The woman, who had severe cognitive impairment and was at high risk for falls, was supposed to be under direct supervision in the activity room at Ansley Cove Healthcare and Rehabilitation. Instead, CNAs repeatedly left her alone to attend to other residents.
"Resident left unattended in activity room, while I was giving report to [Emergency Medical Services] to send another resident to the hospital due to critical abnormal labs," registered nurse M wrote after the second fall on January 1, 2025.
The resident had Alzheimer's disease, paranoid schizophrenia, and a fall risk score of 16 indicating high danger. Her care plan specifically noted she "fell at least four times between July and December 2024" and required fall precautions. She was taking Warfarin, a blood thinner that increases bleeding risk, especially dangerous for elderly patients with cognitive issues.
On December 22, 2024, the resident fell to the floor from her wheelchair in the activity room. Staff statements revealed she was part of a group of residents who were supposed to be under direct supervision of an assigned CNA. The CNA explained she left the residents in the room to attend to another resident who needed a shower. Both registered nurses on duty found the resident on the floor with her coloring book nearby.
Ten days later, at 10:30 PM on January 1, 2025, she fell again in the same activity room. This time, RN M had instructed CNAs three times not to leave the resident unattended. The fall was unwitnessed because no staff were present.
A hematoma appeared on the resident's head the following day.
Her physician ordered immediate transfer to the hospital on January 2 for "ecchymosis or bruising and a hematoma on her forehead after a fall." A CT scan found no hemorrhage or skull fractures but showed soft tissue swelling in the left frontal scalp.
"Thanks to God she didn't have a serious injury inside her head," the resident's daughter said. "At the hospital they told me since she was on [Warfarin], she should get checked out there after a fall."
The daughter described her mother's face as "badly bruised for a while" and said the facility informed her "the CNA who was with her mother got up and left her alone in the activity room."
RN M described the resident as "a well-known fall risk who needed staff supervision, sometimes one-to-one, to ensure she did not crawl out of bed or slide out of her wheelchair." On the night of the second fall, the resident was agitated, so RN M asked CNAs to keep her in a common area and monitor her closely.
"While she attended to another resident in a crisis situation, she repeatedly looked towards the nurses' station where resident #4 sat in her wheelchair, and repeatedly instructed the CNAs to ensure someone stayed with her," the inspection report states.
RN M later heard a moan from the activity room and discovered the resident on the floor, parallel to her wheelchair, with no CNA present.
The facility's Director of Rehabilitation confirmed the resident "was not able to stand and transfer without moderate assistance from one person, and if she was not inclined to cooperate, it might be necessary for two people to assist for safety reasons."
"She is impulsive and thinks she can do stuff," the director said, adding that supervision was "the most important approach to keep resident #4 and other cognitively impaired residents safe."
Despite the repeated falls when left unattended, the facility's Director of Nursing never updated the care plan to reflect the resident's need for increased supervision. After the December fall, she added a non-slip pad for the wheelchair. After the January fall that caused the head injury, she asked therapy to evaluate wheelchair positioning and a reacher device.
The nursing director maintained these interventions were appropriate, even though both falls occurred when CNAs left the resident alone in violation of the facility's fall prevention program.
The staffing problems that led to the abandonment run deeper than individual CNAs making poor decisions. Multiple staff members described a facility stretched too thin to provide adequate care.
"Staffing is definitely a concern. I have brought it up to the DON [Director of Nursing] and Administrator," RN M told inspectors. She explained that insufficient staffing "was not an isolated thing" and that "there are not always enough staff to watch the residents who needed more supervision."
The facility operates a fall prevention program where CNAs rotate through one-hour shifts sitting in the activity room with high-risk residents. But CNAs described how this system breaks down when the facility runs with only three nursing assistants.
"One person sitting in the room leaves only two on the floor," CNA E explained. "Everybody is busy and it's hard to take care of your people and another assignment too."
CNA F, who was assigned to 11 residents but supervising only one in the activity room, said other CNAs answered call lights for her residents "if they were not busy." But she couldn't guarantee care was provided: "If I have showers scheduled, they have to wait."
CNA L was more direct: "To be honest, I am not giving the best care possible to my residents as I can't leave the fall risks in the activity room."
Multiple CNAs described residents who couldn't use call lights waiting for care during the hour-long rotations. CNA C said the supervision requirement "took up at least two and sometimes three hours out of her 8-hour shift" and that CNAs "get angry because we can't do our own job."
"You are like a prisoner in that room, looking out while your own residents are not getting the right care," CNA I said. "Yes, someone might answer the call lights, but they are not doing everything else in the line of giving care."
The facility's own assessment acknowledged that 50% of residents were "totally dependent on staff for assistance with dressing, transfers, toileting, and mobility" and that all but three residents required assistance from one to two staff for basic functions.
CNAs repeatedly told management they needed additional staffing. The facility's Staffing Coordinator confirmed that "CNAs and nurses had complained to her regarding the difficulties of supervising the residents in the fall prevention program while caring for their assigned residents."
She relayed these concerns to the Administrator and Director of Nursing multiple times, but they "reminded me of the numbers related to the census." The coordinator believed she could only schedule three CNAs for 33 residents and needed approval to add a fourth.
"She was not aware there was no maximum limit for staffing or that staffing should reflect the different levels of care and supervisions necessary to meet residents' needs," inspectors noted.
The Administrator and Director of Nursing claimed they were unaware staff felt overwhelmed or had concerns about meeting residents' care needs. When confronted with extensive staff testimony about inadequate staffing, the Administrator acknowledged that staffing "should also reflect residents' needs" but had been operating primarily based on census numbers since a recent change of ownership.
The resident who fell twice continues to live at the facility, where CNAs still rotate through hour-long supervision shifts in the activity room, leaving their other assigned residents to wait for care that may or may not come.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Ansley Cove Healthcare and Rehabilitation from 2025-02-15 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for Ansley Cove Healthcare and Rehabilitation
- Browse all FL nursing home inspections