Oasis at the Conch Republic Nursing and Rehab

In the surveyor’s words

From the most serious findings on record at Oasis at the Conch Republic Nursing and Rehab, in the surveyor’s own words.

• Immediate jeopardy, patternF600Oct 26, 2023

  Based on record review, review of the facility's policies and procedures, and staff interviews, the facility failed to protect residents from neglect when they failed to ensure residents received food in the appropriate texture to prevent accidental choking for 2 (Residents #1, and #4) of 4 sampled residents. The facility's failure to provide the services necessary to prevent neglect placed other residents with similar conditions at a likelihood of serious illness and/or death and resulted in the determination of Immediate Jeopardy. Resident #1 had a diagnosis of Dysphagia (impaired Swallowing) and had been downgraded to a pureed diet (all food has been ground, pressed, and/or strained to a soft, smooth consistency, like a pudding) with nectar thickened liquids on [DATE]. […]

• Immediate jeopardy, patternF692Oct 26, 2023

  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. Resident #1 had a diagnosis of Dysphagia (impaired swallowing). On [DATE] 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 [DATE] Resident #1 did not receive a pureed diet for lunch and choked on the food. Staff suctioned food particles from the resident's mouth. […]

• Immediate jeopardy, isolatedF578Mar 15, 2024

  Based on record review and interview, the facility failed to implement their policy and procedure and honor the resident's documented advance directives, including Do Not Resuscitate status for 1 (Resident #1) of 3 residents reviewed. On [DATE] at approximately 11:40 a.m., Resident #1 was found without a pulse or respiration. Staff did not verify Resident #1's advance directives for code status and administered cardiopulmonary resuscitation (CPR) against the resident's documented wishes to withhold CPR in the event of cardiac or respiratory arrest. Applying the reasonable person concept, the failure to honor the resident's wishes for a natural, dignified death created a likelihood for serious psychosocial harm. […]

• Immediate jeopardy, isolatedF678Mar 15, 2024

  Based on clinical record review and staff interview, the facility failed to implement their policies and procedures by failing to verify code status and administering cardiopulmonary resuscitation (CPR) to 1 (Resident #1) of 2 sampled residents found without pulse or respiration, against the resident's documented wishes and physician's order for DNR (Do not resuscitate). On [DATE] at approximately 11:40 a.m., Resident #1 was found without a pulse or respiration. Staff did not verify Resident #1's code status and administered cardiopulmonary resuscitation (CPR) against the resident's documented wishes, and the physician's orders to withhold CPR in the event of cardiac or respiratory arrest. […]

• Actual harm, isolatedF697Jan 11, 2023

  Based on interview and record review the facility failed to assess for pain and administer prescribed narcotic pain medications for 2 residents (Resident #1 and Resident #9) of three residents surveyed for pain. The residents failed to receive their prescribed pain medications due to not having appropriate staffing to ensure two nurses with access were available to retrieve the medications from the emergency medication dispenser. The failure to administer the pain medications as ordered caused harm to the residents as demonstrated by both residents verbalizing untreated pain at a level of 10, and mental anguish demonstrated by one resident (Resident #1) weeping and crying due to pain, and one resident (Resident #9) verbalizing how frustrated she became because her pain got to a level of 10… […]