Health inspection·July 18, 2025

F 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to provide the appropriate notices of financial liability for 2 of 3 residents reviewed for Skilled Nursing Facility (SNF) Beneficiary Protection Notification, of a total sample of 26 residents, (#06 and #09).Findings: 1. Resident #06 was admitted to the facility on [DATE] with diagnoses including paroxysmal atrial fibrillation, hypertensive heart disease, type 2 diabetes and benign prostatic hyperplasia (enlarged prostate). Review of resident #06's financial record revealed he began a Medicare Part A skilled nursing stay on 4/23/25 with last covered day on 5/31/25. He remained in the facility and was considered private pay effective 6/01/25. A SNF Beneficiary Protection Notification review revealed resident #06 received a Notice of Medicare Non-Coverage (NOMNC) at the end of his Medicare Part A stay but did not receive a Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN). 2. Resident #09 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including encounter for surgical aftercare following surgery on the digestive system, benign prostatic hyperplasia with lower urinary tract symptoms, paroxysmal atrial fibrillation and hypertensive heart disease with heart failure. Review of resident #09's financial record revealed he began a Medicare Part A skilled nursing stay on 5/05/25 with last covered day on 6/13/25. He had managed Medicaid as his primary payer effective 6/14/25. A SNF Beneficiary Protection Notification review revealed resident #09 received a NOMNC at the end of his Medicare Part A stay but did not receive a SNF ABN. Review of residents who discharged from a Medicare Part A stay in the last six months revealed there were seven residents who discharged from a Medicare Part A stay without using all available days and remained in the facility. On 7/17/25 at 10:15 AM, the Regional Accounts Receivable Director stated there was a change as to who was responsible for issuing the beneficiary forms around the time these forms were missed. She explained the Regional Social Services Director (SSD) issued them previously, but the responsibility was passed to the facility SSD. She stated the facility SSD was not made aware of the need to issue a SNF ABN along with the NOMNC when a resident remained in the facility. She acknowledged they should have been issued to residents #06 and #09. The facility's policy and procedure for Medicare Advance Beneficiary and Medicare Non-Coverage Notices indicated if the facility believed that Medicare would not pay for an otherwise covered skilled services, the resident or representative would be notified in writing why the service(s) may not be covered and of the resident's potential liability for payment of the non-covered service(s). Residents Affected - Few Page 1 of 10 105886 105886 07/18/2025 Ansley Cove Healthcare and Rehabilitation 1301 W Maitland Blvd Maitland, FL 32751

F 0778 Help the resident make transportation arrangements to and from radiology services. Level of Harm - Minimal harm or potential for actual harm Based on interview, and record review, the facility failed to make transportation arrangements for a resident to a specialty medical care appointment, for 1 of 1 residents reviewed for transportation, of a total sample of 26 residents, (#8). Findings: Review of resident #8's record revealed an admission date of 8/17/22. Her diagnoses include spinal stenosis (narrowing), opioid dependence, hereditary and idiopathic neuropathy (nerve pain), chronic pain syndrome, fusion of spine, fibromyalgia, bursitis (inflammation of fluid filled sacs) of right hip and connective tissue stenosis of neural canal of lumbar region. On 7/14/25 at 11:27 AM, the resident stated there were often issues related to her appointments and transportation. She explained she had missed some appointments before and was supposed to have a Magnetic Resonance Imaging (MRI) appointment today which was set up by her pain management physician. The resident conveyed when she talked to staff this morning about her appointment, they said they were not aware of it and so no arrangements were set up. Resident #8 expressed she was very upset because the appointment was made months in advance and required her to be sedated due to her claustrophobia. Review of resident #8's electronic medical record (EMAR) revealed a progress note dated 5/08/25 at 1:57 PM, written by the Social Services Director which indicated the resident had a scheduled appointment for intravenous (IV) sedation for MRI, and a computed tomography (CT) scan on 7/21/25 at 1:00 PM, to arrive at 11:00 AM with a staff member to be transported by the local public transportation company. Review of a note written on 5/08/25 at 1:54 PM, indicated resident #8 had an appointment scheduled for IV sedation for MRI and CT scan on 7/14/25 at 2:30 PM, to arrive at 1:00 PM with a staff member, transportation to be provided by local public transport company. On 7/16/25 at 3:08 PM, the Social Service Director confirmed she wrote the two progress notes on 5/08/25 about the resident's appointments. She stated she did not typically handle transportation and appointments, but the resident was more comfortable with her than other staff. The Social Service Director explained her process was to write information down and then pass it along to nursing staff for them to handle. She confirmed that back in May, the resident was using the local public transportation company but had since been switched to a different transportation company. The Social Service Director acknowledged she did not call the new transportation company to arrange transport for the appointment. She clarified that appointments were put into the resident's orders by nursing, but the Social Service Director could not remember who she passed the new information to at the time of the appointment. On 7/16/25 at 12:15 PM, in a joint interview with the Director of Nursing (DON) and the Unit Manager (UM), the UM said she arranged transportation for resident #8 to her appointments. She explained the resident made her own appointments and notified the facility of the time, date and location of said appointment. The UM continued that she would text the transportation company with the resident's appointment information when she was informed of the appointment. She said the facility kept a transport calendar with all resident appointments for the month. Review of transportation calendar on 7/16/25 at 3:20 PM, with the UM revealed no appointment for resident #8 on 7/14/25 for transportation to her MRI and CT. The calendar did show an appointment for 7/21/25. The UM said she added the 7/21/25 appointment to the calendar on 7/15/25 after she had contacted the pain management physician. She confirmed another appointment was added for September as a make-up appointment for the missed appointment from 7/14/25. On 7/16/25 at 3:35 PM, the DON stated that their process for resident appointments was to write an order in the resident's EMAR listing the date, time, and nature of the appointment. The DON acknowledged there was no order for the resident's appointment on 7/14/25 nor for the one on 7/21/25 until 7/15/25, after they were informed by resident #8 of the missed 7/14/25 appointment. The DON confirmed the progress note on 5/08/25 by the Social Service Director with the appointment Residents Affected - Few 105886 Page 2 of 10 105886 07/18/2025 Ansley Cove Healthcare and Rehabilitation 1301 W Maitland Blvd Maitland, FL 32751

F 0778 details. She stated she was unsure how she missed that. The facility policy titled Resident Transportation revised September 2017 indicated the facility would meet the needs for residents' transportation. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 105886 Page 3 of 10 105886 07/18/2025 Ansley Cove Healthcare and Rehabilitation 1301 W Maitland Blvd Maitland, FL 32751

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm The facility failed to ensure food was served to residents was palatable and served at appetizing temperatures for 2 of the approximately 18 residents who received meal trays from the satellite kitchen and ate in their room, of a total sample of 26 residents.Findings:During the initial screening of residents on 7/14/25 and 7/15/25, several residents stated the food often arrived at their room cold. On 7/16/25 at 12:50 PM, five prepared lunch meal trays were observed sitting in the dining area, three on a cart and two on the counter. Certified Nursing Assistant (CNA) A stated she requested the trays be prepared and provided for her but that four of the trays were for assisted diners and therefore had not yet been served to the residents.At that time the non-insulated lids covering the main plate was observed to have a hole in the middle from which the heat from the food could escape. CNA B arrived at the dining area and explained the CNAs request meals from the tray line server one at a time to ensure they were hot when delivered to residents. She confirmed on this occurrence, that procedure was not followed.On 7/16/25 at 1:05 PM, as the last tray was delivered to a resident, temperatures were taken for two of the remaining trays, then the food was tasted by the Certified Dietary Manager (CDM) for appetizing temperatures and palatability. On the pureed meal tray, the pureed Swiss steak was 116 degrees Fahrenheit (F) and tasted slightly warm but was determined by the CDM to not be at an appetizing temperature. For the second tray containing a regular diet, the peas were 106 degrees F, and the potatoes were 100 degrees F. Per the CDM both tasted cold and were deemed not to be at an appetizing temperature. The CDM stated the procedure for meal trays was they were to be requested one at a time and delivered immediately to ensure the food was served at an appetizing temperature, but in this case, that procedure was not followed. She added it was important to ensure food was served at an appetizing temperature for residents, so they have a good dining experience, and were more likely to eat the food to maintain their nutritional status.The residents who received these meals were all unable to communicate their opinion of their meal temperatures.The facility's undated policy entitled Record of Food Temperatures indicated hot foods would be held at 135 degrees F or greater and would be stirred during holding to redistribute heat throughout the food product. Residents Affected - Some 105886 Page 4 of 10 105886 07/18/2025 Ansley Cove Healthcare and Rehabilitation 1301 W Maitland Blvd Maitland, FL 32751

F 0847 Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure the binding arbitration agreement explicitly granted the resident or their representative the right to rescind the agreement within 30 calendar days of signing it, failed to include that the signer was allowed to communicate with federal, state, or local officials, health department employees, and a representative Ombudsman, and failed to include evidence that the signer acknowledged they understood the agreement for 9 of 9 residents who signed binding arbitration agreements, of a total sample of 26 residents.Findings:On 7/14/25, the facility provided a sample of their Arbitration Agreement which indicated any party signing the agreement had three (3) days from execution of the agreement to cancel or rescind it, instead of 30 days, as required.On 7/18/25 at 10:30 AM, the Admissions Director stated she was responsible for meeting with the resident/resident representative post-admission to get the documents in the admission packet signed and verified the admission agreement included the arbitration agreement. She stated she reviewed the arbitration agreement with the resident/representative and that nine of the current 34 residents had signed the facility's arbitration agreement. The Admissions Director added she was aware the arbitration agreement was not accurate in regard to the provision of three days to rescind the agreement. She said she was anxious to update and correct the form with the residents. The admission Director provided a copy of a recently admitted residents' arbitration agreement for resident #41 as an example, who was admitted on [DATE] and was the responsible party for his account. Resident #41 signed the arbitration agreement which indicated he had three days from execution of the agreement to cancel or rescind it. Review of the agreement revealed it did not include that the signer was allowed to communicate with federal, state, or local officials, health department employees, and a representative Ombudsman, and did not include evidence that the signer acknowledged they understood the agreement.On 7/18/25 at 11:00 AM, the Administrator stated that even though the facility was in the process of finalizing a new facility contract with an updated arbitration agreement, they could not use it yet because they were waiting for the final inspection before legally changing the name of the facility from its previous name to the new one. Residents Affected - Some 105886 Page 5 of 10 105886 07/18/2025 Ansley Cove Healthcare and Rehabilitation 1301 W Maitland Blvd Maitland, FL 32751

F 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 ensure the Quality Assessment & Assurance (QAA) / Quality Assurance and Performance Improvement (QAPI) committee conducted performance improvement activities to ensure prior improvement measures were sustained. Findings: Review of the facility's current QAPI Plan revealed the purpose of the plan was to provide a means to identify and resolve present and potential negative outcomes related to resident care and services; provide structure and processes to correct identified quality and/or safety deficiencies; and to establish and implement plans to correct deficiencies and to monitor the effects of the action plans on resident outcome. The facility had a deficiency cited at F880, for concerns with infection control during the previous recertification survey conducted 9/16/24 through 9/19/24. During this survey, the facility was found to be in noncompliance with

F880. As a result of the repeat deficiency, it was identified there was insufficient auditing and oversight to prevent the citation. On 7/18/2025 at 12:27 PM, the administrator stated the facility had a QAPI committee that met monthly. He explained the committee reviewed department audits as well as survey outcomes, survey window, facility star rating and Quality Measures. He stated when an issue was identified, the QAPI committee would create a performance improvement plan to address the concern and monitored progress through audits reported back to QAPI committee. Findings from the current survey were reviewed with the Administrator. He acknowledged there were repeat citations from the previous recertification survey but was unable to say where the process failure occurred. The Administrator explained he would have to look into the issue further as there was a recent change in ownership and several changes in administration staff. He acknowledged the performance improvement process should continue even with staff changes for the benefit of the residents and staff. 105886 Page 6 of 10 105886 07/18/2025 Ansley Cove Healthcare and Rehabilitation 1301 W Maitland Blvd Maitland, FL 32751

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain a system for tracking and monitoring infections for 3 out of 5 residents, (#13, #22, #35) reviewed for transmission-based precautions; and failed to identify and implement a system to prevent the spread of communicable diseases by not encouraging and providing hand hygiene for 16 of 16 residents reviewed for dining at the facility, of a total sample of 26 residents.Findings: Residents Affected - Some 1. Resident #13 was admitted to the facility on [DATE] with diagnoses including dementia with mood disturbances, persistent asthma, chronic kidney disease, type 2 diabetes and muscle weakness. Review of the resident #13's physician orders revealed no orders for contact isolation. Review of her care plan initiated 3/12/25 revealed no focus for transmission-based precautions. Resident #22, resident #13’s roommate, was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following stroke affecting left non-dominant side, congestive heart failure, and cardiomegaly (enlarged heart). Review of resident #22's physician orders revealed no orders for contact isolation. Review of her care plan initiated 2/07/25 revealed no focus for transmission-based precautions. During medication administration observation on 7/16/25 at 9:21 AM, Licensed Practical Nurse (LPN) I prepared medications for resident #13. On the outside of the resident’s door, was a contact precaution sign which indicated that anyone entering the room should wear gown and gloves and perform hand hygiene. The sign did not indicate which resident (or both) was on isolation precautions. Also outside the room was a plastic container for personal protective equipment (PPE) which was empty of gowns. LPN I entered resident #13’s room without donning PPE. In the room, resident #13 was sitting up in bed with the Unit Manager (UM) at her bedside assisting her with breakfast. The UM was seated in the residents’ Geri-chair beside her bed wearing no PPE. LPN I exited the room and entered again without donning PPE. LPN I stood next to the resident’s bed and leaned over to give the resident her medication, all without gloves or a gown. 2. Resident #35 was initially admitted to the facility on [DATE] with diagnosis including dementia, chronic kidney disease, and facial weakness following stroke. Review of the medical record revealed the resident was readmitted to the facility on [DATE] following a hospitalization with a diagnosis of human Metapneumovirus. Physician orders revealed resident #35 had the antibiotic Cefuroxime Axetil 500 milligrams, twice a day for seven days for infection with a start date of 7/10/25. Per the Centers for Disease Control's Appendix A Guideline for Isolation Precautions it is recommended for infections with human metapneumovirus contact plus standard precautions including use of a mask were used for the duration of the illness, (retrieved on 8/01/25 from www.cdc.gov). On 7/16/25 at 9:26 AM, an isolation sign for droplet precautions was observed on resident #35’s door. A plastic container for PPE was nearby but had no gowns. Review of the electronic medical record (EMAR) revealed the resident did not receive the medication on 7/11/25 at 9:00 AM with an administration note which read, “resident not swallowing and holding medication in mouth.” Further review of the EMAR revealed the resident did not receive 105886 Page 7 of 10 105886 07/18/2025 Ansley Cove Healthcare and Rehabilitation 1301 W Maitland Blvd Maitland, FL 32751

F 0880 Level of Harm - Minimal harm or potential for actual harm the medication on 7/12/25 at 9:00 AM with an administration note which read, “call pharmacy to stat.” Review of the EMAR revealed the resident did not receive the medication again on 7/15/25 at 9:00 AM, with an administration note that indicated, “resident not swallowing medication.” Review of the resident's physician orders revealed there were no orders for droplet isolation. Review of his care plan initiated 3/27/25 revealed no focus for transmission-based precautions or antibiotic therapy. Residents Affected - Some On 7/17/25 at 9:18 AM, Certified Nursing Assistant (CNA) D was observed placing resident #35’s meal tray down on the plastic container which held PPE before entering the resident’s room. CNA D stated she needed to go find PPE since there was an isolation sign for droplet precautions on the door and the container of PPE was empty. CNA D returned and stated the Director of Nursing (DON) informed her resident #35 was not on isolation for droplet precautions and therefore PPE was not required. On 7/17/25 at 9:23 AM, CNA D reported that resident #35 was not on isolation for droplet precautions and therefore she did not need to wear PPE when delivering the resident’s meal tray. She then wondered if the assigned nurse could remove the droplet isolation sign from the resident’s door. On 7/16/25 at 9:48 AM, the DON explained both she and the UM were responsible for infection control at the facility. She stated that the UM was responsible for making sure all PPE supplies were outside the room that was on isolation precautions as well as ensure the appropriate signage was on the door. The DON acknowledged that residents #22 and #13 had no current orders for isolation contact precautions. She was unable to provide a reason why the room had a contact isolation precaution sign on the door if the residents inside did not actually have an order for contact precautions. When DON was informed of resident #35 having a droplet isolation precaution sign on his door and an empty PPE supply box outside, she stated she “didn’t think that room was on precautions,” but said she would look into it. On 7/17/25 at 9:55 AM, the DON confirmed she verified whether residents #13 and #22 had orders for isolation precautions and determined they were not supposed to be on isolation precautions. She acknowledged she did not check to see if they had the correct signage for precautions. She stated that the position of Infection Preventionist was shared between herself and the UM. The DON stated her expectation was for the UM to perform daily rounds to verify which residents were on isolation precautions and refill the PPE supplies outside rooms if needed. On 7/17/25 at 11:36 AM, the DON confirmed resident #35 did not have an order for isolation for droplet precautions nor a care plan focus for it. She stated that while reviewing the resident’s medical record she noted he was admitted to the facility with orders for an antibiotic for treatment of Human Metapneumovirus (HMPV) and he was to remain on droplet isolation precautions until the course of antibiotics was complete. The DON explained that upon admission an order for droplet isolation precautions should have been added to the resident’s EMAR, but it was not. The DON said she relied on the infection control section of their healthcare software to track infections and antibiotics, but she did not actually review the antibiotic orders to verify their accuracy or to determine if any transmission-based isolation precautions were required. The DON explained she expected the UM to monitor the orders and acknowledged infections and antibiotics had not been properly tracked. On 7/18/25 at 11:28 AM, the DON said when a resident was on any type of transmission-based isolation precautions (TBP) an order was added to the resident’s EMAR so staff could easily identify which resident was on isolation precautions. The DON reiterated that while she and the UM shared the role of Infection Preventionist, the UM was responsible for performing the daily rounds of the 105886 Page 8 of 10 105886 07/18/2025 Ansley Cove Healthcare and Rehabilitation 1301 W Maitland Blvd Maitland, FL 32751

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some facility to ensure accurate signage for TBP on resident rooms and to ensure PPE containers were stocked with appropriate supplies. The DON confirmed she was also responsible for monitoring of infections, antibiotics and TBP. The DON was unable to say how incorrect signage and an empty PPE container for residents #13 and #25 was left in place if infections and TBP were monitored as part of their daily surveillance including walking past that room without correcting the issues. When asked if part of her monitoring and tracking of infections included making sure all the doses of an antibiotic were given, she replied “no”. She stated she expected nurses to put information such as missed doses of antibiotics in their 24-hour report book as well as to notify the doctor. In the case of a resident missing doses of an antibiotic, she acknowledged the physician should be notified and then typically doses were added to extend the course of the antibiotic, so the resident received the full dose. The DON stated she was unaware resident #35 had missed three doses of his antibiotic. 3. On 7/14/25, the dining room was observed from 12:00 to 12:35 PM during the lunch service. No hand hygiene was offered by staff to any of the 13 residents eating there. On 7/15/2025 at 11:50 AM, two Activities staff finished an activity with residents and announced to the residents they were going to move everyone to the dining room for lunch. Resident #10, #43, along with two additional residents were moved directly from the room with the activity into the dining room and stayed there until they ate. At 11:57 AM, resident #43 was transported to his room to add a 2nd hospital gown to cover his back and was then transported back to the dining room without washing his hands. No hand hygiene was offered to any of the 12 residents who ate lunch in the dining room for this meal. On 7/17/25 at 8:50 AM, resident #10 stated she ate breakfast in her room and ate lunch and dinner in the dining room. She added that staff did not offer her a way to clean her hands before breakfast nor was she offered a way to clean or disinfect her hands prior to the meals in the dining room. Resident #10 said it would be nice to be offered a way to clean our hands since we touch lots of things during the day. On 7/17/25 at 9:02 AM, Certified Nursing Assistant (CNA) A delivered breakfast, raised the head of the bed, and set up the tray for resident #42, but did not offer hand hygiene. The resident stated the aide assigned to provide her care today did not assist with washing her face and hands before breakfast like she preferred. At 9:04 AM, CNA A delivered breakfast to resident #10 and did not offer hand hygiene. CNA A explained she was not the assigned CNA for resident #42 today, it was CNA C. At 9:07 AM, CNA C confirmed she did not offer to wash residents #10 and #42 this morning before their meal because they were asleep when she arrived. She stated she didn't offer hand hygiene to residents prior to their meals but said it was a good idea. CNA C conveyed it was important to have residents clean their hands before meals to help prevent illness and the spread of germs. In a joint interview on 7/17/25 at 9:26 AM with the DON and the UM, they said the DON was the primary Infection Control nurse, but the UM assisted her. The DON and UM stated they were not aware staff had not offered/assisted residents to have their hands and faces washed before breakfast when they ate in their room. They acknowledged residents brought into the dining room for lunch and dinner were not offered hand hygiene prior to the meals. The DON and UM added, it was important to offer hand hygiene before meals to prevent germs as residents touched things throughout the day and was important to perform before meals. The UM acknowledged she had not provided education to staff on washing residents' hands before meals but had provided education for cleaning their own hands. The facility’s policy entitled Assistance with Meals, dated September 2013, indicated all 105886 Page 9 of 10 105886 07/18/2025 Ansley Cove Healthcare and Rehabilitation 1301 W Maitland Blvd Maitland, FL 32751

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some employees who provided assistance to residents with meals would be trained and demonstrate competency in the prevention of foodborne illness, including personal hygiene practices and safe food handling. The facility job description for Infection Preventionist (IP) revised April 2012 listed the responsibilities of the position to include, develop, maintain and periodically update infection control precautions. The document indicated the IP was responsible to ensure adequate supplies of PPE were on hand and readily available to personnel who perform procedures that involved exposure to bodily fluids. The description detailed the IP was responsible to ensure all nursing service personnel follow established isolation precautions and aseptic technique to include standard/universal precautions. The facility assessment most recently updated 8/01/24 indicated, “the infection prevention program will include detection, prevention and control of infections among residents and personnel through on-going monitoring. The Infection Preventionist will be responsible for the overall daily functions of the infection prevention program to include surveillance and maintaining a line listing of infections.” 105886 Page 10 of 10