Ansley Cove Healthcare And Rehabilitation

During a retuned call, CNA G stated resident #2 was already deceased when she arrived to work at 11:30 PM on [DATE].

She said the resident was stiff and cold to the touch.

She explained CNA C, who worked from 3 PM to 11 PM, told her she did not provide care for resident #2 during the entire shift, but did not provide a reason.

She reported the Administrator and DON pressured her to give false witness statements, which she did because she feared retaliation if she did not do so.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

12/19/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Ansley Cove Healthcare and Rehabilitation

1301 W Maitland Blvd Maitland, FL 32751

SUMMARY STATEMENT OF DEFICIENCIES

Review of the witness statements revealed statements were not collected from the CNAs working the 11:00 PM -7:00 AM shift or from LPN A.

The DON did not explain why follow up did not occur to obtain the missing statements from all staff working.

The DON acknowledged inconsistencies documented in resident #2's medical record.

Contrary to the medical director's statement that he had shared the hospital records findings, the DON stated the medical director had not provided details from his review of hospital records.

The DON mentioned the facility did not have access to the hospital records and was unaware of the physical findings documented by EMS or the hospital noting the resident had been deceased for some time.

The DON presented documentation of drills conducted after the event; however, there was no documentation of the dates, response times, staff participants, or debriefing following the drills.

The DON stated the facility did not have a loudspeaker system and staff would yell during emergencies but could not confirm whether this could be heard inside resident's rooms.

The DON mentioned there was no debrief with staff following the event.

She stated she asked LPN E why she did not further assess the resident after noticing something different, and LPN E responded the resident did not look well and she notified RN B.

The DON confirmed the documentation did not include details of CPR performed or whether vital signs were attempted and stated all staff should have responded to the emergency.

Review of the facility's policy and procedure titled Activities of Daily Living (ADLs) revised on [DATE] revealed an intent to based it on the resident's comprehensive assessment and consistent with the resident's needs and choices.

Review of the facility's policy and procedure titled Documentation in Medical Record revised on [DATE] read, Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

12/19/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Ansley Cove Healthcare and Rehabilitation

1301 W Maitland Blvd Maitland, FL 32751

SUMMARY STATEMENT OF DEFICIENCIES

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to conduct a Quality Assurance and Performance Improvement (QAPI) meeting when allegations of neglect and concerns were identified related to the death of resident #2.Findings:Cross Reference F-F600, F-F684, F-F610, and F895On [DATE] just after midnight, resident #2 was found unresponsive and staff initiated cardiopulmonary resuscitation (CPR).

The resident was transferred to the hospital by Emergency Medical Services (EMS).

The EMS and hospital records noted resident #2 was very rigid with stiff extremities and core body temperature of 90.7 degrees Fahrenheit.

The records indicated the resident displayed signs and symptoms of rigor mortis indicating the resident had been deceased for some time, before staff had identified the resident to be unresponsive and initiated CPR. On [DATE] at 2:41 PM, the Nursing Home Administrator (NHA) stated he was responsible for the monthly QAPI meetings with the Director of Nursing and the Medical Director. He said that all incidents such as neglect, falls and abuse were brought forth to the meetings. He noted the QAPI program was intended to look at any systemic breakdowns and trends.The NHA spoke about the incident when resident #2 was found unresponsive on [DATE]. He stated that witness statements were collected related to the CPR event and they were used to conduct an internal investigation. He explained the investigation was intended to ensure staff provided timely and effective CPR.

The Administrator did not address any timelines of the event or conclusive times the resident was last cared for. He explained the investigation was not brought to QAPI because there were no concerns with staff performance during the code blue event where CPR was performed.Review of 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 On [DATE] at 11:05 AM, the Medical Director confirmed he attended monthly QAPI meetings. He stated he reviewed resident #2's hospital record, which noted resident #2 had arrived at the hospital with stiff extremities, hyperthermia, and exhibited signs of rigor mortis.

The Medical Director said he provided this information to the NHA and DON but did not participate in any QAPI meetings related to the incident nor inquired why the incident was not brought to QAPI.On [DATE] at 1:43 PM, the DON said she was aware resident #2's assigned Certified Nursing Assistant (CNA) had documented, resident #2 was not in the facility during the 3 PM to 11 PM shift on the evening of [DATE].

She did not explain why the CNA documented the resident was not in the facility.

Interviews with other staff disclosed the CNA told them she did not provide care to resident #2 as she thought the resident was in the hospital.

The Administrator and DON 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 did not explain how resident #2 was left unattended, died and was in rigor mortis without staff noticing.

The Administrator said the facility received a text, alleging the 3 PM to 11 PM CNA had neglected resident #2 by not providing any care to her during the entire shift.

The Administrator indicated he was aware of this text and the allegation of neglect on [DATE].

Although the NHA was aware of the neglect allegation, there was no QAPI meeting held to ensure identified concerns were addressed.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

12/19/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Ansley Cove Healthcare and Rehabilitation

1301 W Maitland Blvd Maitland, FL 32751

SUMMARY STATEMENT OF DEFICIENCIES

hospice was discussed.

The medical director stated he was informed of the incident the following day and the facility was conducting an internal investigation.

Contrary to the Administrator's statement the medical director stated he shared findings from his review of the hospital records with facility leadership.

Review of resident #2's medical record revealed she was seen by the nurse practitioner on [DATE] but there were no recommendations made related to hospice care.On [DATE] at 1:20 PM, the staffing coordinator confirmed LPN A had texted her on [DATE] related to not receiving her paycheck.

She said LPN A made allegations of neglect for resident #2 related to CPR event.

The Staffing Coordinator stated she forwarded the message to the Administrator and Human Resources (HR) manager.On [DATE] at 1:55 PM, the HR manager confirmed she received the text message from staffing coordinator but did not report the allegations of neglect because she was not clinical.On [DATE] at 3:08 PM, the Administrator confirmed he received the text message with LPN A's allegations of neglect and acknowledged he did not report the allegations.On [DATE] an email was sent to the State Agency (SA) field office from the Administrator that noted, just wanted to give a heads up we had a very disgruntled employee that the facility terminated today.

The employee indicated that they would be contacting the SA to get the facility shut down.

The employee in question was listed as LPN A.On [DATE] at 1:52 PM, the compliance officer who handled the hotline when employees called with concerns stated it was the expectation that all staff conducted themselves in an ethical manner and avoided falsifying documentation or providing false information related to residents.

She defined ethical behavior as having good moral character.

Facility ID: