Staff performed CPR on resident #2 just after midnight, but emergency medical services and hospital records showed she had a core body temperature of 90.7 degrees Fahrenheit and displayed signs of rigor mortis, indicating she had been deceased for some time before anyone noticed.
The nursing assistant told other staff she didn't provide care to the resident during the 3 PM to 11 PM shift because she thought the woman was in the hospital. She documented in the medical record that the resident was not in the facility during her shift.
Administrator responsibilities collapsed after the death. Despite receiving a text message alleging the nursing assistant had neglected the resident by not providing any care during the entire shift, the facility's nursing home administrator never convened a required Quality Assurance and Performance Improvement meeting to review what went wrong.
The administrator told inspectors on December 19 that he was responsible for monthly QAPI meetings with the Director of Nursing and Medical Director. He said all incidents involving neglect, falls and abuse were brought to these meetings, which were intended to identify systemic breakdowns and trends.
But he never called a meeting about this death.
The administrator explained to inspectors that witness statements were collected about the CPR event and used for an internal investigation. He said the investigation was intended to ensure staff provided timely and effective CPR. He did not address timelines of when the resident was last cared for or conclusive times about the event.
His reasoning for skipping the required quality meeting: there were no concerns with staff performance during the code blue event where CPR was performed.
The Medical Director confirmed he attended monthly QAPI meetings and had reviewed the resident's hospital record, which noted she arrived with stiff extremities, hypothermia, and signs of rigor mortis. He provided this information to the administrator and Director of Nursing but did not participate in any QAPI meetings about the incident. He never asked why the death wasn't brought to QAPI.
Hospital records painted a stark picture. Emergency medical services found the resident very rigid with stiff extremities when they arrived. The core body temperature of 90.7 degrees and rigor mortis indicated she had been dead for hours before staff initiated CPR.
The Director of Nursing acknowledged she was aware the assigned nursing assistant had documented that resident #2 was not in the facility during the 3 PM to 11 PM shift on the evening she died. The DON could not explain why the nursing assistant made this documentation.
Staff interviews revealed the nursing assistant told colleagues she didn't provide care to the resident because she believed the woman was in the hospital.
Neither the administrator nor Director of Nursing could explain how their internal investigation demonstrated the resident received quality care and timely CPR when hospital findings showed she had been deceased for some time and was in rigor mortis.
The administrator couldn't explain how the resident was left unattended, died, and reached rigor mortis without staff noticing.
Federal inspectors found witness statements, hospital records, and staff interviews revealed inconsistencies with timelines, CPR recordings, documentation and false witness statements related to the death.
The facility received the text message alleging neglect on the same day inspectors arrived. The administrator acknowledged he was aware of this text and the allegation that the 3 PM to 11 PM nursing assistant had neglected resident #2 by not providing any care during her entire shift.
Quality assurance requirements exist specifically for situations like this. Federal regulations require nursing homes to maintain an ongoing quality assessment and assurance program that reviews quality deficiencies and develops corrective plans of action when problems are identified.
The death of resident #2 represented exactly the type of incident that should trigger immediate quality review. A resident died unnoticed for hours while her assigned caregiver documented she wasn't even in the building. The nursing assistant told multiple staff members she thought the resident was hospitalized when she was actually dying in her room.
Yet no quality meeting occurred.
The administrator's internal investigation focused narrowly on whether staff performed CPR properly once they found the resident unresponsive. This missed the fundamental breakdown: how a resident could die unattended and reach rigor mortis without anyone noticing.
The facility's quality assurance failure meant no systematic review of what allowed a resident to die alone and unmonitored. No analysis of staffing patterns, check procedures, or communication breakdowns that led to the nursing assistant believing her assigned resident was elsewhere.
The Medical Director's passive role compounded the problem. Despite reviewing hospital records that clearly showed the resident had been dead for hours before CPR began, he never questioned why this death wasn't brought to the quality committee he regularly attended.
The Director of Nursing similarly failed to ensure proper quality review despite knowing the assigned nursing assistant had documented the resident as absent from the facility during the shift when she died.
Federal inspectors classified this as a quality assurance violation affecting some residents with minimal harm or potential for actual harm. But for resident #2, the harm was absolute. She died alone, unnoticed, while her caregiver thought she was somewhere else entirely.
The administrator's explanation that there were "no concerns with staff performance during the code blue event" revealed a fundamental misunderstanding of quality assurance obligations. The concern wasn't CPR technique. The concern was how a resident could die unobserved for hours while staff documented her as absent.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Ansley Cove Healthcare and Rehabilitation from 2025-12-19 including all violations, facility responses, and corrective action plans.