Health inspection·October 16, 2025

F 0600 Level of Harm - Actual harm Residents Affected - Few due to fluctuations of weakness, fatigue, and weight bearing status. On 8/06/25, a Focus was added for an actual fall related to unsteady gait with an intervention for 72 hour neuro-checks, and on 10/03/25, wheelchair to be locked when in use per family request. On 9/16/25 after a second fall, a Focus was added for risk of falls related to impaired balance, impaired cognition, and unsteady gait (walking). Interventions were added for a floor mat while the resident was in bed, neuro checks for 72 hours and keep bed in lowest position while in bed. On 10/06/25, interventions were added to anticipate and meet resident's needs, non-skid footwear when out of bed, ensure the call light is within reach, and encourage the resident to use it for assistance as needed. On 10/06/25, a Focus was added for risk of abnormal bleeding related to use of anticoagulant (blood thinner) medication.There was no fall prevention Care Plan Focus from 7/28/25 to 9/16/25, over six weeks. The Order Summary Report showed resident #1 required monitoring for side effects of opioid medications including sleepiness, dizziness, and confusion. Physician's ordered medications included: (8/05/25) Trazodone (anti-depressant) 25 Milligrams (MG) at bedtime for depression/insomnia, (8/22/25) Oxycodone (opiate pain) 10 MG every six hours for pain, (9/10/25) Methadone (opiate pain) 15 MG twice daily for pain, and (9/17/25) Ativan (anti-anxiety) 0.5 MG twice daily, increased (9/24/25) to 0.5 MG every two hours as needed for agitation and anxiety.MDS Care Area Assessments (CAAs) for Falls with positive Care Plan Decisions in both Modified Comprehensive Assessments with ARDs of 8/04/25 (Admission) and 9/05/25 (Significant Change) had triggering conditions associated with resident #1's history of falls and the use of high-risk medications. Both assessments were modified during the survey to correct omissions of the resident's fall history and actual fall in the facility. There were no Focuses in the Comprehensive Care Plan for fall risks associated with high-risk opiate, anti-anxiety, or anti-depressant medications.The Physical Therapy (PT) Evaluation & Plan of Treatment completed 7/29/25 noted resident #1 required high complexity inpatient skilled therapy services 5 times weekly. The Fall Risk Assessment noted the resident was a fall risk with a history of greater than 10 falls in the previous 6 months. The reason for therapy noted the resident had balance and safety awareness deficits. The note read, Due to the documented physical impairments and associated functional deficits, without skilled therapeutic intervention, the patient is at risk for falls, further decline in function and decreased participation with functional tasks.The Occupational Therapy (OT) Evaluation & Plan of Treatment completed 7/29/25 noted resident #1 required skilled inpatient services with precautions that read, Fall risk.The Speech Language Pathologist (SLP) Evaluation and Plan of Treatment documented resident #1 required skilled therapy services with a diagnosis of Cognitive Communication Deficit. Included goals read, Patient will increase cognitive skills to Mild to improve ability to decrease risk for falls, increase ability to participate in ADLs and return to prior level of living. Precautions read, fall risk, confusion.In an interview on 10/15/25 at 11:05 AM, the Therapy Director recalled resident #1 received skilled therapy services during July-August 2025 after admission to the facility. She checked the medical records and explained the resident had significant memory deficits, inattention, and poor safety awareness with scores that were, very poor with severe cognitive decline at the time skilled therapy services ended on 8/30/25. She explained there were daily clinical discussions and weekly meetings where the resident's fall risk levels, plans of care, and interventions were discussed amongst the IDT. She said it was known that resident #1 was a fall risk.The Fall Risk Evaluation completed upon admission on [DATE] was marked negative for any history of falls in the previous 3 months and noted that resident #1 was able to walk however, a Gait/balance risk assessment was not done and marked, not able to perform function. The evaluation was scored at 9 (moderate/low) risk because of the questioned responses. A score of 10 or higher indicated a high risk. The Risk for Falls (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105886 If continuation sheet Page 2 of 15 Printed: 05/28/2026 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 105886 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 0600 Level of Harm - Actual harm Residents Affected - Few section was not marked for a care Focus nor indicated prevention interventions were needed.A Post Fall Evaluation completed 8/06/25 noted resident #1 fell in her room while attempting go to the bathroom alone. No Pre or Post-Fall Risk Scores were entered, and no new fall prevention interventions were marked.A handwritten Hospice Plan of Care Revision/Physician Orders note dated 8/08/25 noted symptoms of weakness and agitation. Interventions included, Monitor/assess safe environment, prevent falls, and anticipate needs.A nurses Progress Note completed by Licensed Practical Nurse (LPN) B on 9/16/25 noted resident #1 fell and was observed lying on the ground in her room. Staff determined the resident attempted to use the bathroom unassisted. The call bell was observed resting on the bed. Resident #1's medical record included two handwritten Neurological Assessment Flow Sheets (neuro-checks) for unwitnessed falls that occurred on 9/16/25 and 10/03/25. There were no records to indicate nurses completed neuro-checks for the resident's first unwitnessed fall at the facility on 8/06/25.On 10/14/25 at 2:27 PM, LPN B said she knew resident #1 and she was frequently included in her assignments during the 7:00 AM to 3:00 PM shift. The nurse recalled on 9/16/25, resident #1 had a second fall in her room. She said she was aware the resident previously fell but she wasn't the nurse then. The nurse explained she was completing medication pass when a Certified Nursing Assistant (CNA) alerted her that resident #1 fell. She said it was common for residents that were known as a fall risk to be placed near the nurses station, but it was difficult for staff to constantly supervise them, especially during medication pass and when CNAs were tasked with assisting them back to bed after dinner. She recalled a fall mat was placed after that fall and explained she took it upon herself to try and check on the resident every hour during her shifts. The nurse explained, after resident #1 was admitted to the facility, she became increasingly confused. She recalled that CNA F told her that on 10/03/25 during the 3:00 PM to 11:00 PM shift, the resident was among other residents placed in wheelchairs at the nurses station after dinner while they waited for assistance back to bed. The nurse recalled CNA F described that during the shift it got busier, no one was watching resident #1, and she fell.In an interview on 10/15/25 at 2:02 PM, CNA F said she knew resident #1 and she was often included in her assignments during the 7:00 AM to 3:00 PM and 3:00 PM to 11:00 PM shifts. She explained it was common practice to have residents sit in their wheelchairs near the nurses station after dinner while they waited for CNAs to assist them back to bed for the night. She said she was aware resident #1 was confused, frequently tried to get out of bed, and she often found her in bed with her leg dangling over the side. She said staff knew it was important to keep an eye on her. She said the resident often verbalized, get me out of here. The CNA recalled on 10/03/25 after dinner, resident #1 was very agitated sitting in the wheelchair near the nurses station, and she threw a blanket onto the floor several times. She said at about 7:45 PM, she noticed the wheelchair was unlocked and observed the resident leaning forward in the chair. She explained she asked the resident to sit back, locked the wheelchair, and told her she would return in a few minutes to assist her to bed because she had to help another CNA with another resident. She recalled a few minutes later while she was in another resident's room, she heard resident #4's daughter yelling out for help because someone fell, so she left and headed down the hallway towards the nurses station where she saw resident #1 on the floor. The CNA said she did not recall seeing any Tasks or Safety directives in the electronic documentation program that CNAs used about watching for a fall. She conveyed that CNAs relied on reports to/from each other and nurses about increased awareness for residents with high fall risks. The Kardex for Certified Nursing Assistants (CNAs) dated as of 10/14/25 noted SAFETY with, encourage resident to use call light for assistance, place floor mats on floor when resident is in bed, and wheelchair to be locked when in use per family request.An Interdisciplinary (IDT) progress note completed by (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105886 If continuation sheet Page 3 of 15 Printed: 05/28/2026 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 105886 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 0600 Level of Harm - Actual harm Residents Affected - Few the former Director of Nursing (DON) dated 9/16/25 noted that resident #1 lost her balance and fell in her room after attempting to walk to the bathroom independently. Fall prevention interventions included: bed in lowest position, floor mats when available, encourage to use call bell when in need of help, continue non-slip socks, and neuro-checks.A Fall Risk Evaluation backdated on 10/05/25 with an effective date of 9/16/25 completed by the former DON indicated resident #1 was disoriented x 3 (person, place, time) at all times, chairbound, there was no Change in Condition in the previous 14 days, no assistive devices (wheelchair) were used, a Gait/balance assessment was not done, and the Fall Risk was again scored at 9 (moderate/low risk).A handwritten Hospice Plan of Care Revision/Physician Orders note dated 9/18/25 noted resident #1 had increased symptoms of anxiety and new anti-anxiety medication was ordered. Included interventions were monitoring for falls and anxiety.A nurses Skilled Evaluation progress note dated 9/21/25 noted resident was alert with forgetfulness and special safety care included having the call light within reach and a low bed. Functional notes indicated resident #1 was non-weight bearing when walking, had poor standing balance, and she was bedfast all or most of the time. A note dated 9/22/25 indicated there were no Safety concerns.A nurses progress note completed by LPN E dated 9/23/25 indicated resident #1 was confused, attempting to get out of bed unassisted, and the Hospice nurse was notified who later evaluated the resident.Two unsuccessful attempts were made to contact LPN E on 10/15/25 at 10:24 AM and 10/16/25 at 2:01 PM.A handwritten Hospice Plan of Care Revision/Physician Orders note dated 9/24/25 noted resident #1 had increased agitation. Included interventions were monitor/assess agitation, and the Ativan medication was increased to 0.5 MG sublingually (under the tongue) every 2 hours as needed.An Order Note dated 9/24/25 included a warning for possible drug interactions with active medication orders for Methadone, Oxycodone, and Ativan coadministration with moderate to severe severity because of increased central nervous system depression.A Nurses note dated 9/27/25 showed the Hospice provider was called due to family concerns and an overall decline in resident #1's ADL functioning.A nurses Skilled Evaluation note dated 10/02/25 read for Special Care/Safety, Call light is within reach.A nurse Progress Note completed by LPN A on 10/03/25 noted resident #1 received Methadone pain medication at 6:00 PM. LPN A's Late Entry Incident Note dated 10/03/25 at 8:20 PM noted resident #1 was in a wheelchair in front of the nurses station during medication pass. While the nurse was in a resident room administering medications, the note read, [resident name] fell out her wheelchair and hit her head on the floor. A progress note completed by LPN A on 10/03/25 indicated resident #1 sustained a laceration to her forehead and 911 was activated for emergency transportation to the hospital and read, resident sent to hospital due to unwitnessed fall.Major risk factors that increase fall risk include: one or more previous falls, medications, and troubles with movement and/or cognition. Opiate, Benzodiazepine (anti-anxiety), and anti-depressant medications are associated with fall risk can cause confusion, fatigue, blood chemistry abnormalities, heart rate/rhythm changes, blood pressure drops upon standing after sitting/lying down, sedation, and balance problems. Many medicines have side effects that may increase the risk of falls. Taking more than one of these medicines increases the risk even more. (retrieved from mayoclinic.org on 10/20/25)The hospital records dated 10/04/25 noted resident #1 required emergency department services after an unwitnessed fall. The note stated the resident fell out of her wheelchair and was found with a forehead laceration with blood on her hands and clothes. She was diagnosed with blunt head trauma and a laceration that required sutures.A Fall Risk Evaluation completed by the former DON was backdated on 10/05/25 with an effective date of 10/03/25 and noted a Gait/balance assessment was not completed (not able to perform). Resident #1's fall risk was again scored as 9 (moderate/low). The actioned clinical suggestions read, Rubber-soled shoes or nonskid slippers worn (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105886 If continuation sheet Page 4 of 15 Printed: 05/28/2026 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 105886 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 0600 Level of Harm - Actual harm Residents Affected - Few for ambulation.The Fall Risk Evaluation Graph showed Fall Risk Scores of 9 (moderate/low risk) on 7/28/25, 8/06/25, 9/16/25, and 10/03/25. The scores did not change even after resident #1 had three unwitnessed falls at the facility.Two unsuccessful attempts were made to interview the former DON by telephone on 10/15/25 at 1:25 PM and 10/16/25 at 9:07 AM.In an interview on 10/15/25 at 11:21 AM, the MDS Coordinator explained falls, care plan interventions, and revisions were discussed in clinical meetings every morning, and in weekly Interdisciplinary Team (IDT) review meetings. She recalled resident #1's falls were previously discussed in those meetings, and interventions were reviewed. She said fall interventions were mostly entered into the Care Plan by both the DON and the MDS Coordinator. She explained the Care Area Assessment (CAA) of the MDS triggered fall risk factors and care plan decisions. On 10/16/25 at 9:17 AM, she checked resident #1's medical record and found there was incorrect fall history coding in resident #1's MDS's. She checked the Comprehensive Care Plan and confirmed that a Fall prevention care plan was not entered timely, and the fall history prior to admission was missing. She relayed that the previous MDS Coordinator did not thoroughly check all the medical records and had missed it. She said on 8/05/25, an intervention was entered that read, encourage to use the call light. She checked the BIMS score and confirmed the resident scored 8 out of 15 which indicated cognitive impairment. She conveyed the intervention was not a safe, reliable choice for resident #1 because she would not always remember to use the call light, and she had a second fall after that.On 10/15/25 at 1:51 PM, via the telephone, resident #1's daughter recalled she received a phone call from LPN A on 10/03/25 who informed her that her mom fell from her wheelchair. She explained LPN A said no one was watching the resident because the CNAs were inside other rooms putting resident's down, and the other nurse was in a resident room administering medications. She said staff knew her mom was a fall risk and fell multiple times at home and two other times in the facility. She said she visited often and expressed her concerns to staff about leaving her in a wheelchair alone because she leaned forward, moved forward, and often bent over from the side effects of heavily sedating medications. She said it was common practice after dinner for staff to leave residents in wheelchairs near the nurses station. She said she was very concerned that there was not enough staff supervision for fall prevention safety, and she asked for more supervision before the last fall. She said all they did was put a floor mat in her room and my mom couldn't remember to use a call light. She recalled sending an email to the former DON about her concerns around 9/27/25 because she had visited around 5:00 PM and found the room door was closed, the room was dark, and her mom was restless and halfway off the bed. She said after the last fall, her mother rapidly declined, required oxygen, and 24/7, 1-1 Hospice Crisis Care.On 10/15/25 at 2:23 PM, via the telephone resident #4's daughter recalled on 10/03/25 around 8:00 PM, she had visited her mother when a resident fell out of a wheelchair near the nurses station. She explained no staff were around and it was common practice that residents were left unsupervised in wheelchairs near the nurses station after dinner. She said her mother recently left the facility and also had falls when she was there. She said her mom took blood thinners and she was concerned that she would have a bad fall because staff left residents unsupervised in wheelchairs, all the time. She recalled when resident #1 fell, she observed that a nurse responded to her on the floor and she heard her yell out, where is everybody? She stated, That's why my mom isn't there anymore; I told them multiple times she was not supervised, and she was going to fall.According to the Agency for Healthcare Research and Quality (AHRQ), a history of a fall is the single best predictor of future falls, and 30-40% of those residents who fall will do so again. Fall Management programs and prompt staff response with proper plan of care development, interventions, and investigation of fall circumstances are crucial fall prevention steps. The AHRQ resource read, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105886 If continuation sheet Page 5 of 15 Printed: 05/28/2026 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 105886 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 0600 Level of Harm - Actual harm Residents Affected - Few Resident response must also be monitored to determine if an intervention is successful. Changes in care and alternate interventions should be decided based on continued assessment of the resident and family input. (retrieved on 10/21/25 from https://www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/man2.html).On 10/14/25 at 3:26 PM, Registered Nurse (RN) G said she worked the 3:00 to 11:00 PM shift and she knew resident #1 well. She recalled resident #1 was restless and needed more than average supervision and stated, you are supposed to do 30 minute or one hour checks.On 10/15/25 at 11:49 AM, via the telephone, RN D said she worked 3:00 PM to 11:00 PM and 11:00 PM to 7:00 AM shifts, and resident #1 was frequently included in her assignments. The RN recalled prior to the last fall, the resident experienced increased restlessness and frequently dangled her feet off the bed. She did not recall seeing any individualized fall prevention interventions or orders in the electronic medical record. The RN stated, I was very concerned about her fall risk; the safety and wellness stuff was like nursing.On 10/15/25 at 2:30 PM, Physical Therapy Assistant (PTA) I recalled she knew resident #1 well who was frequently assigned to her for previous therapy services. She said without staff assistance, the resident would likely fall, precautions were part of the plan of care, and nursing was responsible for implementing therapy recommendations.On 10/14/25 at 3:45 PM, the Unit Manager explained she knew resident #1, and the resident was frequently agitated. The RN recalled resident #1 had increased agitation and attempted to climb out of bed. She said residents with a history of falls should be checked at least every 30 minutes. She stated, the former DON was involved with this one; I know they work together with MDS and if they need me to do anything, they let me know.On 10/15/25 at 9:54 AM, the Hospice Case Manager RN recalled resident #1 had a recent fall after she came forward while sitting in a wheelchair near the nurses station. The nurse explained the resident was on a combination of narcotic medications that caused increased drowsiness. She said after the last fall, the resident's condition declined further, and she was placed on Crisis Care with expected imminent death.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 recalled on 10/03/25, she worked during the 3:00 PM to 11:00 PM shift but was not resident #1's assigned nurse. She recalled after she exited another resident's room, she proceeded down the hallway towards the nurses station, and in the distance she saw something on the floor. She explained as she got closer, she realized it was a resident, and she immediately responded rendering aid, and she did not see anyone else around. She said after dinner, it was a typical practice to place residents with known fall risks in their wheelchairs near the nurses station while they waited for CNAs to assist them back to bed. The DON explained she was not aware of a specific Falls Program. 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, changes in condition, and the risk score should 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. She stated there were missing interventions in the care plan, and she could not find a baseline care plan. The DON recalled on 10/03/25 during the 3:00 PM to 11:00 PM shift when she worked on the unit, she observed resident #1 slumped over in the chair at times, and she should not have been left unsupervised. She said it was unrealistic to expect CNAs and nurses to provide increased supervision to residents in wheelchairs at the nurses station while they provided medication administration, responded to needs, and assisted other residents to bed. She conveyed resident #1 should have received (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105886 If continuation sheet Page 6 of 15 Printed: 05/28/2026 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 105886 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 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: 105886 If continuation sheet Page 7 of 15 Printed: 05/28/2026 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 105886 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 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement appropriate interventions to include provision of adequate supervision to mitigate the prevention of fall with injury for 1 of 4 residents reviewed for Quality of Care, (#1).The facility's failure to increase supervision for a resident with a history of repeated falls who also received high-risk medications resulted in actual harm.Findings:Review of the medical record revealed resident #1, a [AGE] year-old female was admitted to the facility from an acute care hospital on 7/28/25 with diagnoses including generalized muscle weakness, difficulty in walking, lack of coordination, and cognitive communication deficit.Review of the most recent Modified Minimum Data Set (MDS) Comprehensive Significant Change Assessment with an Assessment Reference Date (ARD) of 9/05/25 revealed during the look back period, resident #1 scored 8 out of 15 on the Brief Interview for Mental Status (BIMS) which indicated moderate cognitive impairment. The Functional Abilities and Goals assessment showed the resident did not use mobility devices such as a wheelchair or walker and required moderate staff assistance to complete Activities of Daily Living (ADLs) and mobility functions. Walking was not assessed due to medical condition/safety concerns. The resident was incontinent with bladder and bowel functions, had a history of falls since admission/entry or re-entry/prior assessment, and she received high-risk antidepressant, opioid (narcotic pain), and antiplatelet (blood clot prevention) medications. The Modified MDS Comprehensive admission Assessment with an ARD of 8/04/25 noted resident #1 scored 8 out of 15 on the BIMS, had at least 1 fall in the last month prior to admission/entry/re-entry, and at least 1 fall in the last 2-6 months prior to admission/entry/reentry. Both assessments indicated a Care Area was triggered for an identified problem of Confusion/disorientation/forgetfulness, risk of high-risk medication adverse effects including sedation manifested by short-term memory loss, decline in cognitive abilities, drowsiness, and increased risk for Falls with noted positive Care Plan Decisions. On 10/14/25 at 10:45 AM, resident #1 was observed lying in bed in her room with her eyes closed. Two healing bruises were observed on the resident's forehead, measuring approximately 2 Centimeters (CM) in length by 0.5 CM in width. The Hospice provider's Crisis Care Licensed Practical Nurse (LPN) was sitting at the resident's bedside. The nurse said the bruises were from a recent fall, and the resident's status changed to Crisis Care on 10/12/25 during the night shift. On 10/15/25 at 10:52 AM, resident #1 was observed in her room lying in bed. She was awake and somewhat restlessly changing positions. The Crisis Care LPN was sitting at her bedside.The nurses' Clinical admission assessment dated [DATE] noted resident #1 did not have a history of falls in the last month or six months prior to admission/entry/re-entry with one fall prevention intervention to keep the call light within reach. No Safety Education/Notification concerns were identified, and no Care Planning Focus Safety Concerns were indicated.The Care Plan Report's Focuses included: (7/29/25) ADL self-performance deficit related to generalized weakness/medications/effects of medications with an intervention of 1-2-person assistance due to fluctuations of weakness, fatigue, and weight bearing status. On 8/06/25, a Focus was added for an actual fall related to unsteady gait with an intervention for 72-hour neuro-checks, and on 10/03/25, wheelchair to be locked when in use per family request. On 9/16/25 after a second fall, a Focus was added for risk of falls related to impaired balance, impaired cognition, and unsteady gait (walking). Interventions were added for a floor mat while the resident was in bed, neuro checks for 72 hours and keep bed in lowest position while in bed. On 10/06/25, interventions were added to anticipate and meet resident's needs, non-skid footwear when out of bed, ensure the call light is within reach, and encourage the resident to use it for assistance as needed. On 10/06/25, a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105886 If continuation sheet Page 8 of 15 Printed: 05/28/2026 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 105886 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 Residents Affected - Few Focus was added for risk of abnormal bleeding related to use of anticoagulant (blood thinner) medication.There was no fall prevention Care Plan Focus developed from 7/28/25 to 9/16/25, over six weeks,The Order Summary Report showed resident #1 required monitoring for side effects of opioid medications including sleepiness, dizziness, and confusion. Physician's ordered medications included: (8/05/25) Trazodone (anti-depressant) 25 Milligrams (MG) at bedtime for depression/insomnia, (8/22/25) Oxycodone (opiate pain) 10 MG every six hours for pain, (9/10/25) Methadone (opiate pain) 15 MG twice daily for pain, and (9/17/25) Ativan (anti-anxiety) 0.5 MG twice daily, increased (9/24/25) to 0.5 MG every two hours as needed for agitation and anxiety.On 10/15/25 at 11:05 AM, the Therapy Director recalled resident #1 received skilled therapy services during July-August 2025 after admission to the facility. She checked the medical records and explained the resident had significant memory deficits, inattention, and poor safety awareness with scores that were, very poor with severe cognitive decline at the time skilled therapy services ended on 8/30/25. She explained there were daily clinical discussions and weekly meetings where the resident's fall risk levels, plans of care, and interventions were discussed amongst the IDT. She said it was known that resident #1 was a fall risk.Review of the therapy evaluations for Physical Therapy, Occupational Therapy and Speech Therapy dated 7/29/25 all indicated resident #1 was at risk for falls.On 10/14/25 at 2:27 PM, Licensed Practical Nurse (LPN) B said she knew resident #1, and she was frequently included in her assignments during the 7:00 AM to 3:00 PM shift. The nurse recalled on 9/16/25, resident #1 had a second fall in her room. She said she was aware the resident previously fell but she wasn't the nurse then. The nurse explained she was completing medication pass when a Certified Nursing Assistant (CNA) alerted her that resident #1 fell. She said it was common for residents that were known as a fall risk to be placed near the nurses' station, but it was difficult for staff to constantly supervise them, especially during medication pass and when CNAs were tasked with assisting the residents back to bed after dinner. She recalled a fall mat was placed after that fall and explained she took it upon herself to try and check on the resident every hour during her shifts. The nurse explained, after resident #1 was admitted to the facility, she became increasingly confused. She recalled that CNA F told her that on 10/03/25 during the 3:00 PM to 11:00 PM shift, the resident was among other residents placed in wheelchairs at the nurses' station after dinner while they waited for assistance back to bed. The nurse recalled CNA F described that during the shift it got busier, no one was watching resident #1, and she fell.On 10/15/25 at 2:02 PM, CNA F said she knew resident #1, and she was often included in her assignments during the 7:00 AM to 3:00 PM and 3:00 PM to 11:00 PM shifts. She explained it was common practice to have residents sit in their wheelchairs near the nurses' station after dinner while they waited for CNAs to assist them back to bed for the night. She said she was aware resident #1 was confused, frequently tried to get out of bed, and she often found her in bed with her leg dangling over the side. The CNA said staff knew it was important to keep an eye on her. She said the resident often verbalized, get me out of here. The CNA recalled on 10/03/25 after dinner, resident #1 was very agitated sitting in the wheelchair near the nurses station. The resident threw a blanket onto the floor several times. The CNA stated at about 7:45 PM, she noticed the wheelchair was unlocked and observed the resident leaning forward in the chair. She explained she asked the resident to sit back, locked the wheelchair, and told the resident she would return in a few minutes to assist her to bed. She stated at the time she had to help another CNA with another resident. She recalled a few minutes later while she was in another resident's room, she heard resident #4's daughter yelling out for help because someone fell. The CNA explained at that time she headed down the hallway towards the nurses' station where she saw resident #1 on the floor. The CNA said she did not recall seeing any Tasks or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105886 If continuation sheet Page 9 of 15 Printed: 05/28/2026 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 105886 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 Residents Affected - Few Safety directives in the electronic record regarding fall risk precautions for resident #1. She conveyed that CNAs relied on reports to/from each other and nurses about increased awareness for residents with high fall risks. A nurse Progress Note completed by LPN A on 10/03/25 noted resident #1 received Methadone pain medication at 6:00 PM. LPN A's Late Entry Incident Note dated 10/03/25 at 8:20 PM noted resident #1 was in a wheelchair in front of the nurses station during medication pass. While the nurse was in a resident room administering medications, the note read, [resident name] fell out her wheelchair and hit her head on the floor. A progress note completed by LPN A on 10/03/25 indicated resident #1 sustained a laceration to her forehead and 911 was activated for emergency transportation to the hospital and read, resident sent to hospital due to unwitnessed fall.Review of resident #1's medical record revealed hospital records dated 10/03/25, noted resident #1 required emergency department services after an unwitnessed fall. The note stated the resident fell out of her wheelchair and was found with a forehead laceration with blood on her hands and clothes. She was diagnosed with blunt head trauma and a laceration that required sutures.On 10/15/25 at 11:21 AM, the MDS Coordinator explained falls, care plan interventions, and revisions were discussed in clinical meetings every morning, and in weekly Interdisciplinary Team (IDT) review meetings. She recalled resident #1's falls were previously discussed in those meetings, and interventions were reviewed. She said fall interventions were mostly entered into the Care Plan by both the Director of Nursing (DON) and the MDS Coordinator. She explained the Care Area Assessment (CAA) of the MDS triggered fall risk factors and care plan decisions. On 10/16/25 at 9:17 AM, the MDS Coordinator 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, and the fall history prior to admission was missing. She relayed that the previous MDS Coordinator did not thoroughly check all the medical records and must've missed it. She said on 8/05/25, an intervention was entered that read, encourage to use the call light. She checked the BIMS score and confirmed the resident scored 8 out of 15 which indicated cognitive impairment. The MDS Coordinator confirmed the intervention was not a safe, reliable choice for resident #1 because she would not always remember to use the call light, and she had a second fall after that.According to the Agency for Healthcare Research and Quality (AHRQ), a history of a fall is the single best predictor of future falls, and 30-40% of those residents who fall will do so again. Fall Management programs and prompt staff response with proper plan of care development, interventions, and investigation of fall circumstances are crucial fall prevention steps. The AHRQ resource read, Resident response must also be monitored to determine if an intervention is successful. Changes in care and alternate interventions should be decided based on continued assessment of the resident and family input. (retrieved on 10/21/25 from https://www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/man2.html).Review of the facility's standards and guidelines dated 9/01/21 titled Fall Prevention Program outlined compliance guidelines that included use of standardized risk assessments that categorized low, moderate, and high scores. Nurses initiate interventions of the resident's baseline care plan in accordance with the risk level. The high-risk protocol included additional interventions of increased frequency of rounds, sitter if indicated, medication regimen review, alternate call system access. Risk factors are evaluated when developing a comprehensive care plan. Interventions are monitored for effectiveness, and the plan of care is revised as needed. After a fall, the facility will complete a post-fall assessment, review the resident's care plan and update as indicated, and document all assessments and actions.Review of the facility's undated standards and guidelines titled Incidents and Accidents outlined its purposes included meeting regulatory requirements for analysis, conducting root (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105886 If continuation sheet Page 10 of 15 Printed: 05/28/2026 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 105886 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: 105886 If continuation sheet Page 11 of 15 Printed: 05/28/2026 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 105886 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 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain accurate and complete medical records for 1 of 4 residents reviewed for Quality of Care, (#1). Specifically, the Director of Nursing (DON) incorrectly documented and backdated resident records, resulting in inaccurate information in the clinical record and the Minimum Data Set (MDS) Coordinator inaccurately recorded fall histories. This deficient practice had the potential to affect all residents by compromising the accuracy and integrity of resident medical information used to make care decisions.Findings:Review of the medical record revealed resident #1, a 58-year- old female was admitted to the facility from an acute care hospital on 7/28/25 with diagnoses including generalized muscle weakness, difficulty in walking, lack of coordination, and cognitive communication deficit.Review of the most recent Modified Minimum Data Set (MDS) Comprehensive Significant Change Assessment with an Assessment Reference Date (ARD) of 9/05/25 revealed during the look back period, resident #1 scored 8 out of 15 on the Brief Interview for Mental Status (BIMS) that indicated moderate cognitive impairment. The Functional Abilities and Goals assessment showed the resident did not use mobility devices such as a wheelchair or walker and required moderate staff assistance to complete Activities of Daily Living (ADLs) and mobility functions. Walking was not assessed due to medical condition/safety concerns. The resident was incontinent with bladder and bowel functions, had a history of falls since admission/entry or reentry/prior assessment, and she received high-risk antidepressant, opioid (narcotic pain), and antiplatelet (blood clot prevention) medications. The Modified MDS Comprehensive admission Assessment with an ARD of 8/04/25 noted resident #1 scored 8 out of 15 on the BIMS, had at least 1 fall in the last month prior to admission/entry/reentry, and at least 1 fall in the last 2-6 months prior to admission/entry/reentry. Both assessments indicated a Care Area was triggered for an identified problem of Confusion/disorientation/forgetfulness, risk of high-risk medication adverse effects including sedation manifested by short-term memory loss, decline in cognitive abilities, drowsiness, and increased risk for Falls with noted positive Care Plan Decisions. The Fall Risk Evaluation completed upon admission on [DATE] was marked negative for any history of falls in the previous 3 months and noted that resident #1 was able to walk however, a Gait/balance risk assessment was not done and marked, not able to perform function. The evaluation was scored at 9 (moderate/low) risk because of the questioned responses. A score of 10 or higher indicated a high risk. The Risk for Falls section was not marked for a care Focus nor indicated prevention interventions were needed.A Fall Risk Evaluation backdated on 10/05/25 with an effective date of 9/16/25 completed by the former DON indicated resident #1 was disoriented x 3 (person, place, time) at all times, chairbound, there was no Change in Condition in the previous 14 days, no assistive devices (wheelchair) were used, a Gait/balance assessment was not done, and the Fall Risk was again scored at 9 (moderate/low risk).A Fall Risk Evaluation completed by the former DON was backdated on 10/05/25 with an effective date of 10/03/25 and noted a Gait/balance assessment was not completed (not able to perform). Resident #1's fall risk was again scored as 9 (moderate/low).The Fall Risk Evaluation Graph showed Fall Risk Scores of 9 (moderate/low risk) on 7/28/25, 8/06/25, 9/16/25, and 10/03/25. The scores did not change even after resident #1 had three unwitnessed falls at the facility.Two unsuccessful attempts were made to interview the former DON by telephone on 10/15/25 at 1:25 PM and 10/16/25 at 9:07 AM.In an interview on 10/15/25 at 11:21 AM, the MDS Coordinator explained that fall interventions were mostly entered into the Care Plan by both the DON and the MDS Coordinator. She explained the Care Area Assessments (CAAs) of the MDS triggered fall risk factors and care plan decisions. On 10/16/25 at 9:17 AM, she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105886 If continuation sheet Page 12 of 15 Printed: 05/28/2026 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 105886 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: 105886 If continuation sheet Page 13 of 15 Printed: 05/28/2026 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 105886 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 F0600 (Free from Abuse and Neglect), F0610 (Investigate/Prevent/Correct Alleged Violation), F0689 (Free of Accident Hazards/Supervision/Devices). On 7/14/25, a recertification survey was conducted, and Enforcements were issued for 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 F0610 and F0600 and 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: 105886 If continuation sheet Page 14 of 15 Printed: 05/28/2026 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 105886 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: 105886 If continuation sheet Page 15 of 15