Ansley Cove Healthcare And Rehabilitation

F 0600 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

increased supervision after she had two falls and increased restlessness. In a joint interview with the Nursing Home Administrator (NHA) and DON, the DON stated, we review any falls, make sure there is a care plan, and make sure there is a fall assessment; there isn't a formal Fall Program.In a telephone

interview on 10/16/25 at 1:29 PM, resident #1's primary care physician recalled he was aware the resident recently fell out of a wheelchair and required hospital emergency care. He said the facility tried to increase supervision as best they could and also did what was best for the facility. He relayed he expected nurses, CNAs and Therapists to communicate residents needs to prevent falls.On 10/16/25 at 1:45 PM in a telephone interview, the Medical Director said he expected the facility to have an active Falls Prevention Program. He conveyed the facility was not obligated to provide 24/7 1-1 sitters, and families were welcomed to provide them.In a joint interview with the Nursing Home Administrator (NHA) and DON, the NHA recalled there were issues with resident #1's payor source and it was previously discussed that the resident required 1-1 care and he thought she needed to be transferred to a higher level of care. He said the facility could not allow a constant sitter and he didn't have any elopement risks. The NHA stated, neglect is when you leave a resident unattended for a period of time that cannot perform any ADLs for themselves which includes eating or personal care and anything essential.Review of the standards and guidelines titled Abuse, Neglect, and Exploitation dated 1/01/22 read, Neglect means failure of the facility, it's employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The policy outlined that its prevention practices included identification, ongoing assessment, and care planning for appropriate interventions and monitoring of residents with needs and behaviors which might lead to neglect.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/16/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Ansley Cove Healthcare and Rehabilitation

1301 W Maitland Blvd Maitland, FL 32751

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Actual harm

cause analysis to ascertain causative/contributing factors to avoid and prevent future reoccurrences and improvement of resident care management, and assuring appropriate and immediate interventions and corrective actions were implemented. Investigation of incidents/accidents included completion of a Fall Risk Evaluation when the resident's condition changed.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/16/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Ansley Cove Healthcare and Rehabilitation

1301 W Maitland Blvd Maitland, FL 32751

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

checked resident #1's medical record and confirmed there was incorrect fall history coding in resident #1's MDS's. She checked the Comprehensive Care Plan and acknowledged a Fall prevention care plan was not entered timely, the fall history prior to admission and risks associated with high-risk medications was missing. She relayed that the previous MDS Coordinator did not thoroughly check all the medical records and must've missed it.No fall prevention Care Plan Focus was developed for resident #1's Plan of Care from 7/28/25 to 9/16/25, over six weeks.On 10/15/25 at 11:35 AM, the DON was interviewed and said she had been in the position for about one week. She said as part of her new role, she recently checked resident #1's records and found individualized care plan interventions were missing, and some Fall Risk Evaluations completed by the previous DON were backdated. On 10/16/25 at 9:57 AM, the DON checked resident #1's Fall Risk Evaluations and acknowledged the risk scores never increased after falls. She said

they were incorrectly scored and should have included the resident's prior fall history and subsequent falls as a change in condition. She said if the assessments were scored correctly, the risk score would have been at least 10, which was considered High. She said it was not acceptable to backdate assessments as

they were expected to be completed immediately or within 24 hours, and nurses were expected to document accuracy in the medical records.Review of the DON and nurses Job Descriptions noted the expectation of abilities to relay correct and accurate information regarding residents' conditions in all communication forms.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/16/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Ansley Cove Healthcare and Rehabilitation

1301 W Maitland Blvd Maitland, FL 32751

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Based on interview and record review, the facility failed to maintain an effective Quality Assurance and Performance Improvement (QAPI)/Quality Assessment and Assurance (QAA) program by not identifying and addressing repeated deficiencies and by not ensuring complete monitoring documentation for corrective action plans. The deficient practice resulted in a pattern of unresolved quality concerns and had

the potential to affect more than a limited number of residents by not ensuring consistent monitoring and follow-up of identified problems.Findings:On a previous complaint survey dated 2/15/25, Centers for Medicare & Medicaid Services (CMS) Enforcements were issued that included F-F0600 (Free from Abuse and Neglect), F-F0610 (Investigate/Prevent/Correct Alleged Violation), F-F0689 (Free of Accident Hazards/Supervision/Devices). On 7/14/25, a recertification survey was conducted, and Enforcements were issued for F-F0867 QAPI/QAA Improvement Activities.On 10/16/25 at 2:10 PM, the Nursing Home Administrator (NHA) explained that their QAPI program included non-compliance assessments/review, and identification of identified problems reported by each department during their monthly regular and Ad Hoc (when needed) meetings. He recalled the last monthly meeting was held on 9/30/25. The NHA explained that the program's intention was to identify any deficiencies or trends in each department's monthly reported information, and it was collectively determined what issues the committee decided to work on.The NHA explained the last Performance Improvement Plans (PIPs) for F-F0610 and F-F0600 and F-F0689 Enforcements related to Falls in February 2025 were completed as the QAPI committee determined substantial compliance was met effective 4/01/25. He stated there had been three different Directors of Nursing (DONs) since February 2025 and he was unable to locate the POC documents.The NHA said the DON was responsible to ensure nursing related corrective actions were active and sustained. He said he was unaware how substantial compliance for the citations was determined and didn't have the records to review. The NHA stated there was a failure of DONs to track and ensure measures in place were implemented to sustain corrective measures.The facility did not implement an ongoing, systematic QAPI program to ensure that identified problems were corrected and prevented from recurring. The failure of the facility to maintain complete monitoring documentation and address repeated deficiencies demonstrated that the QAPI program was not effective.Review of the facility's standards and guidelines titled, QAPI Monitoring dated 1/20/22 noted the program's intentions were to systematically monitor performance indicators as part of the QAPI program. Data collection activities to track performance indicators based on data analysis are monitored/evaluated monthly for evaluation of progress towards goals and remain active for a minimum of one calendar year.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/16/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Ansley Cove Healthcare and Rehabilitation

1301 W Maitland Blvd Maitland, FL 32751

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0895

Have a Compliance and Ethics Program.

Level of Harm - Minimal harm or potential for actual harm

Based on observation, interview, and record review, the facility failed to ensure the Director of Nursing (DON) adhered to ethical expectations and professional standards by backdating evaluations with incorrect documentation; lacked evidence of education or competency training for the role, and readily available employee program access. Findings:On 10/16/25 at 12:05 PM, via the telephone, the facility's Human Resource Assistant said she also served the role of Compliance Officer. She explained as part of the compliance program, the facility was expected to have posters readily visible for employees to access contact information and resources. She said she did not attend any clinical or meetings regarding resident care and only visited for employee situations that may include investigations, disciplines, or terminations.

She said the Compliance and Ethics Program was outlined with education during employee orientation and included expectations of honesty in documentation and stated, anything that happens to a resident has to be documented honestly and 100% correctly; it affects the care, safety, and health of the residents.On 10/16/25 at approximately 11:00 AM, the DON said the Compliance Program posters were on the Assisted Living Facility (ALF) side of the building, but not on the Skilled Nursing side and provided a rolled-up poster

she said the Nursing Home Administrator (NHA) had just received.On 10/16/25 at 12:50 PM, the NHA checked the employee file of the former DON and said he could not locate the signed Job Description, nor

the acknowledgement of their Compliance and Ethics Program orientation education.Review of the facility's standards and guidelines dated 1/20/22 and titled Compliance and Ethics Program outlined components that included sufficient resources and authority to assure compliance, ongoing communication through education of standard policies and procedures, and compliance achievement activities, such as monitoring, auditing, reporting systems, and data integrity processes, and annual training all which was meant to promote quality care.

Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet