Ansley Cove Healthcare And Rehabilitation

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

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

11:30 PM to 11:45 PM, she was at the medication cart when she heard LPN E inform RN B that resident #2 was deceased . She recounted that LPN E questioned CNA C about when she had last seen resident #2 and CNA C started yelling that she had not taken care of resident #2 because she thought the resident was

in the hospital. She said LPN E stated resident #2 was in rigor mortis when she was found so it must have been a few hours since she passed. She said LPN E assisted RN B with running the code, calling the DON, and placing the crash cart in resident #2's room prior to EMS arrival. LPN A revealed she observed RN B performing CPR on resident #2 even though she was already deceased . She learned resident #2's core body temperature was 90.7 F from EMS, when they returned to pick up equipment they left behind which confirmed she had been deceased for a long time. LPN A said she was not asked to write a witness statement by the DON or NHA. On [DATE REDACTED] at 11:09 AM, resident #2's granddaughter/Power of Attorney (POA) said she learned of her grandmother's passing from the hospital on [DATE REDACTED] some time after 1:00 AM.

The emergency room physician informed her resident #2 had no pulse on the way to the hospital, that her body was cold, and that she had most likely been deceased for some time. The granddaughter stated a family member visited with resident #2 on [DATE REDACTED] and she appeared anxious, and confused. She said her grandmother was mostly non-verbal and required a lot of care because she was unable to move on her own. She believed the facility neglected to provide the care her grandmother needed and were not forthcoming about her death. On [DATE REDACTED] at 2:40 PM, the NHA and DON who was also the Abuse Coordinator were interviewed. The DON recalled receiving a call from RN B at approximately 12:30 AM on [DATE REDACTED] to inform her resident #2 was found unresponsive and CPR was initiated. She said she instructed RN B to collect witness statements from staff involved. The DON denied knowing resident #2 had passed when she was called and maintained she did not instruct staff to perform CPR on an already deceased resident. She said the medical director informed her and the NHA that resident #2 had passed away at the hospital because he had reviewed the hospital record. The DON and NHA denied knowing resident #2 had already passed prior to being found by staff and that she arrived at the hospital in rigor mortis with a body temperature of 90.7 F. On [DATE REDACTED] at 11:03 PM, the medical director stated nurses were expected to initiate CPR for full code residents when indicated. He mentioned dependent residents were expected to be checked approximately every two hours. The medical director stated he was informed of the incident the following day and that the facility was conducting an internal investigation. He indicated he shared findings from his review of the hospital records with facility leadership. Review of the facility's policy and procedure

on CPR revised [DATE REDACTED] revealed staff should not perform CPR if the resident showed obvious signs of clinical death including rigor mortis. The facility's policy and procedure on Abuse, Neglect, and Exploitation revised [DATE REDACTED] defined neglect as the failure of the facility, its 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. Possible indicators of neglect include failure to provide care needs such as comfort, safety, feeding, bathing, dressing, and turning/repositioning.

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Facility ID:

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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

12/19/2025

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 0610 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

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

[DATE REDACTED]. The Administrator and DON said they did not include any witness statement or interview from the EMS responders for the facility's investigation. The DON said since the code blue she had reinterviewed the staff who had given statements. However, neither the Administrator nor DON could explain why they did not seek out a statement from LPN A, the staff person who alleged neglect. On [DATE REDACTED] at 12:22 PM, CNA G indicated she was assigned to resident #2 on [DATE REDACTED] during the 11 PM to 7 AM shift. She said she was unable to talk and ended the call. During a retuned call, CNA G stated resident #2 was already deceased when she arrived to work at 11:30 PM on [DATE REDACTED]. 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.

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

12/19/2025

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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

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

the incident the following day and shared findings from his review of the hospital records with facility leadership. On [DATE REDACTED] at 2:40 PM, an interview was conducted with the Administrator (NHA) and the DON.

The DON stated she received a call from RN B after resident #2 was transferred to the hospital. She indicated she instructed the nurse to collect witness statements from staff working that night. 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 REDACTED] 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 REDACTED] 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.

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

12/19/2025

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

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

12/19/2025

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

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

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 REDACTED] but there were no recommendations made related to hospice care.On [DATE REDACTED] at 1:20 PM, the staffing coordinator confirmed LPN A had texted her on [DATE REDACTED] 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 REDACTED] 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 REDACTED] 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 REDACTED] 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 REDACTED] 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.

Event ID:

Facility ID:

If continuation sheet