff L said if the resident was unable to sign the social services would have called the resident's power or attorney and have them sign the paperwork, either by coming in, by email, by fax, or whatever needed to be done to get the DNR Form DH1896 form signed immediately. Staff L said Resident #2 returned to the facility in [DATE] with a new code status of DNR. Staff L said social services should have reached out to the family to verify the DNR status and get the paperwork completed. Staff L said I don't know that they did reach out to Resident #2's family to verify the code status and get the DNR Form DH1896 signed. When asked if Staff L saw a completed, sign DNR Form DH1896 for Resident #2, she stated, Correct to my knowledge I have never seen one. Staff L said she could not speak for nursing, but she did not reach out to Resident #2's family to confirm DNR status or get the paperwork completed. Staff L said after Resident #2 left the facility she heard about the facility not having Resident #2's signed DNR Form DH1896 for EMS and CPR being done on the resident. An interview was conducted on [DATE] at 1:25 p.m. with Staff J, Physician Assistant (PA). Staff J said he was called on [DATE] about Resident #2 being in distress and being sent to the hospital. Staff J said there had been several discussions with Resident #2's family about code status and possible hospice prior to going out to the hospital in [DATE]. Staff J said Resident #2 went out with a full code status and returned to the facility on [DATE] with a DNR code status. He said they were told the family made the decision to change the code status while the resident was in the hospital. Staff J said typically when a resident changed to a DNR status the nurse would have given him/her the DNR Form DH1896 to sign. Staff J said he routinely signed the DNR Form DH1896 forms but had not signed one for Resident #2. Staff J said he was told on [DATE] Resident #2 was being evaluated by EMS and lost a heart rate, and EMS started a code while in the facility. 2)Review of admission Records showed Resident #12 was admitted to the facility on [DATE] with diagnoses including wedge compression fracture of T5-T6 vertebra, encephalopathy, muscle wasting and atrophy and protein calorie malnutrition.Review of Resident #12's provider orders showed: -Full Resuscitation Start: [DATE]. Discontinued [DATE]-Do Not Resuscitate Start: [DATE]. Review of Resident #12's medical record revealed a printed and signed order for Full Code on the first page. The second page of the hard chart revealed a completed, signed DNR Form DH1896, dated [DATE]. An interview was conducted on [DATE] at 4:39 p.m. with Staff R, RN. Staff R said when a code was called staff pulled the residents chart to look for code status. Staff R was observed looking at Resident #12's hard chart. Staff R opened the chart and said, [Resident #12] is a full code. The front page was then flipped over and Staff R said, [Resident #12] has a signed DNR? Staff R said, it shouldn't be like that 3) Review of admission Records showed Resident #13 was admitted on [DATE] with diagnoses including altered mental status and urinary tract infection. Review of Resident #13's admission Assessment showed the resident was oriented to person, place, time and situation. Review of Resident #13's provider orders showed: -Do Not Resuscitate Start [DATE]. Review of Resident #13's medical record revealed a DNR Form DH1896 from signed by the provider, however, it had not been signed by the resident/resident representative. The resident's provider signed the form on [DATE]. An interview was conducted on [DATE] at 4:32 p.m. with the Risk Manager, Director of Nursing (DON) and Nursing Home Administrator (NHA). The Risk Manager said when she watched the facility video of EMS leaving with Resident #2 she did not feel (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105327 If continuation sheet Page 18 of 31 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 09/11/2025 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 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some like the paramedics were doing compressions. She said the paramedic's hand was on the resident's chest, but she did not feel like what the paramedic was doing was compressions. The DON said the facility should have had the completed, signed DNR Form DH1896, but the facility staff did not do CPR on Resident #2. The DON said they went by the [DATE] AHCA 5000-3008 to see that Resident #2 was a DNR status. She said, this is like our physician order form. The DON said they did not get any other information or DNR paperwork from the hospital, they just went by the AHCA 5000-3008 The DON said social services tried to call the family but did not get a response. She confirmed there was no documentation social services had reached out to the family to confirm Resident #2's updated code status. The NHA said Staff J, PA would have been the provider to sign the DNR Form DH1896 for Resident #2. The Risk Manager and DON reviewed the medical record of Resident #12. When the front of the chart was opened the DON said Resident #12 was a full code she then flipped the page and confirmed there was a signed DNR for the resident. The DON and Risk Manager said the hard chart should not have both a full code order and signed DNR order in the chart and confirmed it would lead to confusion. Upon review of the resident's medical record, they confirmed Resident #12 did have a DNR order and stated the full code order should have been removed from the hard chart when the resident changed their code status to DNR. The DON and Risk Manager reviewed Resident #13's DNR Form DH1896 and confirmed it was not signed by the resident. They both agreed the DNR form would not be valid since it was not signed. The DON said Resident #13 is her own responsible party and should have been asked to sign the DNR Form DH1896 upon admission.Review of a facility policy titled CPR Code Status Orders & Response, updated February 2023, revealed the following:Policy: The facility provides Basic Life Support (BLS) CPR only. The physician's order for full code or Do Not Resuscitate is written based on the wishes of the resident/resident representative. Advanced Directives will be honored.Do Not Resuscitate (DNR) ORDER: Cardiopulmonary resuscitation will not be initiated in the absence of pulse or respirations.In the absence of Advanced Directives or physician orders, the resident will be considered a Full Code status, unless the resident and/or resident representative verbalizes wishes on admission assessment to change to withhold CPR.Code status orders and wishes will be reviewed on admission, quarterly, PRN and with significant change of condition by the Interdisciplinary team.Code status orders will be renewed by physician's review and signature on monthly orders. Code status physician's order (DNR or Full Code), state specific forms and/or resident preference documentation will be filed as the first item within the medical record.Social Services will be notified if resident has any general questions and concerns about advance directives.The facility does not provide Advanced Life Support.ON ADMISSIONStaff will verify the presence of Advance Directive documents and confirm resident or resident representative wishes with regard to CPR. The resident will be considered full code unless the resident/representative wishes to change their decision.1. Obtain Advance Directive decision making documents at the time of admission. If not available at time of admission, request the resident representative to bring copies to the facility as soon as possible.2. Discuss code status preference with the resident/resident representative.3. Document resident/resident representative preferences in the medical record. If the resident's wishes are different than the admission orders, or if the orders do not address the code status, and the resident does not want to receive CPR, staff will document resident's wishes in the record and contact the physician to obtain the order.4. Notify physician if the resident/resident representative preference is changed, obtain order. In the event that the physician is not available the medical director may be contacted for the order.5. While awaiting the physician's order to withhold CPR, facility staff should document discussions with the resident or resident representative, including the resident's wishes to refuse CPR. If the resident or resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105327 If continuation sheet Page 19 of 31 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 09/11/2025 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 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete representative verbalizes the wish not to receive CPR two staff members will witness and document this request, the conversation of the request will be printed and placed as the first document of the medical record.a. While the physician's order is pending, staff will honor the documented verbal wishes of the resident or the resident's representative, regarding CPR.Changing code status/while awaiting physician's order:The resident and/or resident representative may change the code status at any time. The staff must notify the MD, describe the requested change and request an order for the DNR or Full Code status to execute the change.The resident wishes will be communicated verbally shift to shift, both witnesses must document conversation in the in the medical record, print and placed as the first document of the medical record.The facility's immediate actions to remove the Immediate Jeopardy included: -On [DATE] a house wide audit was completed verifying advanced directives and two identified variances were corrected. One code status was updated in the medical record, and it is clear to staff of the resident wishes and one next of kin validated the resident's advance directives with a signature on [DATE].-Regional Nurse Consultant provided education to 100% of the clinical management team related to Advanced Directives on [DATE].-Licensed Nurses were educated by the Director of Nursing and the facility clinical administration team related to Advanced Directives, reviewing AD/CS orders, process for completing a DNR order and honoring a resident choice, code blue process and placement of code status in resident hard chart at 97% by [DATE].-The Regional [NAME] President completed the Essential Core Functions: Resident care and Quality of Life, Human Resources, Physical Environment and Atmosphere and Leadership and Management with the Nursing Home Administrator on [DATE].-The Director of Risk Management completed the Essential Core Functions: Resident Care and Quality of Life, Human Resources, Physical Environment and Atmosphere and Leadership and Management with the Director of Nursing on [DATE].-Code Blue drills started on [DATE] and completed on [DATE] each shift.-ADHOC Quality Assurance meeting was conducted today [DATE] to review the removal plan including the medical director.Verification of the facility's removal plan was conducted by the survey team on [DATE].- Interviews were conducted with forty-three nurses and CNAs who worked various shifts, the Director of Nursing, the Assistant Director of Nursing, the Nursing Home Administrator, and the Social Services team. The staff members were able to state that they had been trained and were knowledgeable about the new policies and procedures initiated by the facility.- A review of in-service documentation revealed 100% of staff had acknowledged education and training related to procedures for residents' code status, code drills, and advanced directives process. Based on verification of the facility's Immediate Jeopardy removal plan the immediate jeopardy was determined to be removed on [DATE] and the non-compliance was reduced to a scope and severity of E. Event ID: Facility ID: 105327 If continuation sheet Page 20 of 31 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 09/11/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide supervision to prevent elopement for one resident (#1) out of four residents reviewed for elopement risk. On 7/26/25 Resident #1 exited the facility at 6:30 p.m., unnoticed by staff. Resident #1 was mildly impaired, confused, and had an electronic monitoring device in place. Resident #1 followed another resident out the door which was remotely opened by staff. The door alarm was disabled by a resident who was aware of the code after Resident #1 triggered the alarm upon exit. Resident #1 walked approximately 0.2 miles to a hospital near the facility and was returned with assistance of law enforcement to the facility at 9:00 p.m. This failure created a situation that resulted in a worsened condition and the likelihood for serious injury and or death to Resident #1 and resulted in the determination of Immediate Jeopardy on 9/10/2025. The findings of Immediate Jeopardy were determined to be removed on 9/11/2025 and the severity and scope was reduced to a D after verification of removal of immediacy of harm.Findings included: A review of Resident #1's admission record revealed an admission date of 1/19/24 with diagnoses to include encephalopathy, unspecified, generalized anxiety disorder, mild cognitive impairment of uncertain or unknown etiology, syncope and collapse, and alcohol use, unspecified. A review of Resident #1‘s quarterly Minimum Data Set (MDS), dated [DATE], under section C-Cognitive Patterns, revealed a Brief Interview for Mental Status (BIMS) score of 12, indicating moderately impaired cognition. Section GG - Functional Abilities, revealed the resident used a walker for mobility and ambulated independently. Section P, Restraints and Alarms, revealed a wander/elopement alarm was used daily. A review of Resident #1's quarterly MDS, dated [DATE], revealed the same information was marked in sections C, GG, and P as in the assessment date of 7/26/25. A review of Resident #1's order summary report, to include completed and discontinued orders, revealed the following:- LOA [leave of absence] with escort for impaired cognition/elopement risk, with an order date of 1/29/24.- Electronic Wander Bracelet: Apply electronic wander bracelet to the L [left] ankle due to elopement risk, with a start date of 1/22/24 and discontinued 6/6/25.- Electronic Wander Bracelet: Check function with the transponder daily on night shift. Replace electronic wander bracelet if not working correctly. every night shift for poor safety awareness, with a start date of 1/22/24 and discontinued 9/3/25.Electronic Wander Bracelet: Apply electronic wander bracelet to the L ankle due to elopement risk exp [expiration] 3/22/27 every day shift until 03/19/2027 23:59 change the wanderguard, with an order date of 6/6/25 and discontinued 9/3/25. - CBC [complete blood count] with diff [differential], CMP [comprehensive metabolic panel] and UA&PCR [urinalysis and polymerase chain reaction test] one time only for Behaviors for 1 Day. with a start date of 7/7/25 and end date of 7/8/25. A review of Resident #1's care plan revealed the following:- COGNITION: [resident name] has impaired cognitive function/dementia or impaired thought processes r/t [related to] Impaired decision making Date Initiated: 08/01/2025 Revision on: 08/01/2025, with interventions to include, Report to Nurse any changes in cognitive function, specifically changes in: . memory . confusion . Date Initiated: 08/01/2025.- FALL: [resident name] is at Risk for falls or fall related injury because of: Deconditioning, hx [history] of falls Date Initiated: 01/21/2024 Revision on: 01/29/2024 . ELOPEMENT RISK: [NAME] is at risk for elopement The resident has cognitive impairment and is independently mobile Date Initiated: 01/23/2024 Revision on: 01/29/2024., with a goal to include the following, [resident name] will not exit the facility without staff knowledge, or appropriate supervision Date Initiated: 01/23/2024 Revision on: 07/29/2025., and with interventions to include the following, . Apply electronic wander bracelet due to elopement risk Date Initiated: 02/09/2024 . Obtain an order for LOA with escort Date (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105327 If continuation sheet Page 21 of 31 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 09/11/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Initiated: 02/09/2024 . A review of Resident #1's progress notes revealed the following: - 2/8/24 social services note, SW [Social Worker] was made aware that [resident name] continues to ambulate throughout the facility and has been noted to go to the door and look out the glass. He continues to have a wander guard to ankle. He told SW that he wanted to be discharged to [address] where he was going to reside with his [family member]. SW contacted [family member] at [phone number] . SW was told that [address] was an address where [resident] resided at in [state] and that resident's [family member] had passed away in [year]. She further explained that resident did not have a home in [state] and has been staying at a homeless shelter prior to being admitted to the hospital and subsequently [facility name]. She further stated that when talking to her [family member] he has told her that he has been staying at a motel and that he was wanting to leave to go to the bar and was planning on returning to the motel. SW met with resident following this conversation and conducted a BIMS [Brief Interview for Mental Status] assessment which indicated that [resident name] score was at this time an 11. During conversation it was also determined that he thought that he was in [state] at this time and had forgotten he was now in [state]. He asked why he could not just walk out the facility and stated that he would make his way there. It was discussed that in order to discharge from the facility it would have to be a safe and appropriate discharge and walking out of facility with no predetermined location would not be safe.- 7/7/25 general progress note, Resident observed with behaviors of going to other residents rooms and followed staff easy to redirect by staff.PA [Physician Assistant] made aware. New order received for labs. POA [power of attorney] notified.- 7/9/25 general progress note CBC,CMP results reviewed by PA with no new order at this time.UA result reviewed resident start Bactrim. POA notified.- 7/26/25 change in condition (CIC) evaluation completed at 22:01, . The Change In Condition/s reported on this CIC Evaluation are/were: Behavioral symptoms (e.g. [example] agitation, psychosis) . Mental Status Evaluation: Increased confusion(e.g. disorientation) Other symptoms or signs of delirium (e.g. inability to pay attention, disorganized thinking) . Behavioral Status Evaluation: Other behavioral symptoms . Nursing observations, evaluation, and recommendations are: . wander guard in place and intact and functioning properly. B. New Testing Orders: - Blood Tests Urinalysis or culture . 7/26/25 post event note, . The following event has occurred: Patient left facility without the proper sign out process . The resident is cognitively impaired, and evaluation of facial expression indicates there is no pain. - 7/27/25 general progress note, 1:1 [one to one] care s/p [status post] elopement continues, patient is cooperative with no signs or symptoms of distress.- 7/28/25 general progress note, Clarification: Unauthorized leave/behavior. - 7/28/25 psychotropic medication note, . Medication Type: . Antianxiety Targeted Behaviors: What behaviors is the resident demonstrating that warrants the use of the psychotropic medication(s)? . Wandering . Care Plan Update (Elopement Risk): FOCUS: Elopement Risk - Resident is at risk for elopement GOAL: The resident will not exit the facility without staff knowledge, or appropriate supervision INTERVENTION: Apply electronic wander bracelet due to elopement risk INTERVENTION: Verify the location of the electronic wander bracelet during routine care . - 8/8/25 psychiatry progress note, Date of Service: 2025-07-26 . The patient is seen today at the request of staff after he went outside, he stated that he took a walk and went to the hospital that is across the street from the facility. He was returned unharmed to the facility by law enforcement . he stated that he was just going out for a walk because he was going to a reunion with some friends. The patient has a BIMS of 12 and is doing well and shows no signs or symptoms of any abuse, neglect and no psychosocial distress or injuries noted. History of Present Illness: This patient was admitted to the facility on [DATE] due to encephalopathy with no known allergies. Patient has a medical history of anxiety, alcohol use . Medical necessity/Reason (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105327 If continuation sheet Page 22 of 31 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 09/11/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few for encounter for today? S visit: . Reportable Incident .- 9/3/25 social services note, Spoke with [resident name] on this date about moving back to the memory care unit per care plan team, due to his prior attempt to leave building. I also spoke with his [family member], on this date to inform her of the move and she agreed but is worried that he won't have as much area to walk around. I let her know that we would monitor how he does in MC [memory care] and let her know if we notice any changes. A review of Resident #1's physician's notes revealed the following: - 5/29/25, . Chief Complaints: 1. Monthly medical visit-s mild dementia . Interim History: [age of resident] male, with medical history including ETOH [alcohol] abuse, previous episodes of syncope . General Examination: . MENTAL STATUS: alert and oriented 2- 3 - some confusion and disorientation. NEUROLOGIC: cognitive deficits noted at admission - likely chronic encephalopathy secondary to EtOH . Plan: . 4. Generalized anxiety disorder . Clinical Notes: May 29thpatient is seen ambulating throughout the facility. He was friendly, outgoing and show no signs of anxiety. He is followed monthly by Psychiatry. April 21st- . He was last seen by psych on March 31st, with their documentation indicating that he reported to them that he does not like being here but is coping well on his own without medications. -7/9/25, . Chief Complaints: 1. Altered mental status - confusion . HPI: . seen today for follow-up after nursing had reported a significant change in mental status and requested UA to rule out organic cause for his confusion. Urinalysis consistent with UTI [urinary tract infection]. Examination: . MENTAL STATUS: alert and oriented 2-3- some confusion and disorientation. Plan: . 1. Urinary tract infection, site not specified . Clinical Notes: July 9th - urinalysis consistent with urinary tract infection. Patient seen today and does appear mildly more confused. Nursing reports patient had been wandering into other patient's rooms and had been very confused when attempts were made to redirect . 2. Muscle wasting and atrophy, not elsewhere classified, multiple sites . July 9th - . does appear to be more confused and uncertain as to where his room in his - patient does not have any confusion at baseline .- 7/29/25, .HPI: . seen today for follow-up on labs that were ordered due to concern for AMS [altered mental status] after recent elopement. Examination: . MENTAL STATUS: alert and oriented 2- 3 - some confusion and disorientation. Plan: Treatment: 1. Altered mental status, unspecified Clinical Notes: July 29th- labs reviewed. No leukocytosis, electrolyte imbalance, anemia, acute kidney injury or urinary tract infection . His previous urinary tract infection showed strong case for a urinary tract infection, but PCR was negative. Patient did receive full 7 days of Bactrim at that time. July 28th- patient appears to be very close to baseline level of cognition. Recent elopement - He does present with mild increase in anxiety and possibly increased confusion . A review of Resident #1's psychiatry notes revealed the following:- 3/31/25, HPI [history of present illness] General: . Past psych [psychiatric] history includes alcohol use, tobacco use, GAD [generalized anxiety disorder], cognitive impairment. The patient reports that he does not like being at the facility. He reports he does have some anxiety and depression feelings due to being at the facility, but he is coping well on his own. A review of Resident #1's evaluations revealed the following:- 2/9/24 elopement risk, A. Evaluation 1. Does the resident have a diagnosis of dementia, or is the resident cognitively impaired or confused AND Is the resident independently mobile either by ambulation or in a wheelchair? 1. Yes . 2. Does the resident exhibit any if the following elopement risk factors? (Select all that apply) . 5. Wandering . 7/26/25 BIMS evaluation, . Score: 10 . Category: Moderate Impairment . - 7/26/25 elopement risk, A. Evaluation 1. Does the resident have a diagnosis of dementia, or is the resident cognitively impaired or confused AND Is the resident independently mobile either by ambulation or in a wheelchair? 1. Yes . 2. Does the resident exhibit any if the following elopement risk factors? (Select all that apply) . 3. Desires to leave facility; verbalizes desires to leave facility such as I (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105327 If continuation sheet Page 23 of 31 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 09/11/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few don't want to stay here, how do I get out of here, I'm looking for my [family member] etc. 5. Wandering . 10. Attempting to tailgate behind staff, visitors, and/or other residents . A review of the abuse/neglect log revealed Resident #1's elopement was not documented in July 2025. A review of the incident and accident report from 7/8/25 to 9/8/25 revealed Resident #1's elopement was not documented. On 9/8/25 at 9:17 a.m., an observation of Resident #1 revealed he was laying down in bed. Resident #1 did not have a wander monitoring device on. He said he has never tried to leave the facility and could not recall a time when he successfully did. Resident #1 stated, Staff don't let me leave. He stated if he tried to leave, Everyone in the world comes to get me. He said he recalled being in another room before. Resident #1 said he was not sure why there was a room change. He stated he walked around a lot. On 9/8/25 at 11:25 a.m., an interview was conducted with Staff F, Registered Nurse (RN) Supervisor. He confirmed he was the supervisor on duty when Resident #1 left the faciity on 7/26/25. He said a Certified Nursing Assistant (CNA), Staff G, opened the door for Resident #10 who had signed out on LOA. Staff F, RN Supervisor said Staff G, CNA did not see Resident #1 follow Resident #10 out the door. He said Resident #10 called him and said Resident #1 followed him outside. Staff F, RN Supervisor said Resident #10 called the facility approximately five minutes after leaving the facility. He said a code silver was called and a head count was completed in which they discovered Resident #1 was missing. He stated, Staff looked everywhere. Staff F, RN Supervisor said Resident #1 was found by the hospital and police brought him back to the facility. He said he thought the resident was out of the facility for approximately 30 minutes. Staff F, RN Supervisor said the wander exit alarm was functioning and he did not know who shut it off. He stated, It alarmed when the resident came back into the facility. He said Resident #1 told him he went to see if he could get a drink at the bar. Staff F, RN Supervisor said Resident #1 was put on 1 to 1 supervision after the event. He said Resident #1 is now in the memory care unit because they do not want to repeat what happened. He stated, We don't have the manpower to keep him on 1 to 1. Staff F, RN Supervisor said Resident #1 being in the memory care unit is safer and more appropriate. On 9/8/25 at 11:51 a.m., an interview was conducted with Resident #10. He said on 7/26/25 he was trying to leave the facility to take the bus and Resident #1 was by the front door. Resident #10 said he was signing out at the front desk when Resident #1 approached him about the door code. He said he told Resident #1 he did not know the code. He said he went to Staff G, CNA to ask him to open the door and also attempted to warn him about Resident #1 trying to exit. Resident #10 said Staff G, CNA opened the front door remotely from the unit, he heard the wander guard alarm go off and then went left towards the bus stop. He said he recalled three or four staff members who came out while he was waiting at the bus stop and then saw them return inside the facility. He said he never called the facility or saw where Resident #1 went. He stated, When I leave, I don't worry about what happens. Resident #10 stated when he returned from LOA, I got cornered by staff. He stated they asked him, Why did you let him [Resident #1] through. He said the police brought Resident #1 back to the facility. He said facility staff never asked him for a statement. Resident #10 stated, I never signed anything. On 9/8/25 at 12:38 p.m., a phone interview was conducted with Staff F, Advanced Practice Registered Nurse (APRN). She said she saw Resident #1 due to the incident. She stated, He stepped outside for a second and his BIMS was repeated after the incident. Staff F, APRN said Resident #1 told her he took a walk to the hospital which was across the street. She stated, He had mild forgetfulness. Staff F, APRN said she thought he might have had a lapse that day. She said she was not sure how long Resident #1 was away from the facility. Staff F, APRN said when she asked the resident what he was trying to do, his response was he hoped to meet some friends that worked at the hospital. She stated law enforcement had found him and brought (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105327 If continuation sheet Page 24 of 31 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 09/11/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few the resident back to the facility. On 9/8/25 at 3:03 p.m., a phone interview was conducted with Resident #1's family member. She said Resident #1 has a history of dementia and alcohol abuse. She said his dementia is of unknown origin but potentially related to the resident's issue with alcoholism. The family member said the facility called her around 10:20 p.m. the day the resident exited the facility unwitnessed. She stated she was told he, Snuck out with another resident and found him 20 minutes later. The family member said she suspected Resident #1 was looking for alcohol, and the facility confirmed he told them he was looking for beer. She stated, Sometimes he has better days than others. The family member said Resident #1 referenced family members who have passed, but thinks they are alive, or say he's going to walk down the street of a state he used to reside in. She said the resident's sister and father had dementia. The family member said she did not think the resident had a wander guard on before the incident. She said the staff told her, the day she was notified he had left, about putting a wander guard on him in case he tried to leave again. The family member said the social service staff member called her last week and told her Resident #1 is now in the memory care unit. She said they told her that it is closed off and easier to watch him. The family member said staff have expressed to her Resident #1 wanted to go to an assisted living facility (ALF), but he had never expressed that to her. She stated, It's a horrible idea. He asks about people who've been dead 20 to 30 years. He's been an alcoholic since he was [AGE] years old. He's a danger to himself and others, he cannot be out alone. On 9/8/25 at 3:30 p.m., an interview was conducted with the Nursing Home Administrator (NHA) and Director of Nursing (DON). The DON said Resident #1 exited the facility on 7/26/25 at 5:00 p.m. The DON said code silver was completed, and it was determined he was out of facility for two and a half to three hours. She said he was evaluated when he returned to the facility, and he was alert and oriented to person, place, time, and event (x4). The DON said she interviewed the resident when he returned, and he knew what he was doing as he told them he planned to go across the street to get a drink. The DON confirmed he had an electronic monitoring bracelet on when he left, and it was functioning. The DON said Resident #1 has had an electronic monitoring bracelet for as long as she's been at the facility. The NHA said the alarm did go off at that time he left, and confirmed staff did not respond to the alarm. She said the alarm was shut off and it was unclear who did it at that time. She said they were not sure if a staff member turned off the alarm. The NHA said they heard a resident had shut it off, not knowing how they would know the code. She stated there were no staff present by the front door where Resident #1 exited. The NHA said Staff G, CNA confirmed he opened the door for Resident #10 but said he did not hear the alarm. She said there are cameras on the unit and Staff G, CNA must have opened the door remotely and did not see Resident #1 leave. The DON said Resident #1's assigned nurse told the supervisor she had just seen him eating dinner, then he was not there. The DON said Resident #1 had no exit seeking behaviors. The NHA said the capability of remotely opening the front door was removed after Resident #1 exited the facility. She said currently staff have to walk to the front door to let residents out. The NHA stated they did not report this because, It was an unauthorized exit. He didn't ask to go out. She said Resident #1 did not follow the LOA process. The DON stated, He was alert and oriented, had a plan, able to navigate himself here. She said Resident #1 was already on his way to the facility and he brought himself back. The NHA and DON said they did not feel he was in harm's way. The NHA said the criteria did not make Resident #1 an elopement risk. On 9/8/25 at 4:23 p.m., a review of Resident #1's change in condition evaluation, dated 7/26/25, was completed with the DON. She confirmed she completed the change in condition evaluation after the resident returned. She said she was assessing him for the behaviors marked on the evaluation, not that he had them. The DON stated it, Shouldn't have been marked (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105327 If continuation sheet Page 25 of 31 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 09/11/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few like that. On 9/9/25 at 11:39 a.m., an interview was conducted with the Risk Manager (RM). She confirmed the facility was able to identify who turned the wander guard alarm off. She stated, [Resident #11] positioned himself in the lobby and turned it off. The RM said when Resident #11 was interviewed, he said he picked up on the codes to disable the exit alarm. She confirmed Staff G, CNA remotely opened the door, the alarm went off, and Resident #11 shut off the alarm. She said the NHA and DON interviewed Resident #1 and #11. She confirmed no other residents were interviewed. She said she was present, as a witness, during the interview with Staff G, CNA. She said he confirmed he didn't hear the alarm and acknowledged he unlocked the door remotely as he was in the back unit. The RM said Resident #10 was interviewed, but it was not documented. She stated, All he said was somebody let me out, he went out the door and didn't see anyone leave. On 9/9/25 at 1:31 p.m., a phone interview was conducted with Staff J, Physician Assistant (PA). He said Resident #1 had eloped. He said another resident let him out of the building, he was found by police and brought back to the facility. Staff J, PA confirmed he was initially called about the incident before Resident #1 returned. He stated, I can't say how long he was out for. He never eloped prior to that. He would walk around the building and do laps nonstop but never tried to leave before. Staff J, PA said Resident #1 is mildly cognitively impaired and has a BIMS of 12-13. He said the resident has a history of alcoholism and had a cognitive deficit from that. Staff J, PA stated there are, Somethings he [Resident #1] doesn't quite remember. When asked why Resident #1 is currently in the secured/memory care unit, he stated, Guessing it is because he eloped and impaired enough. He confirmed Resident #1 was previously mildly impaired. He stated, They got lucky, what if he tries to leave a second time. Staff J, PA confirmed when Resident #1 eloped, he was not safe because of his cognition. He stated, Unless they have a perfect BIMS score, they probably should not go out alone. He confirmed Resident #1 can go on LOA with assistance for cognition. Staff J, PA confirmed there was a risk for him being out on his own, due to his history of alcohol abuse and cognitive impairment. On 9/9/25 at 3:14 p.m., an interview was conducted with Resident #11. He confirmed he knew the code for the exit door and turned off the alarm the day Resident #1 left the facility. He said it is usually a false alarm when the alarm goes off, so he assumed a resident set it off when they passed by that area. Resident #11 said it's very loud. He said the next day, on 7/27/25, he found out a resident left the facility. Resident #11 stated, I know I shouldn't have done that, but it was going off and no staff were present. He stated he previously knew the code because, Staff don't hide it. He said they do not cover the code when they are putting it in the keypad. Resident #11 said staff members have yelled it out to each other as well. He said he thinks the alarm going off happened around 4:00 - 4:30. Resident #11 said the alarm woke him up and it was on long enough that he was able to get up and turn off the alarm. Resident #11 said there's been times when staff who do not normally work in the reception area do not know the code. He said he has told them he knows the code, gives it to them, and those staff have been thankful when he has done that. A review of Resident #11's annual MDS, dated [DATE], section C Cognitive Patterns, revealed a BIMS score of 15 indicating intact cognition. On 9/9/25 at 5:28 p.m., a review of video footage from 7/26/25 revealed the following: - At 6:27:10 p.m., Resident #1 was observed walking towards the front door and stopped at the end of the reception desk. No staff were observed in the reception area.- At 6:27:21 p.m., Resident #1 was observed walking away from the front/reception area. - At 6:27:31 p.m., Resident #10 was observed ambulating to the reception area and wrote in the resident sign out log. Resident #1 was observed walking up behind him and stood to the right of Resident #10, next to the reception desk. - At 6:28:26 p.m., Resident #1 left the front area while Resident #10 continued writing in the sign out log. - At 6:28:32 p.m., Resident #1 came back to the front (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105327 If continuation sheet Page 26 of 31 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 09/11/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few area. Throughout the observation, Resident #1 was standing slightly to the right side of the garbage can located in the front area. It was unclear if the wander guard alarm was going off at that time as there was no audio in the footage observed. - At 6:30:34 p.m., Resident #10 returned to the front reception area and positioned himself right in front of the door. Resident #1 was also in the same area, but in front of the garbage can. - At 6:30:55 p.m., the front doors opened, Resident #10 exited the facility going to the left, and Resident #1 exited right behind him walking towards the left. - At 6:31:24 p.m., Resident #11 was observed ambulating to the front of the facility, went to the keypad, and left the front reception area. - At 6:31:34 p.m., the front doors opened again and closed approximately ten seconds after. Throughout the footage observed, no staff were present, (Video Evidence Obtained). On 9/10/25 at 3:17 p.m., an observation of an electronic wander device was conducted with the RM, and when the device was in proximity to the door the alarm was activated. The RM was holding the device and walked to the point where the fire alarm and garbage can are located by the front door. The exit alarm went off when she passed the fire alarm and garbage can, (Photographic Evidence Obtained). An observation of the 200 unit, where Staff G, CNA was working on 7/26/25, revealed the exit alarm could be heard but it was not loud. Around room [ROOM NUMBER], the exit alarm could not be heard. From rooms 201 to 217, the exit alarm could be heard. During previous interviews with the RM, DON and NHA, they confirmed Staff G, CNA told them he did not hear the exit alarm. On 9/11/25 at 12:15 p.m., an interview was conducted with Staff I, CNA. She said Resident #1 was in the front/reception earlier in the day on 7/26/25. Staff I, CNA said he tried to leave through the front door earlier that day. She stated, We sent him back to nursing staff. She said she called the nurse to let them know he was exit-seeking. She said around the time residents are finished with dinner, the lobby is cleared, and no residents are present. She stated, I warned the nursing staff about him before I left. Staff I, CNA said she noticed his patterns had changed. She said he was usually with another resident walking around the facility, but around that time of the incident, he was wandering by himself. Staff I, CNA said she asked Resident #1 why he tried to leave and where he was going. She stated, He said he wanted to go get a few drinks across the street. Staff I, CNA said he seemed confused as he mentioned he wanted to go see his family member. She stated, I don't know if his [family member] was still alive and I asked social services about that. A review of the facility's policy titled, Abuse Prevention Program, dated November 2024, revealed the following: The facility has designated and implemented processes, which strive to reduce the risk of abuse, neglect, exploitation, mistreatment, and misappropriation of resident's property. These policies guide the identification, management, and reporting suspected, or alleged, abuse, neglect, mistreatment, and exploitation. It is expected that these policies will assist the facility with reducing the risk of abuse, neglect, exploitation, and misappropriation of resident's property through education of staff and residents, as well as early identification of staff burn out, or resident behavior which may increase the likelihood of such events. Neglect . Failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress . Alleged Violation . A situation or occurrence that is observed or reported by staff, resident, relative, visitor of others but has not yet been investigated, and if verified, could be noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property. The Administrator, DON, and/or designated individual are responsible for the investigation and reporting of suspected, or alleged, abuse, neglect, and exploitation and misappropriation. A review of the facility's policy titled, Elopement - Overview, dated October 2021, revealed the following, OVERVIEW The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105327 If continuation sheet Page 27 of 31 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 09/11/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete facility elopement definition is as follows: Elopement occurs when a resident leaves the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so. The facility's immediate actions to remove the Immediate Jeopardy included: F689 Removal Plan- Resident #1 was put on enhanced supervision on 7/26/25 and then moved to the secure unit on 9/3/25.- On 7/26/25 and 7/27/25 an audit was completed by the DON and the facility's clinical administration team for current residents to ensure accuracy of assessment for cognition and mobility.Through the course of the initial audit, identified variances were corrected regarding LOA status.- Staff were educated on the policy and procedures related to resident supervision, following procedures for residents leaving the facility for leave of absence, as well as the facility unauthorized exit protocols at 100% completion by 7/30/25. - Staff were educated by the DON and the facility clinical administration team on the door code process and the process to report unauthorized knowledge of the facility door codes at 100% completion by 7/30/25.- The remote door releases were deactivated on 7/27/25.- Code Silver drills were completed from 7/26/25 to 8/5/25 every shift.- Random audits were completed at 100% from 7/29/25 to 8/30/25 regarding unauthorized exit, resident LOA status, and resident elopement risk.- Ad hoc QA meeting was conducted on 7/27/25 to review the removal plan, which included the medical director. Verification Event ID: Facility ID: 105327 If continuation sheet Page 28 of 31 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 09/11/2025 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 - Some 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. Based on observations, interviews, and record reviews, the facility failed 1) to properly store and secure medications for two residents (#8 and #9) out of twenty resident sampled, and 2) to properly secure medications out of reach of residents in one nursing station (200) out of four nursing stations. Findings included: An observation and interview was conducted on 9/8/25 at 07:30 a.m. with Resident #8. There was a tube of zinc oxide paste skin cream on the bedside table. Resident #8 stated, “This was brought with me from the hospital and has been in my room since arrival, however it has since been discontinued.” (Photographic evidence obtained) An observation and interview was conducted on 9/8/25 at 07:40 a.m. with Resident #9. There was a tube of Betamethasone Valerate cream on the windowsill. Resident #9 was asked if the medication belong to the resident and the resident replied, “I think so.” (Photographic evidence obtained) During an interview on 9/8/25 at 1:53 p.m. with the Director of Nursing (DON), the DON stated, “All employees are given training regarding misplaced medications in the resident's room. As it pertains to self-administered medication (SAM) residents, we do have a policy, however as of this date, we do not have any SAM residents in the facility and if we find medications in the resident's room, we send them back to the pharmacy. The facility also discourages residents and visitors from bringing in any medications to the facility. During an interview on 9/8/25 at 12:35 p.m. with Staff A, Registered Nurse (RN), Staff A stated, “I adhere to the six patient rights when administering medications, so I would never administer a medication that does not belong to the resident. After I administer a medication, I document the administration in the electronic health record. If there is a medication that is left in the room after administration, I would follow policy and report it to the DON and secure the medication. We do not currently have any SAM residents in this facility. During an interview on 9/8/25 at 10:55 a.m. with Staff B, RN, Staff B stated, “If a resident has a discontinued medication that is left in the resident's room, we return the medication to the pharmacy and we do not have any SAM residents in the facility. During an interview on 9/8/25 at 11:05 a.m. with Staff C, RN, Staff C stated, “Before administration of medications, I confirm the order in the electronic health record and ensure the six resident rights for medication administration, then if after administration, if the medication is not fully used, it is either wasted or returned to the pharmacy depending on the medication. The facility does not currently have any SAM residents. During an interview on 9/8/25 at 11:10 a.m. with Staff D, Licensed Practical Nurse (LPN), Staff D stated, “If I have a discontinued medication, I will return it to the pharmacy and if I find a medication left in the resident's room, I will take it out and return it to the pharmacy. The facility does not currently have any SAM residents. During an interview on 9/8/25 at 11:15 a.m. with Staff E, CNA, Staff E stated, “If I find a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105327 If continuation sheet Page 29 of 31 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 09/11/2025 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 medication in the resident's room, I will report it to the on-duty nurse. I am not aware of any SAM residents in the facility. A review of discontinued medications in the electronic health record revealed Resident #8 was prescribed Zinc Oxide and the medication had been discontinued. Residents Affected - Some A review of current and active medications in the electronic health record revealed Resident #9 was prescribed Betamethasone Valerate cream, which was active on 7/22/23 to be used for dermatitis. An observation was conducted on 9/8/25 at 6:27 a.m. of a prescription medication sitting at the 200 hall nurses' station and there was an unlocked treatment cart containing prescription medication sitting outside the nurses' station. There were no staff in sight of the treatment cart of nurses' station. An observation was conducted on 9/8/25 at 3:14 p.m. of two full medication bubble packs, two bottles of liquid medication, and one bag of nebulizer treatments were sitting at the 200 hall nurses' station with no staff in sight and residents sitting nearby. Review of the facility policy titled Self-Administration by resident, dated 11/17, revealed the following: Residents who desire to self-administer medications are permitted to do so with a prescriber's order and if the nursing care center's interdisciplinary team has determined that the practice would be safe and the medications are appropriate and safe for self-administration. Review of the facility policy titled Storage of medication, dated 9/18, revealed the following: Policy: Medications and biologicals are stored properly, following manufacturers 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. 1. Internally administered medications are stored separately from medications used externally such as lotions, creams, ointments, and suppositories. 2. Outdated, contaminated, discontinued or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal (Refer to Section 5-Disposal of Medications, Syringes and Needles), and reordered from the pharmacy (Refer to Section 3.2-Ordering and Receiving Non-Controlled Medications), if a current order exists. Review of the facility policy titled Medication administration general guidelines, dated 9/18, revealed the following: Medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices and only be persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication. 1. During administration of medications, the medication cart is kept closed and locked when out of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105327 If continuation sheet Page 30 of 31 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 09/11/2025 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 sight of the medication nurse. No medications are kept on top of the cart. The cart must be clearly visible to the personnel administering medications when unlocked. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105327 If continuation sheet Page 31 of 31