Casa Mora Rehabilitation And Extended Care
CASA MORA REHABILITATION AND EXTENDED CARE in BRADENTON, FL — inspection on September 11, 2025.
Found 6 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
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.
105327 09/11/2025
Casa Mora Rehabilitation and Extended Care 1902 59th St W Bradenton, FL 34209
unable to complete a written concern will be assisted by staff to prepare and submit the form.4.
The
appropriate department for investigation.
Social Services will monitor and document resident /
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.
105327 09/11/2025
Casa Mora Rehabilitation and Extended Care 1902 59th St W Bradenton, FL 34209
said Resident #1 did not follow the LOA process.
The DON stated, He was alert and oriented, had a
the criteria did not make Resident #1 an elopement risk. On 9/9/25 at 1:31 p.m., a phone interview
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, abuse, neglect, and exploitation and misappropriation.
105327 09/11/2025
Casa Mora Rehabilitation and Extended Care 1902 59th St W Bradenton, FL 34209
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.
105327 09/11/2025
Casa Mora Rehabilitation and Extended Care 1902 59th St W Bradenton, FL 34209
mentioned he wanted to go see his family member.
She stated, I don't know if his [family member]
jeopardy to resident health or Prevention Program, dated November 2024, revealed the following: The facility has designated and safety 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
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 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: F-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
105327 09/11/2025
Casa Mora Rehabilitation and Extended Care 1902 59th St W Bradenton, FL 34209
visible to the personnel administering medications when unlocked.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.