The incident occurred just after midnight when staff at Ansley Cove Healthcare and Rehabilitation found resident #2 unresponsive and began CPR. Emergency Medical Services transported the resident to the hospital, where records documented the person arrived with very rigid, stiff extremities and the abnormally low body temperature.
Hospital records indicated the resident displayed signs and symptoms of rigor mortis, showing the person had been deceased for some time before staff identified them as unresponsive and initiated resuscitation efforts.
The facility's administrator never convened a required Quality Assurance and Performance Improvement meeting to investigate the death, despite being aware of neglect allegations and the disturbing hospital findings.
Federal inspectors found the nursing home failed to follow mandatory quality improvement protocols when serious incidents occur. The administrator told inspectors he was responsible for monthly QAPI meetings with the Director of Nursing and Medical Director, and that all incidents involving neglect, falls and abuse were supposed to be brought to these meetings.
He said the QAPI program was intended to identify systemic breakdowns and trends.
But when discussing the incident with resident #2, the administrator explained that witness statements were collected about the CPR event and used for an internal investigation. He said this investigation was intended to ensure staff provided timely and effective CPR.
The administrator did not address timelines of the event or conclusive times the resident was last cared for. He told inspectors the investigation was not brought to QAPI because 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 resident #2's hospital record. He told inspectors the hospital noted the resident arrived with stiff extremities, hypothermia, and exhibited signs of rigor mortis.
The Medical Director said he provided this information to the administrator and Director of Nursing. But he did not participate in any QAPI meetings related to the incident, nor did he inquire why the incident was not brought to QAPI.
The Director of Nursing told inspectors she was aware that resident #2's assigned Certified Nursing Assistant had documented the resident was not in the facility during the 3 PM to 11 PM shift on the evening before the death. She could not explain why the CNA documented the resident was not in the facility.
Interviews with other staff revealed the CNA told them she did not provide care to resident #2 because she thought the resident was in the hospital.
Federal inspectors found witness statements, hospital records, and staff interviews related to resident #2 being found deceased revealed inconsistencies with timelines, CPR recordings, documentation and false witness statements.
The administrator and Director of Nursing could not provide an explanation for how the facility's investigation demonstrated resident #2 received quality care and timely CPR when the hospital's findings noted the resident had been deceased for some time and was in rigor mortis.
The administrator could not explain how resident #2 was left unattended, died and was in rigor mortis without staff noticing.
The administrator told inspectors the facility received a text message alleging the 3 PM to 11 PM CNA had neglected resident #2 by not providing any care during the entire shift. The administrator indicated he was aware of this text and the allegation of neglect.
Despite being aware of the neglect allegation, no QAPI meeting was held to ensure identified concerns were addressed.
The violation represents a failure to maintain basic quality oversight systems required by federal regulations. Quality assurance programs are designed to identify problems before they result in resident harm and to implement corrective actions when serious incidents occur.
The case illustrates how breakdowns in basic monitoring can have fatal consequences. A resident died unnoticed for hours, with staff only discovering the death when the body had already begun the process of rigor mortis, indicated by the rigid extremities and dropped body temperature documented by hospital staff.
The facility's response focused narrowly on whether CPR was performed correctly, rather than addressing the fundamental question of how a resident could die unattended for an extended period without staff awareness.
The administrator's decision not to convene a QAPI meeting suggests the facility treated the incident as a CPR training issue rather than a systemic failure requiring comprehensive review and corrective action.
Federal inspectors classified the violation as causing minimal harm or potential for actual harm, affecting some residents. The inspection was conducted in response to a complaint filed against the facility.
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.