MAITLAND, FL - State inspectors have cited Ansley Cove Healthcare and Rehabilitation for multiple care violations, including failures that led to preventable falls and injuries for vulnerable residents requiring specialized supervision.
Supervision Breakdowns Lead to Repeated Falls
The most serious violations centered on a cognitively impaired resident who experienced two preventable falls within a 10-day period, both occurring when staff abandoned their supervisory duties. The resident, diagnosed with Alzheimer's disease, severe cognitive impairment, and multiple fall risk factors, was prescribed blood thinning medication that significantly increased her risk of serious injury from head trauma.
On December 22, 2024, the resident fell from her wheelchair in the facility's activity room while participating in a fall prevention program designed specifically for high-risk residents. According to inspection records, the Certified Nursing Assistant (CNA) assigned to supervise the group left the residents unattended to give another resident a shower. A housekeeper present in the room was cleaning and did not witness the fall.
The situation repeated itself just 10 days later on January 1, 2025, when the same resident fell again in the activity room. Investigation revealed that a registered nurse had explicitly instructed three CNAs multiple times not to leave the resident unattended, yet staff disregarded these direct orders. "They weren't paying attention to me. I don't know why she was abandoned in the activity room," the nurse told investigators. "I felt like it was insubordination by the CNAs as several times I told them to sit with her."
The facility's Administrator later acknowledged that staff education following the first incident was inadequate, reaching only 13 of 45 nursing staff members and no activities staff, despite activities personnel being assigned to monitor residents in the activity room.
Critical Medical Protocols Ignored After Falls
The violations extended beyond inadequate supervision to dangerous gaps in post-fall medical care. After the January 1st fall, nursing staff failed to implement standard neurological monitoring protocols despite the resident's use of blood thinning medication, which dramatically increases the risk of life-threatening brain bleeding.
Medical standards require comprehensive neurological assessments following any unwitnessed fall, particularly for patients on anticoagulant therapy. These protocols call for monitoring vital signs, pupil responses, reflexes, and consciousness levels every 15 minutes for the first hour, then at increasing intervals for up to 72 hours. The monitoring is essential because bleeding in the brain can develop gradually and may not be immediately apparent.
Instead of following these protocols, nursing staff conducted only a basic assessment and failed to initiate the required neurological checks. The facility's Director of Nursing confirmed that "nurses would adhere to accepted standards of practice and conduct post-fall neurochecks immediately after the incident," yet this standard was not followed.
The consequences became apparent the following morning when staff discovered a golf ball-sized hematoma on the resident's forehead. The resident's daughter described the incident as "scary" because her mother was on blood thinners and hit her head when she fell. Hospital staff emphasized that her mother needed immediate hospital evaluation after any falls involving possible head injuries.
Investigation Failures Raise Neglect Concerns
State inspectors found that facility leadership failed to conduct thorough investigations that could have identified patterns of neglect and prevented repeated incidents. Despite clear evidence that CNAs repeatedly abandoned their supervisory duties, facility administrators did not classify the incidents as potential neglect requiring mandatory reporting.
The facility's abuse prevention policy specifically requires identification of neglect patterns, thorough investigations, and implementation of changes to prevent future occurrences. However, the Administrator acknowledged that he relied heavily on the Director of Nursing's investigative findings without asking "hard questions" to ensure incidents didn't meet reporting criteria.
"I reviewed the fall investigations again and confirmed he could now see that there was not enough detail in some statements," the Administrator told inspectors, admitting the investigations were inadequate.
The Director of Nursing maintained that the resident was "adequately supervised" despite acknowledging that falls occurred when CNAs left her unattended and ignored explicit nursing instructions to remain with the resident.
Widespread Personal Care Deficiencies
Beyond the fall prevention failures, inspectors documented significant deficiencies in basic personal hygiene care affecting multiple residents. These violations demonstrate systemic problems in ensuring residents receive fundamental daily care services.
Inspectors observed a cognitively intact resident whose fingernails had grown approximately one-third inch long with uneven, sharp edges. Thick debris was packed under the nails, creating infection risks and compromising the resident's ability to safely handle food and personal items. "This is the longest they have ever been in my life. I don't think they do that here," the resident told inspectors, explaining she hadn't asked for nail care because she didn't want to bother staff.
Another resident with severe cognitive impairment was found with similarly neglected fingernails containing brown and gray waxy substances underneath. Staff confirmed the nails were "too long and very dirty" with "a large amount of debris wedged underneath."
Additional personal care violations included a resident found with poor oral hygiene, food particles visible throughout her mouth, and soiled clothing that had not been changed after meals. Despite care plans requiring daily oral hygiene and assistance with dressing, these basic needs were not being met.
Medical Implications of Care Failures
The documented violations carry serious health consequences that extend beyond immediate discomfort. Inadequate supervision of fall-risk residents can result in traumatic brain injuries, fractures, and other life-threatening complications, particularly for those on blood thinning medications where internal bleeding risks are significantly elevated.
Poor personal hygiene creates multiple health hazards including bacterial infections, oral diseases that can affect nutrition and medication absorption, and skin breakdown that can develop into serious pressure ulcers. For cognitively impaired residents who cannot advocate for themselves or recognize hygiene needs, consistent staff attention to these details is essential for preventing serious medical complications.
The failure to follow post-fall neurological monitoring protocols represents a particularly dangerous gap in care. Brain bleeding from falls can be subtle initially but progress rapidly to life-threatening situations. The standardized monitoring protocols exist specifically because symptoms may not appear immediately, and early detection is crucial for successful treatment.
Industry Standards and Expectations
Nursing homes are required to maintain comprehensive fall prevention programs that include environmental modifications, staff training, and individualized supervision protocols based on each resident's specific risk factors. These programs must include clear procedures for staff coverage during breaks or emergencies to ensure continuous supervision of high-risk residents.
Federal regulations require that residents receive necessary care to maintain their highest possible physical, mental, and psychosocial well-being. This includes ensuring residents who cannot perform activities of daily living receive appropriate assistance with personal hygiene, oral care, and grooming.
The facility's own policies required nail care at least twice weekly during baths or showers, oral care at least twice daily, and immediate post-fall neurological assessments for residents on blood thinning medications. These internal standards align with industry best practices and federal requirements.
Additional Issues Identified
The inspection revealed other concerning patterns including inadequate staff education on supervision requirements, with only 13 of 45 nursing staff receiving training after the initial fall incident. Activities staff, despite being assigned supervisory duties, received no training on fall prevention protocols or emergency procedures.
Documentation deficiencies were noted throughout resident care records, with no evidence of care refusals that might explain gaps in personal hygiene assistance. The facility's investigation procedures were found inadequate for identifying root causes and implementing corrective measures to prevent recurring incidents.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Savannah Cove from 2025-02-15 including all violations, facility responses, and corrective action plans.
💬 Join the Discussion
Comments are moderated. Please keep discussions respectful and relevant to nursing home care quality.