Health inspection·October 26, 2023

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Review of the clinical record revealed Resident #1 had an admission date of 12/28/2019. Current diagnoses included Dysphagia (difficulty swallowing food or liquids). The physician's diet orders dated 12/30/22 were for a Dysphagia Advanced Mechanical texture (soft food that require more chewing ability), and regular, thin consistency liquids. The Quarterly Minimum Data Set (MDS) assessment with an assessment reference date of 9/29/23 noted Resident #1 experienced loss of liquids/solids from mouth when eating or drinking, coughing, or choking during meals or when swallowing medications, complained of difficulty or pain with swallowing. The nursing progress note dated 10/06/23 at 2:58 p.m., note revealed documentation, Resident had excessive coughing during lunch from eating soup. Diet was downgraded to puree from mechanical soft. Therapy referral completed and submitted. Updated diet slip submitted. MD (physician) made aware. On 10/07/23 in a progress note the Licensed Practical Nurse documented the Certified Nursing Assistant (CNA) called her to resident's room. Resident #1 was actively choking on his meal. The suction machine was needed to clear secretions and food particles from the resident's mouth. Resident #1 continued to cough after airway was cleared. The resident began to talk and said he was fine, had no complaint of pain or discomfort to the chest area. On 10/7/23 at approximately 5:30 p.m., Resident #1 had a delayed response in following commands, persistent excessive coughing, and a drop in oxygen to 88%. On 10/7/23 at 6:35 p.m., the Licensed Practical Nurse documented Resident #1 was sent to the emergency room for delayed response in following command, persistent excessive coughing spell, and a drop in oxygen status. On 10/10/23 a nursing progress note documented Resident #1 was readmitted to the facility. The diagnosis listed was, Choked and aspiration PNA (Pneumonia). On 10/11/23 the physician documented Resident was sent to the emergency room (ER), with concerns for aspiration after choking at lunchtime. Patient was examined in the ER with relevant labs run and then admitted for Aspiration Pneumonia and respiratory failure. Patient readmitted in stable condition, will complete antibiotic therapy, will have therapy availed to him to assist with regaining his baseline status before this event . Review of the facility's investigative findings included reviewing the resident's diet order which stated puree, nectar thickened liquids. Resident #1 received a Mechanical Soft Tray on 10/07/23 at lunch of chopped chicken. The Dietary Manager verified the diet order was entered correctly in the tray ticket system. The new tray tickets were not printed or filed. The Dietary Manager's assistant who was responsible to make the diet change in the system was also responsible to print and file the new tray tickets but failed to do so. On 10/6/23 at dinner and on 10/7/23 for breakfast and lunch Resident #1 continued to receive a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106089 If continuation sheet Page 2 of 14 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 106089 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oasis at the Conch Republic Nursing and Rehab 5860 W Junior College Rd Key West, FL 33040 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 0600 mechanical soft diet instead of the pureed diet. Level of Harm - Immediate jeopardy to resident health or safety On 10/23/23 at 11:45 a.m., the Registered Dietitian (RD) said she started going around at lunch to look at every mechanical/puree tray to make sure they were correct. She said today (10/23/23) was her third day auditing. She said on 10/20/23 during her audit, she found one resident (Resident #4) on a mechanical diet received a regular tray. She said the kitchen made the wrong tray, but the floor staff also delivered the wrong consistency tray to the resident. She said the facility was in the process of implementing different color tickets for the different diets. She said they will finalize the colored ticket today (10/23/23) and they will go into effect tomorrow (10/24/23). Residents Affected - Some On 10/23/23 at 1:05 p.m., the Dietary Manager said an update for Resident #1's diet came through as he was leaving on Friday afternoon. He gave it to his assistant and told her it was important. He explained the normal process is to update the computer, print the new meal ticket with the new diet on it, remove the old meal ticket from the tray line folder and replace it with the new ticket. He said the assistant updated the computer system but must have gotten distracted. She didn't replace the ticket in the tray line folder. He said the change to puree didn't show on the tray line ticket and Resident #1 received a mechanical diet for dinner on 10/6/23, and for breakfast and lunch on 10/7/23. On 10/23/23 at 1:47 p.m., the Speech Therapist said, It was a Friday, the nurse came to me and said he (Resident #1) was having problems with the mechanical soft texture. We downgraded to puree and nectar thick. I agreed it was appropriate. The nurse completed the requisition form, one form came to therapy, and one went to kitchen to alert about the downgrade. Something happened in kitchen that it didn't go through. He (Resident #1) got the mechanical and that caused him to choke. On 10/23/23 at 2:11 p.m., the Assistant Dietary Manager said the Dietary Manager asked her to put the new order for Resident #1 into the system. She said she entered the new order into the computer system and must have gotten sidetracked. She didn't print the new meal ticket and did not put it into the folder for tray line. She said Resident #1's mechanical soft diet was downgraded to puree, but the mechanical soft diet ticket was still in the tray line file. She said she was supposed to take the old one out and replace it with the new one. On 10/24/23 at 1:13 p.m., the Administrator said the Assistant Dietary Manager forgot to file the ticket and as a consequence the wrong consistency was served. He said they put a Performance Improvement Plan in place and started audits of the tray line, consistency/diet, dietary and clinical computer systems to ensure diets match. They held in-services including topics on proper meals and service, trays, and proper diet. On 10/24/24 at 12:54 p.m. the RD said on 10/20/23 while auditing room trays, she found Resident #4 who was on a mechanical soft diet received a regular consistency meal tray, consisting of a Peanut Butter and Jelly (PBJ) sandwich, breaded fish, potatoes, and some sort of vegetable. She said Resident #4 had the PBJ sandwich in his hand and had broken the bread apart with his hands. She took the tray and brought him a mechanical soft diet. She brought the issue to the Administrator. She said that was when she decided to do audits each day and that it was an ongoing process. She said she found the mechanical veggies to be cut a little big and she would be re-educating what size needs to be for mechanical veggies. On 10/25/23 at 9:30 a.m., the Administrator said since the incident with Resident #1 all staff were in serviced on Abuse, Neglect and Exploitation. The Administrator said he personally gave the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106089 If continuation sheet Page 3 of 14 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 106089 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oasis at the Conch Republic Nursing and Rehab 5860 W Junior College Rd Key West, FL 33040 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 0600 Level of Harm - Immediate jeopardy to resident health or safety in-service on 10/15/23 on the topics of proper meals and service, trays, and proper diet. He said they discussed the incident with Resident #1 and nursing staff was advised to check resident's meal ticket against the meal when delivered to the resident. He verified after this in-service and auditing, somehow, a tray got through both the dietary tray line and the clinical staff, resulting in Resident #4 being served the wrong consistency diet on 10/20/23. He said room to room auditing of trays had not been in their original Performance Plan and they will continue working on improving the plan. Residents Affected - Some The Administrator provided documentation on 10/24/23, the facility held an ad hoc (impromptu) meeting to discuss the 10/20/23 incident when Resident #4 received the wrong consistency diet. The root cause documented was, the wrong consistency was placed on the tray by the dietary aide and the CNA (Certified Nursing Assistant) failed to distinguish it was the wrong consistency. The facility provided documentation on 10/24/23 the facility educated the nursing, and activity staff on recognizing diet textures and liquid consistency. On 10/26/23 the Immediate Jeopardy was removed as of 10/25/23 after verification of implementation of the immediate actions which included: Beginning 10/07/23, current Licensed Nurses were educated by the Director of Clinical Services related to the components of the regulation with emphasis on ensuring residents receive the appropriate diet and initiating emergency response if indicated to include a respiratory assessment. The surveyor verified through review of the education and random staff interviews. On 10/08/23 the Performance Improvement Plan was developed and initiated based on root cause analysis. The surveyor verified through review of the Performance Improvement Plan and interview with the Administrator, The Nursing Home Administrator (NHA), Assistant NHA, and Director of Clinical Services educated by the Chief Risk Officer and Regional Nurse Consultant regarding F600, components of this regulation with emphasis on ensuring incidents are investigated, incident report is completed wit reporting to the Agency for Health Care Administration as indicated, and a system for monitoring that its employees or service providers provide goods or services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. The surveyor verified through review of the education and interview with the Director of Nursing and the Administrator. The current rate of education compliance for current Licensed Nurses, Certified Nursing Assistants, and Dietary staff as of 10/20/23 was 100% completed. The surveyor verified through record review and random staff interviews. Seventeen residents have a diagnosis of Dysphagia and had the potential to be affected by the deficient practice and potentially suffer serious harm, serious injury, serious impairment, or death. The surveyor verified through record review of residents' ordered diet. On 10/8/23, a root cause analysis was conducted and revealed that the dietary assistant failed to complete the process for the diet order change. She completed the order change in the tray card system but failed to print and file the new tray ticket. The surveyor verified through review of facility's investigation and interview with the Administrator and Director of Nursing. 10/8/23, Performance Improvement Plan was developed and initiated based upon Root Cause Analysis. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106089 If continuation sheet Page 4 of 14 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 106089 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oasis at the Conch Republic Nursing and Rehab 5860 W Junior College Rd Key West, FL 33040 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 0600 The surveyor verified through record review of the Performance Improvement Plan. Level of Harm - Immediate jeopardy to resident health or safety 10/09/23, Nursing staff reeducation initiated on timely reporting of incidents and emergency responses. The surveyor verified through record review and random staff interview of Licensed Nurses and Certified Nursing Assistants. Residents Affected - Some 10/11/23, Quality Assurance and Performance Improvement (QAPI) meeting conducted to review the root cause of the incident and to approve the improvement plan. In attendance were the Administrator, Medical Director, Assistant Administrator, Director of Clinical Services. The surveyor verified through record review. 10/11/23, weekly audits initiated and will continue by Registered Dietitian to verify the electronic medical record (EMR) diet order matches the tray ticket in the dietary electronic system. No discrepancies noted. The surveyor verified through review of the audits. 10/12/23 through 10/16/23, Speech Language Pathologist with assistance of Director of Rehabilitation conducted screens of current residents to ensure proper diet texture. The surveyor verified through review of the audits, and interview with the Speech Language Pathologist. 10/14/23, Director of Nursing initiated education for Licensed Nurses including Physical assessment, proper use of the suction machine, procedure guideline for performing oropharyngeal suction, procedure guideline for taking aspiration precautions and aspiration and dysphagia. Education completed 10/19/23. The surveyor verified through review of the education and random Licensed Nurses interviews, including agency nurses. 10/15/23 through 10/20/23, all department staff were educated on Abuse, Neglect, Exploitation and Reporting. The surveyor verified through record review of the education and random staff interviews. 10/16/23, a quality review was conducted by Human Resources/Business Office Manager to verify all Licensed Nurses have up to date CPR (Cardiopulmonary Resuscitation) certifications. All Licensed Nurses have a valid CPR license. The surveyor verified through review of CPR certification. On 10/17/23, a QAPI meeting was conducted with the following members: NHA, Medical Director, DON (Director of Nursing), DOR (Director of Rehab), Dietary Manager, Social Service Director, staffing Development Coordinator, Nurse Practitioner, Activity Director, Registered Dietitian, and the Speech Language Pathologists. The QAPI committee determined that a revision of the improvement plan be implemented consisting of a diet order binder and a diet order change log. The surveyor verified through review of the QAPI meeting and interview with the Administrator. 10/17/23, the Director of Nursing created Diet Binders containing residents' diet orders and are located at each nursing stating and the main dining room. Binders will be maintained by the Registered Dietitian. The surveyor verified through observation of the binders at each nursing station and the main dining room. 10/17/23, NHA conducted an audit of random trays for accuracy of food and fluid texture and consistencies. No discrepancies noted. The surveyor verified through review of the audit. 10/18/23, DON conducted an audit of 5 random trays for accuracy of food and fluid texture and consistencies. No discrepancies noted. The surveyor verified through review of the audit. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106089 If continuation sheet Page 5 of 14 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 106089 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oasis at the Conch Republic Nursing and Rehab 5860 W Junior College Rd Key West, FL 33040 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some 10/18/23, RD conducted an audit of five random trays for accuracy of food and fluid texture and consistencies. No discrepancies noted. The surveyor verified through review of the audit. 10/18/23, RD conducted an audit comparing the EMR physician diet order to the dietary electronic tray ticket system. No discrepancies noted. The surveyor verified through review of the audit. 10/20/23, RD conducted an audit on altered diet or liquids. One discrepancy noted. The tray ticket was correct. The food plated was an uncut peanut butter sandwich. The RD immediately removed the tray without a bite being taken. A correct tray was made and given to the resident. Re-education and disciplinary action was given to the dietary aide who prepared the tray. Re-education and disciplinary action was given to the CNA who delivered the tray. The surveyor verified through review of the audit, and interview with the RD. 10/25/23, an Ad hoc QAPI meeting was conducted with the following members: NHA, Medical Director, DON, and Assistant Administrator. The QAPI committee reviewed the audits and effectiveness for the current plan in conjunction with survey findings. The surveyor verified through review of the QAPI meeting. Newly hired staff will receive education in orientation. Education will include agency and contract staff members. The surveyor verified through interview with the Administrator and Director of Nursing. The Quality Improvement Performance Committee will continue to hold weekly and as needed meetings to review and discuss the results of the ongoing quality monitoring along with staff and resident interviews. The findings of these quality reviews/interviews to be reported to the Quality Assurance/performance Improvement Committee weekly. Quality review schedule modified based on the findings. The surveyor verified through interview with the Administrator and Director of Nursing. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106089 If continuation sheet Page 6 of 14 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 106089 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oasis at the Conch Republic Nursing and Rehab 5860 W Junior College Rd Key West, FL 33040 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Immediate jeopardy to resident health or safety Based on record review, review of policies and procedures, resident and staff interviews, the facility failed to consistently ensure the therapeutic mechanically altered diet was followed for 2 (Residents #1 and #4) of 4 sampled residents on mechanically altered diet. Residents Affected - Some Resident #1 had a diagnosis of Dysphagia (impaired swallowing). On 10/6/23 Resident #1's diet texture was downgraded to a pureed consistency with nectar thickened liquids. The facility failed to provide Resident #1 with the appropriate consistency diet for three meals. On 10/7/23 Resident #1 did not receive a pureed diet for lunch and choked on the food. Staff suctioned food particles from the resident's mouth. On 10/7/23 at approximately 5:30 p.m., Resident #1 was transported to the emergency room for delayed response in following command, persistent excessive coughing spell, and a drop in oxygen status. Resident #1 was diagnosed with acute aspiration pneumonia (food or liquid breathed into the airways) and acute hypoxemic (low oxygen in the blood) respiratory failure. The facility's failure to ensure residents receive food in the appropriate consistency placed residents with similar conditions a risk of accidental choking which could result in serious illness or death and resulted in the determination of Immediate Jeopardy. On 10/25/23 at 9:30 a.m., the Administrator was informed of the determination of Immediate Jeopardy (IJ) and provided the IJ templates. The Immediate Jeopardy started on 10/6/23 when the facility failed to implement the new diet order for Resident #1. The Immediate Jeopardy was removed on 10/25/23 after verification of immediate actions implemented by the facility through observation, record review and interviews. The scope and severity were decreased to E, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. The findings included: Cross reference F600. Review of the facility's policy titled, Therapeutic Diet Orders with a revised date of 3/2023 noted a mechanically altered diet is one in which the texture or consistency of food is altered to facilitate oral intake. Examples include soft solids, pureed food, ground meat, and thickened liquids. Dietary and nursing staff are responsible for providing therapeutic diets in the appropriate form and/or the appropriate nutritive content as prescribed. Review of the clinical record revealed Resident #1 was a long term resident at the facility since 12/2019. The Quarterly Minimum Data Set (MDS) assessment with an assessment reference date of 9/29/23 noted (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106089 If continuation sheet Page 7 of 14 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 106089 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oasis at the Conch Republic Nursing and Rehab 5860 W Junior College Rd Key West, FL 33040 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 0692 Level of Harm - Immediate jeopardy to resident health or safety Resident #1 exhibited sings and symptoms of possible swallowing disorder, including complaints of difficulty or pain with swallowing, coughing, or choking during meals or when swallowing medications. Resident #1's cognitive pattern was moderately impaired with a Brief Interview for Mental Status score of 12. Review of the physician's orders revealed on 12/30/22 Resident #1's was on a Dysphagia Advanced Mechanical texture with regular, thin consistency liquids. Residents Affected - Some According to the National Institute of Health, People with dysphagia have difficulty swallowing and may even experience pain while swallowing . Food pieces that are too large for swallowing may enter the throat and block the passage of air. In addition, when foods or liquids enter the airway of someone who has dysphagia, coughing or throat clearing sometimes cannot remove it. Food or liquid that stays in the airway may enter the lungs and allow harmful bacteria to grow, resulting in a lung infection called aspiration pneumonia . (https://www.nidcd.nih.gov/sites/default/files/Documents/health/voice/NIDCD-Dysphagia.pdf) The nursing progress note dated 10/06/23 at 2:58 p.m., note revealed documentation, Resident had excessive coughing during lunch from eating soup. Diet was downgraded to puree from mechanical soft. Therapy referral completed and submitted. Updated diet slip submitted. MD (physician) made aware. On 10/07/23 in a progress note the Licensed Practical Nurse documented the Certified Nursing Assistant (CNA) called her to resident's room. Resident #1 was actively choking on his meal. The suction machine was needed to clear secretions and food particles from the resident's mouth. Resident #1 continued to cough after airway was cleared. The resident began to talk and said he was fine, had no complaint of pain or discomfort to the chest area. The facility provided documentation from the International Dysphagia Diet Standardization Initiative (IDDSI) noting pureed foods do not require chewing, have a smooth texture with no lumps. Per the facility's investigation, Resident #1's lunch meal on 10/7/23 consisted of a mechanical soft diet, including chopped chicken. On 10/7/23 at approximately 5:30 p.m., Resident #1 had a delayed response in following commands, persistent excessive coughing, and a drop in oxygen to 88%. He was sent out to the emergency room and was subsequently admitted to the hospital for three days. On 10/10/23 Resident #1 returned to the facility with a diagnosis of acute aspiration pneumonia and acute hypoxemic respiratory failure. On 10/11/23 the physician documented Resident was sent to the emergency room (ER), with concerns for aspiration after choking at lunchtime. Patient was examined in the ER with relevant labs run and then admitted for Aspiration Pneumonia and respiratory failure. Patient readmitted in stable condition, will complete antibiotic therapy, will have therapy availed to him to assist with regaining his baseline status before this event . On 10/23/23 at 9:55 a.m., in an interview Resident #1 said on 10/7/23 the diet texture had just been changed and he did not really notice the diet was the wrong consistency. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106089 If continuation sheet Page 8 of 14 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 106089 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oasis at the Conch Republic Nursing and Rehab 5860 W Junior College Rd Key West, FL 33040 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 0692 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some On 10/23/23 at 1:05 p.m., in an interview the Dietary Manager said an update for Resident #1's diet came through as he was leaving on Friday afternoon (10/6/23). He said he gave it to his assistant and told her it was important. He explained the normal process is to update the computer, then print the new meal ticket, remove, and replace the old meal ticket from the tray line folder with the new meal ticket. He said the assistant updated the computer system but must have gotten distracted and didn't print or replace the old meal ticket in the tray line folder. Resident #1 received a mechanical texture diet for dinner on 10/6/23 and for breakfast and lunch on 10/7/23. On 10/23/23 at 2:11 p.m., in an interview the Assistant Dietary Manager said on 10/6/23, the Dietary Manager asked her to put the new puree diet order for Resident #1 into the system. She entered it into the computer system, got sidetracked, did not print the new meal ticket, or replace the old meal ticket with the new diet order in the folder for tray line. The meal ticket from the previous mechanical texture diet was still in the tray line folder. On 10/24/23 at 1:13 p.m., in an interview the Administrator said the facility completed a thorough investigation and verified the Assistant Dietary Manager did not print and file the new tray ticket for the pureed diet in the tray line folder. This resulted in Resident #1 receiving the wrong consistency diet. He said they had put a Performance Improvement Plan in place and had started audits of the tray line, consistency/diet audits, auditing the dietary and clinical computer systems to ensure diets match, and had held in-services including topics on proper meals and service, trays, and proper diet. Review of the Performance Improvement Plan dated 10/8/23 showed the following action steps: Education for dietary staff on workflow of tray tickets, completed on 10/20/23. Staff education conducted with focus on facility process for serving meals and utilizing meal ticket to ensure proper diet, completed on 10/15/23. On 10/23/23 at 11:45 a.m., the Registered Dietitian said she started going around at lunch to look at every mechanical/puree tray to make sure they were correct. She said today (10/23/23) was her third day auditing. She said on 10/20/23 during her audit, she found one resident (Resident #4) on a mechanical diet received a regular tray. She said the kitchen made the wrong tray, but the floor staff also delivered the wrong consistency tray to the resident. She said the facility was in the process of implementing different color tickets for the different diets. She said they will finalize the colored ticket today (10/23/23) and they will go into effect tomorrow (10/24/23). On 10/24/24 at 12:54 p.m., in an interview the Registered Dietitian said on 10/20/23 Resident #4 received a regular diet instead of the ordered mechanical soft diet. The resident received a Peanut Butter and Jelly (PBJ) sandwich, breaded fish, potatoes, and some sort of vegetable. She said Resident #4 had the PBJ sandwich in his hand and had broken the bread apart with his hands. She said she took the tray and brought him a mechanical soft diet and brought the issue to the Administrator. The Registered Dietitian also said she found the mechanical veggies to be cut a little big and she would be re-educating what size needs to be for mechanical veggies. The facility provided a Quality Assessment and Performance Improvement (QAPI) Plan dated 10/24/23 with a problem statement indicating a resident received the wrong diet at lunch which was caught (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106089 If continuation sheet Page 9 of 14 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 106089 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oasis at the Conch Republic Nursing and Rehab 5860 W Junior College Rd Key West, FL 33040 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 0692 Level of Harm - Immediate jeopardy to resident health or safety during audit. The wrong consistency diet was placed on the tray by the Dietary Aide during tray line. The Certified Nursing Assistant failed to distinguish it was the wrong consistency. On 10/24/23 the facility educated the nursing staff on the different diet consistencies and implemented a process to ensure a Licensed Nurse checked each tray coming out of the kitchen for the proper consistency diet. Residents Affected - Some On 10/25/23 at 9:30 a.m., in an interview the Administrator said he personally had given the in-service on 10/15/23 on the topics of proper meals and service, trays, and proper diet. He said they had discussed the incident with Resident #1 and staff was advised to check resident ticket against the meal when delivered to the resident. He verified after this in-service and auditing, somehow, a tray got through both the dietary tray line and the clinical staff passed the incorrect tray to Resident #4 on 10/20/23. He said room to room auditing of trays had not been in their original Performance Plan and they will continue working on improving the plan. On 10/26/23 the Immediate Jeopardy was removed as of 10/25/23 after verification of implementation of the immediate actions which included: Beginning 10/7/23, current Licensed Nurses were educated by the Director of Nursing related to the components of the regulation with emphasis on ensuring residents receive the appropriate diet and initiating emergency response if indicated to include a respiratory assessment. The surveyor verified through review of the education and random Licensed Nurses interviews. On 10/8/23, the Performance Improvement Plan was developed and initiated based on root cause analysis. The surveyor verified through review of the Performance Improvement Plan, and Administrator interview. The Nursing Home Administrator (NHA), Assistant NHA, and Director of Nursing educated by the Chief Risk Officer and Regional Nurse Consultant regarding F692 and the components of the regulation with emphasis on ensuring incidents are investigated, incident report is completed with reporting to the Agency for Health Care Administration as indicated and a system for monitoring that nursing staff were competent and appropriately trained to provide the necessary care to the residents to include oversight, monitoring and auditing of training completion or competency by nursing management to prevent a resident from suffering serious harm. The surveyor verified by review of training and random nursing staff interviews, including agency Licensed Nurses. The current rate of education compliance for current Licensed Nurse staff as of 10/20/23 was 100%. The surveyor verified through review of education and random staff interviews. 10/7/23 at 8:00 p.m., the Dietary Manager verbally educated evening dietary staff on proper workflow when creating, reading, printing, and filing of resident meal tickets. They were educated on the importance of providing the proper diet meals and consistencies for the residents. New tickets were printed for the resident involved and filed in the weekend meal tickets. The surveyor verified through interview of the dietary staff. 10/8/23, the Dietary Manager educated the morning dietary staff on proper workflow when creating, reading, printing, and filing of resident meal tickets. Dietary staff were educated on the importance of providing the proper diet meals and consistencies for the residents. The surveyor verified through random interviews of dietary staff. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106089 If continuation sheet Page 10 of 14 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 106089 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oasis at the Conch Republic Nursing and Rehab 5860 W Junior College Rd Key West, FL 33040 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 0692 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some On 10/8/23, a root cause analysis was conducted and revealed the Dietary Assistant failed to complete the process of the diet order change. She completed the order change in the tray card system but failed to print and file the new tray ticket. The surveyor verified through review of the facility's investigation and interview with the Dietary Assistant. On 10/8/23, Performance Improvement Plan was developed and initiated based upon the root cause analysis. The surveyor verified through review of the Performance Improvement Plan and interview with the Administrator. 10/9/23, Nursing staff reeducation initiated on timely reporting of incidents and emergency responses. The surveyor verified through review of the education and random interview with Licensed Nurses and Certified Nursing Assistants. 10/10/23, NHA (Nursing Home Administrator) conducted an audit of random trays for accuracy of food and fluid texture and consistencies. No discrepancies noted. The surveyor verified through review of the audits and interview with the NHA. 10/11/23, QAPI meeting conducted to review the root cause of the incident and to approve the Improvement plan. In attendance were the Administrator, the Medical Director, Assistant Administrator, Director of Nursing. The surveyor verified through review of the QAPI meeting and attendance log. 10/11/23, weekly audits initiated and will continue by Registered Dietitian to verify the electronic computer system diet order matches the tray ticket in the Dietary computer system. No discrepancies noted. The surveyor verified through review of the audits. 10/11/23, written counseling was provided to the Dietary Assistant by the Administrator and Dietary Manager. The surveyor verified through review of counseling and interview with the Dietary Assistant. 10/11/23, the DON conducted an audit of current resident's diet orders to verify the correct tray tickets were in place. No discrepancies noted. The surveyor verified through review of the audits. 10/11/23, Weekly Audits initiated and will continue by Registered Dietitian to verify electronic computer system diet order matches the tray ticket in the dietary computer system. No discrepancies noted. The surveyor verified through review of the audits. 10/11/23, Written counseling was provided to the Dietary Assistant by the Administrator and Dietary Manager. The surveyor verified through interview with the Dietary Assistant. 10/12/23 through 10/16/23, Speech Language Pathologist with assistance of Director of Rehabilitation conducted screens of current residents to ensure proper diet texture. The surveyor verified through review of the audits. 10/12/23, Weekly Audits initiated and continued by the Dietary Manager or Registered Dietician to verify tray accuracy. The surveyor verified through review of the audits. 10/13/23, Dietary Manager was educated via phone by [NAME] President of Operations regarding duties and best practices of Dietary Manager role and duties. The surveyor verified through review of the education and interview with the Dietary Manager. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106089 If continuation sheet Page 11 of 14 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 106089 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oasis at the Conch Republic Nursing and Rehab 5860 W Junior College Rd Key West, FL 33040 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 0692 Level of Harm - Immediate jeopardy to resident health or safety 10-12-2023, 10-13-2023 and 10-16-2023 [NAME] 1 was educated by the Dietary Manager on dietary computer tray card system to be able to input new diet orders and print meal tickets. A return demonstration of the process was performed. 10/18/23, [NAME] 2 was educated by the Dietary Manager on the dietary computer tray card system to be able to input new diet orders and print meal tickets. A return demonstration of the process was performed. The surveyor verified through review of the education and random interviews with dietary staff. Residents Affected - Some 10/14/23, Director of Nursing initiated education for licensed Nurses including Physical assessment, Proper use of the suction machine, Procedure Guideline for Performing Oropharyngeal Suction, Procedure Guideline for Taking Aspiration Precautions and Aspiration and Dysphagia. Education completed 10/19/23. The surveyor verified through review of the education and random interviews with Licensed Nurses. 10/15/23 through 10/20/23, all Department Staff were educated on Abuse, Neglect, Exploitation and Reporting. The surveyor verified through review of the education and random staff interviews. 10/16/23, a quality review was conducted by Human Resources/Business Office Manager to verify all Licensed Nurses have up to date CPR certifications. All Licensed Nurses have a valid CPR license. The surveyor verified through review of the audits. On 10/17/23, a QAPI meeting was conducted with the following members: NHA, Medical director, DON, DOR, Dietary manager, social service director, staffing development coordinator, Nurse practitioner, activity director, registered dietician, and the speech language pathologists. The QAPI committee determined that a revision of the improvement plan be implemented consisting of a diet order binder and a diet order change log. The surveyor verified through review of the QAPI meeting and interview with the Administrator. 10/17/23, Facility Implemented a new Diet Order Change Log Sheet to track daily diet order changes. The surveyor verified through review of the Diet Order Change Log Sheet. 10/17/23, Dietary staff were educated on the Diet Order Change Log by facility Administrator and Dietary Manager. The surveyor verified through review of the education and interview with the Dietary Manager. 10/17/23, Director of Nursing created Diet Binders containing resident's diet orders and are located at each Nursing Station and the Main Dining Room. Binders will be maintained by the Registered Dietitian. The surveyor verified through observation of the binders at each nursing station, the main dining room and interview with the Registered Dietitian. On 10/17/23, NHA conducted an audit of random trays for accuracy of food and fluid texture and consistencies. No discrepancies noted. The surveyor verified through review of the audits. On 10/18/23, DON conducted an audit of 5 random trays for accuracy of food and fluid texture and consistencies. No discrepancies noted. The surveyor verified through review of the audits. On 10/18/23, RD conducted an audit comparing the electronic computer system physician order to the dietary computer tray ticket system. No discrepancies noted. The surveyor verified through review of the audits. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106089 If continuation sheet Page 12 of 14 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 106089 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oasis at the Conch Republic Nursing and Rehab 5860 W Junior College Rd Key West, FL 33040 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 0692 Level of Harm - Immediate jeopardy to resident health or safety On 10/20/23, RD conducted an audit on altered diets or liquids. One discrepancy noted. The tray ticket was correct. The food plated was an uncut peanut butter sandwich. The RD immediately removed the tray without a bite taken. A correct tray was made and given to the resident. Re-education and disciplinary action was given to the dietary aide who prepared the tray. Re-education and disciplinary action was given to the CNA who delivered the tray. The surveyor verified through review of the audits and interview with the RD. Residents Affected - Some On 10/23/23, DON conducted an audit of altered diets. No discrepancies noted. The surveyor verified through review of the audits. On 10/24/23, RD conducted an audit of altered diet or fluid textures and found no discrepancies. The surveyor verified through review of the audits. On 10/24/23 and 10/25/23, RD conducted an audit verifying PCC physician orders to the IMPAC tray ticket system. No discrepancies noted. The surveyor verified through review of the audits. On 10/24/23, RD conducted a tray accuracy audit and found no discrepancies. The surveyor verified through review of the audits. On 10/24/23, an ad hoc QAPI meeting was conducted due to the wrong diet was noted on a tray during the audit conducted on 10-20-23. The root cause analysis showed that the wrong consistency was placed on the tray by the dietary aide and the CNA failed to distinguish it was the wrong consistency. In attendance were the Administrator, medical director, DON, assistant administrator, Director of Maintenance, Activity director, Dietary Manager, Housekeeping supervisor, Director of rehab, Registered dietitian, Unit manager, Licensed Practical Nurse, and Human Resources Director. Initiated a kitchen runner. Increased audit frequency to daily with varying locations and implemented that a nurse verifies the tray is accurate according to the tray ticket when the carts are delivered to the floor prior to delivery to the resident. A nurse in the dining room will verify the tray is accurate according to the tray ticket prior to delivery to the resident. Additional education for CNAs, Nurses, Activities and Dietary was conducted regarding accurately identifying diet and fluid texture types. DON educated CNAs and nurses, Assistant administrator educated Activities staff (one staff member in Italy remains uneducated and will be educated prior to beginning her next shift). Dietary staff were educated by the dietary manager. The surveyor verified through review of the QAPI meeting and interview with the Administrator, and observation of two meals. On 10/25/23, a QAPI meeting was conducted with the following members: NHA, Medical Director, DON, and Assistant Administrator. The QAPI committee reviewed the audits and effectiveness of current plan in conjunction with surveyor findings. The surveyor verified through review of the QAPI meeting. On 10/25/23, RD conducted an audit of diet texture and fluid. No discrepancies noted. The surveyor verified through review of the audit. Newly hired staff will receive education in orientation. Education will include agency and contract staff members. The surveyor verified through review of the Performance Improvement Plan and interview with the Administrator. The Quality Improvement Performance Committee will continue to hold weekly and as needed meetings to review and discuss the results of the ongoing quality monitoring along with staff and resident interviews. The findings of these quality reviews/interviews to be reported to the Quality (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106089 If continuation sheet Page 13 of 14 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 106089 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oasis at the Conch Republic Nursing and Rehab 5860 W Junior College Rd Key West, FL 33040 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 0692 Level of Harm - Immediate jeopardy to resident health or safety Assurance/Performance Improvement Committee weekly. Quality Review schedule modified based on findings. The surveyor verified through review of the Performance Improvement Plan and interview with the Administrator. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106089 If continuation sheet Page 14 of 14