Health inspection·December 19, 2025

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few report dated [DATE], dispatch received the call from the facility at 12:33 AM and arrived on scene at 12:40 AM. Upon arrival resident #2 was cold to the touch, pulseless, in asystole (absence of heart activity), and exhibited stiffness of the neck and face preventing intubation. Resident #2 did not respond to multiple rounds of CPR and did not regain consciousness. On [DATE] at 9:00 AM, interview with EMS staff who responded to the facility on [DATE], said they believed resident #2 had been deceased for some time prior to initiation of CPR.Hospital records dated [DATE], revealed resident #2 arrived at the hospital at 1:14 AM via EMS with very rigid extremities, a core body temperature of 90.7 degrees Fahrenheit (?), and recurrent rigor mortis. According to Medicine Net, after death the body will turn stiff over a few hours. In the stage of rigor mortis, the body begins to harden but is still movable from 0-8 hours and the muscles become fully stiff from 8-12 hours. The stiffness starts on the face/head, neck, chest, and continues down to abdomen and lower extremities. An article by Biology Insights notes that the body cools at an average rate of 1.5 to 2 degrees per hour. (Retrieved [DATE]. https://www.medicinenet.com/what_are_the_stages_of_rigor_mortis/article.htm, https://biologyinsights.com/how-long-does-a-dead-body-stay-warm-after-death/). Normal body temperature is between 97-99 degrees Fahrenheit. Taking the lowest body temperature of 97 degrees F, the estimated time resident #2 had been deceased was at least 3 hours minimum before she was found unresponsive. On [DATE] at 4:34 PM, Licensed Practical Nurse (LPN) F confirmed she was the assigned nurse for resident #2 on [DATE] during the 3-11 PM shift. She said during her initial rounds, resident #2 was peacefully asleep and her vital signs were within normal limits when taken at 4:45 PM. LPN F said she administered medications to resident #2 at around 7:45-8:00 PM via g-tube and she was still sleeping. She said she saw resident #2 again at around 10:15-10:30 PM and she was still sleeping. LPN F did not assess resident #2 for responsiveness or checked if she was breathing because she said it was normal for her to sleep all day due to the medications she was taking. LPN F said she left the facility at 11:30 PM and learned resident #2 had passed when she returned for her shift the next day. A skilled nursing note in resident #2's medical record by LPN F on [DATE] at 10:35 PM, documented resident #2 was alert and oriented x 3 (person, place, time), communicated verbally with clear speech, had warm skin, and took nutrition/hydration orally. This was in contradiction to the MDS assessments and interviews that noted the resident was dependent, non-verbal with severe cognitive impairment and received all nutrition and hydration via gastric tube and not orally. Review of the Medication Administration Report from [DATE]-[DATE] for resident #2, revealed there were no medications ordered or given that would cause excessive sedation or sleepiness. Review of resident #2's Documentation Survey Report for [DATE], revealed that on [DATE] Certified Nursing Assistant (CNA) C documented at 10:59 PM that resident #2 was not available for any of ADL tasks, like bladder/bowel elimination, transfers in/out of bed, personal hygiene, or repositioning in bed. The record noted resident #2 was to be monitored for safety every hour but CNA C documented resident was not available for the entire 3-11 PM shift. The last safety check on that day was documented at 1:50 PM by the 7 AM- 3 PM CNA. On [DATE] at 5:33 PM, CNA C confirmed she was the assigned CNA for resident #2 on [DATE] during the 3-11 PM shift. She recalled she was very busy that evening because she had 12 residents assigned to her. She said resident #2 slept the whole shift except for one time when she opened her eyes slightly and smiled at her. CNA C said resident #2 did not have a bowel movement so there was no need to change her brief, but she emptied her urinary catheter bag once during the shift. She said resident #2 required repositioning every few hours but she did not do it because she was busy. CNA C verified she was at the facility past 12:00 AM completing documentation but didn't learn of resident #2's death until she returned for her shift on [DATE]. In a follow up interview with CNA C on [DATE] at 6:09 PM, she said (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 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few she mistakenly documented resident #2 was not available because she confused her with a resident who was hospitalized in the room next to resident #2.Review of the facility's Admissions and Discharges from [DATE] to [DATE], review of facility census, and medical record revealed resident in the next room was not in the hospital on [DATE] or in the month of November.On [DATE] at 11:30 AM, during a telephone call CNA G said she was assigned to resident #2 on [DATE] during the overnight shift. She said she arrived to work late that night at 11:30 PM and went to do her rounds right away. CNA G recalled resident #2 was asleep and her urinary catheter bag was full. She was unable to explain why she lifted resident #2's covers to touch her legs, but she said resident #2 was cold to the touch. She covered resident #2 back up and walked out of the room without reporting her findings to the nurse. Contrary to CNA C's statement that she emptied the urinary bag, CNA G recalled CNA C reported not emptying resident #2's urinary catheter bag but there was no other communication. CNA G disconnected the telephone call abruptly after being asked if she participated in the code blue. In a later returned phone call, CNA G divulged resident #2 had already been deceased when she arrived for her shift at 11:30 PM. She revealed that when she did rounds, she observed resident #2 appeared stiff and cold to the touch. She added that CNA C disclosed during report that she had not provided any care to resident #2 during the whole shift but did not provide a reason. CNA G verbalized that she felt pressured by the Nursing Home Administrator (NHA) and Director of Nursing (DON) to give false witness statement, and she feared retaliation if she did not do so.On [DATE] at 2:09 PM, Registered Nurse (RN) B confirmed she was the assigned nurse on the 11 PM to 7 AM shift for resident #2 on [DATE]. She received report from LPN F and recalled there was nothing significant reported about resident #2. She said that just after midnight, on [DATE], she was standing at her medication cart with LPN D when LPN E came to tell her she needed to check on resident #2 because she did not look okay, her mouth was open, lips were dry, and she was unresponsive. RN B said LPN E had attempted to do a sternal rub and reposition the resident but she did not respond. RN B recalled going to see resident #2 a little after midnight and she was resting with her mouth open but there was nothing different about her. She said resident #2 was pulseless but her skin temperature was normal. At around 12:25 AM she called a code blue, placed the resident on a back board with assistance from CNA G and LPN D, initiated CPR, and had LPN D bring the crash cart to the room. She recalled police arrived first at about 12:30 AM and took over CPR followed by EMS at 12:35 AM. RN B said resident #2 remained unresponsive and was transferred to the hospital at approximately 12:45 AM. On [DATE] at 3:05 PM, LPN E confirmed she worked 11 PM-7 AM on [DATE]. She said she arrived at the facility on time and had been assigned to train LPN A. While LPN A was at the medication cart, she went to do rounds on her assigned residents and to stock the tube feeds. She recalled entering resident #2's room some time before midnight to stock tube feed supplies and noticed the resident didn't look as good as the last time she saw her. She said resident #2's eyes were closed, she was lying on her left side covered with a blanket, her lips looked ashy and dry, but she looked comfortable. LPN E reported her observations to RN B but she did not perform an assessment on the resident prior to exiting the room. LPN E went about her duties and said RN B approached her just after midnight asking about resident #2's code status because she was unresponsive. RN B called a code, but LPN E said she was not part of it because resident #2 was not her resident. She recalled CNA C was still there charting, so she asked her when she last saw resident #2 and CNA C responded it had been a few hours. On [DATE] at 3:45 PM, LPN A said she was training with LPN E on [DATE] during the 11 PM to 7 AM shift and arrived a few minutes before the start of her shift. She confirmed CNA C was still there charting and LPN F was providing report to RN B. She recalled LPN E did rounds on all residents that night including resident #2 and that at about (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 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 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] 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] 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] 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] 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] 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] 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] 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] 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. 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 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 Respond appropriately to all alleged violations. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and interview, the facility failed to investigate allegation of neglect to ensure staff recognized change in resident condition and provided timely interventions for 1 out of 15 residents reviewed for advanced directives, (#2). On [DATE] after midnight, resident #2 was found unresponsive and staff initiated 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. The facility Administration's failure to consider the hospital report findings indicating the resident had been deceased for some time and failure to conduct a complete and accurate investigation resulted in Immediate Jeopardy starting on [DATE].Findings: Resident #2 was originally admitted to the facility on [DATE]. The resident was hospitalized and readmitted to the facility on [DATE] and her diagnosis included encephalopathy, type 2 diabetes, stroke, heart failure and dementia. Medical record review revealed a Minimum Data Set assessment dated [DATE] in which resident #2 scored 3 out of 15 on the Brief Interview for Mental Status that indicated severe cognitive impairment. The MDS assessment also noted, resident #2 was dependent on staff for all Activates of Daily Living care to include mobility and incontinence care. Due to swallowing difficulties, the resident received all medications and nutrition through gastric tube. The resident had a stage 4 pressure wound to the coccyx. The resident's care plan indicated that staff needed to reposition the resident, every 2 hours at a minimum, to off load the pressure to promote wound healing. Review of staff schedules revealed Certified Nursing Assistant, (CNA) C, was assigned to resident #2 on [DATE], on the 3 PM to 11 PM shift. During an interview on [DATE] at 5:33 PM, CNA C verified she was resident #2's direct caregiver on [DATE], on the 3 PM to 11 PM shift. She said she was overwhelmed because there were only 3 aides, herself included, during the shift and she had 12 residents assigned to her. CNA C said she did not see the off going CNA from the 7AM to 3 PM shift and therefore did not receive a report status on the resident #2's condition on her assignment. She indicated during her initial resident round, resident #2 was sleeping. She added she checked on resident #2, three times during the evening of [DATE]. Contrary to CNA C's statement, review of the medical record revealed CNA C documented resident #2 was not available for any care during the 3 PM to 11 PM shift on [DATE]. CNA C added, she found out resident #2 died, when she came to work the next day. On [DATE] at 2:09 PM, Registered Nurse, (RN) B said her assignment included resident #2, on the 11 PM to 7 AM shift. RN B received an unremarkable report from the off-going nurse from the 3 PM-11 PM shift, Licensed Practical Nurse (LPN) F. RN B explained there were 4 nurses on the 11 PM-7 AM shift, that included herself, LPN E and 2 newly hired nurses, that were in training, LPN A and LPN D. She said just after midnight, LPN E told her to check on resident #2 because resident #2 did not look okay. She said LPN E had attempted a sternal rub but the resident did not respond. RN B was not able to recall the exact time but explained sometime shortly after midnight she went to see resident #2 and the resident did not have a pulse. She recalled around 12:35 AM she called a code blue and placed the resident on a back board with the assistance of a CNA, name not recalled and training nurse, LPN D. She said she conducted the code blue without any assistance from the nurses. She indicated she called EMS and the Director of Nursing, (DON), while doing chest compressions on resident #2 but she did not do any rescue breaths. On [DATE] at 3:49 PM, 4 days later, RN B made changes to her first interview and said, LPN E did not perform a sternal rub on resident #2 and that she did rescue breaths with an Ambu bag during the code blue. On [DATE] at Residents Affected - Few (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 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 3:45 PM, LPN A indicated she was a newly hired nurse and was being trained by LPN E on [DATE], on the 11 PM-7 AM shift. LPN A stated CNA C, the 3 PM to 11 PM, aide that was assigned to resident #2 was still at the facility when she arrived. She said she was on the medication cart and LPN E rounded on all the residents including resident #2, who was not on their assignment. Shortly thereafter, between 11:30 PM and 11:45 PM, LPN A said she overheard LPN E speaking to RN B and the other nurse that was training, LPN D. LPN E asked them if they had checked resident #2 because she was already deceased when she conducted her initial rounds. CNA C, who was still at the facility, was asked when she last checked on the resident during the 3 PM to 11 PM shift. She recalled CNA C screamed and yelled that she had not taken care of resident #2 because she thought resident #2 was in the hospital. LPN A recalled LPN E saying resident #2 was already in rigor mortis. LPN A said RN B and LPN E were on the phone with the Director of Nursing (DON), but she was not able to hear what the DON instructed them to do. LPN A explained based on the two nurses' actions, she assumed the DON instructed them to call EMS and place the crash cart in the resident's room so it would seem CPR was in progress. She stated a police officer arrived before EMS and LPN A escorted him to resident #2's room. LPN A saw RN B performing CPR on resident #2 while LPN E removed the tube feeding. LPN A said she was not asked to provide a witness statement that night. On [DATE] at 11:03 PM, the Medical Director said the expectation was that residents be checked every 2 hours and CPR initiated when indicated. He recalled he was informed of the incident involving resident #2 and code blue, the next day. He indicated he reviewed the hospital record and shared his findings with the Administrator and DON. On [DATE] at 2:40 PM, and [DATE] at 1:43 PM, meetings were held with the Administrator and DON to clarify the inconsistent and varied verbal accounts of events during resident #2's code blue and the findings of the facility's investigation. The DON said she was aware CNA C had documented, resident #2 was not available on the 3 PM to 11 PM shift on the evening of [DATE]. She indicated CNA C's witness statement demonstrated the CNA had provided care to resident #2 but did not explain why CNA C documented the resident was not in the facility. Contrary to the Medical Director's statement, the Administrator and DON said the Medical Director reviewed resident 2's hospital record but had not shared his findings with them. It was pointed out that the hospital record noted resident had signs of rigor mortis when EMS transferred her to 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 DON indicated there were many conditions/diagnoses that would rapidly increase the onset of rigor mortis but could not name a condition or diagnoses resident #2 had that would cause rapid rigor mortis. There was no evidence to support the facility was concerned with any potential neglectful actions prior to or during the code blue. The facility did not submit an Immediate or Five Day report to the State Agency until approximately 27 days later. The Administrator confirmed he sent an email to the State Agency's local field office and the email read, .to give you a heads up we had a very disgruntled employee.Employee indicated that they would be contacting AHCA (Agency for Health Care Administration)/Department of Labor on the facility.they would get the facility Shut Down. The email indicated that it was LPN A that was considered as the disgruntled employee. When pointed out the email did not indicate any allegations of neglect, the Administrator said the facility received a text, from LPN A, alleging CNA C, the 3 PM to 11 PM aide, had neglected resident #2, prior to the code blue. The Administrator indicated he was aware of this text and it's content on [DATE], that is why he sent the email to the AHCA local Field Office. The Administrator could not reasonably explain why he waited until [DATE] to submit the Immediate report when he was aware of an allegation of neglect on (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 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]. 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] at 12:22 PM, CNA G indicated she was assigned to resident #2 on [DATE] 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]. 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: 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 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 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide care and services in accordance with the resident's care plan, the resident's choice and as per professional standards of practice for 1 of 6 residents reviewed for quality of care, out of a total sample of 15 residents, (#2). This failure contributed to the resident being found unresponsive and exhibiting physical signs consistent with having been deceased for some time prior to discovery.On [DATE] just after midnight, resident #2 was found unresponsive and staff initiated cardio-pulmonary 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. The facility's failure to provide care, timely assess and recognize a change in the resident's condition and failure to initiate life-saving interventions prior to the resident's death resulted in Immediate Jeopardy starting on [DATE]. Findings: Cross reference

F600 and F610Review of resident #2's medical record revealed she was originally admitted to the facility on [DATE] and readmitted from an acute care hospital on [DATE] with diagnoses that included encephalopathy, type 2 diabetes, stroke, dysphagia (difficulty swallowing), heart failure, and dementia. Review of resident #2's Medicare 5-Day Minimum Data Set (MDS) assessment with Assessment Reference Date of [DATE] revealed a Brief Interview for Mental Status score of 3 out of 15, that indicated severe cognitive impairment. The MDS assessment noted resident #2 was totally dependent on staff for all Activities of Daily Living (ADLs), including mobility. Resident #2 was incontinent of bowel, had an indwelling urinary catheter and received all medications, nutrition and fluids via a gastrostomy tube (g-tube) due to dysphagia.Review of resident #2's physician orders revealed orders for continuous tube feeding dated [DATE], routine g-tube flushes for hydration dated [DATE], vital signs every shift dated [DATE], daily indwelling catheter care dated [DATE], anticoagulant monitoring every shift for sudden changes in condition dated [DATE], daily wound care dated [DATE], and nightly g-tube site care dated [DATE]. Review of resident #2's comprehensive care plan identified need for assistance with ADLs, initiated on [DATE]. Interventions directed staff to provide total care and reposition the resident at least every 2 hours. The care plan also reflected the resident's advanced directive status as full code, initiated on [DATE]. The goal noted to initiate CPR in the event of cardiac or respiratory arrest. Review of nursing documentation showed a progress note by Registered Nurse (RN) B dated [DATE] at 12:30 AM, which noted the resident was found unresponsive to sternal rub, CPR was initiated, 911 was called, and the resident was transferred to the hospital. Interviews and record review revealed staff failed to identify and respond to a resident #2's change in condition during the 3:00 PM to 11:00 PM shift on [DATE]. The assigned nurse reported administering medications via g-tube and observing the resident with eyes closed but she did not physically assess if the resident was responding or breathing. Staff acknowledged they observed the resident but did not physically assess her to ensure she was breathing. Documentation by the assigned Certified Nursing Assistant (CNA) noted the resident was not available for care during the entire 3 PM to 11 PM shift indicating resident #2 did not receive any ADL care during the shift.On [DATE] at 2:09 PM, Registered Nurse (RN) B stated she received report from the prior shift and no significant concerns about resident #2 were reported. She indicated Licensed Practical Nurse (LPN) E alerted her that resident #2 did not look good shortly after midnight. RN B stated she went to assess resident #2 and found her unresponsive to sternal rub with no palpable pulse and Residents Affected - Few (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 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 initiated code blue at approximately 12:25 AM, indicating CPR was not initiated timely. She explained staff assisted with positioning the resident and obtained the crash cart. RN B stated there was no one assigned to document the code in real time, and there were no CPR role assignments. On [DATE] at 3:05 PM, during a telephone interview, LPN E stated she entered resident #3's room around midnight while stocking supplies and checking tube feedings. LPN E indicated resident #2 appeared different from how she remembered her, with lips appearing ashen/dry. LPN E stated she immediately reported her concerns to RN B, the assigned nurse. LPN E noted she did not assess the resident but informed RN B. She recalled within 5-10 minutes RN B asked her to confirm code status, and she reported resident #2 was a full code. LPN E stated she did not participate in CPR.According to the EMS report dated [DATE], dispatch received a call from the facility at 12:33 AM and arrived on scene at 12:40 AM. Upon arrival, resident #2 was cold to the touch, pulseless, in asystole (absence of heart activity), and exhibited stiffness of the neck and face preventing intubation. Resident #2 did not respond to multiple rounds of CPR and did not regain consciousness. On [DATE] at 9:00 AM, EMS staff who responded to the facility on [DATE], said they believed resident #2 had been deceased for some time prior to initiation of CPR. Hospital records dated [DATE], revealed resident #2 arrived at the hospital at 1:14 AM via EMS with very rigid extremities, a core body temperature of 90.7 degrees Fahrenheit (?), and recurrent rigor mortis. EMS and hospital records indicated the resident had been deceased for some time prior to being found.According to Medicine Net, after death the body will turn stiff over a few hours. In the stage of rigor mortis, the body begins to harden but is still movable from 0-8 hours and the muscles become fully stiff from 8-12 hours. The stiffness starts on the face/head, neck, chest, and continues down to abdomen and lower extremities. An article by Biology Insights notes that the body cools at an average rate of 1.5 to 2 degrees Fahrenheit per hour. (Retrieved [DATE]. https://www.medicinenet.com/what_are_the_stages_of_rigor_mortis/article.htm, https://biologyinsights.com/how-long-does-a-dead-body-stay-warm-after-death/). Normal body temperature is between 97-99 degrees Fahrenheit (F). Taking the lowest body temperature of 97 degrees F, the estimated time resident #2 had been deceased was at least 3 hours minimum before she was found unresponsive. On [DATE] at 3:45 PM, LPN A said she was training with LPN E on [DATE] during the 11 PM to 7 AM shift. She confirmed resident #2's assigned Certified Nursing Assistant (CNA) C from 3-11 PM shift, was still in the facility at this time. She recalled LPN E did rounds on all residents that night including resident #2 and that at about 11:30 PM to 11:45 PM, she heard LPN E inform RN B that resident #2 was deceased . She recounted that LPN E questioned CNA C about when she last checked 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 recalled LPN E said resident #2 was in rigor mortis when she was found her so it must have been a few hours since she passed. She said LPN E assisted RN B to call the Director of Nursing (DON), and placed 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 .On [DATE] at 5:33 PM, during a telephone interview, CNA C stated she checked on resident #2 during the 3:00-11:00 PM shift on [DATE] and reported the resident was resting. She indicated resident #2 never talked to her and was sleeping the whole shift. CNA C said the care she provided was only emptied the catheter bag as resident #2 received tube feeding and did not have a bowel movement during her shift. CNA C stated she documented resident #2 as resident not available in error. During a follow up interview on [DATE] at 6:09 PM, CNA C stated she did not receive report from the 7:00 AM -3:00 PM shift CNA on [DATE]. She indicated she checked on resident #2 and although she was expected to reposition the resident throughout the shift, she was busy and did not do so. She said she mistakenly documented resident #2 was (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 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 not available because she confused her with a resident who was hospitalized in the room next to resident #2. Review of the facility's Admissions and Discharges from [DATE] to [DATE], facility census, and medical record review revealed the resident CNA C said had been hospitalized was at the facility on [DATE] and there were no residents matching the last name provided by CNA C that were in the hospital. On [DATE] at 11:30 AM, during a telephone call CNA G said she was assigned to resident #2 on [DATE] during the overnight shift. She said she arrived to work late that night at 11:30 PM and went to do her rounds right away. CNA G recalled resident #2 was asleep and her urinary catheter bag was full. She said resident #2 was cold to touch when she lifted the bed cover to touch her legs but did not explain why she lifted the covers. She explained she covered resident #2 back up and walked out of the room without reporting her findings to the nurse. CNA G recalled CNA C reported not emptying resident #2's urinary catheter bag but there was no other communication. CNA G disconnected the telephone call abruptly after being asked if she participated in the code blue. CNA G telephoned back and disclosed resident #2 was already deceased when she arrived for her shift at 11:30 PM. She revealed that when she did rounds, she observed resident #2 appeared stiff and cold to the touch. She added that CNA C divulged during report that she had not provided any care to resident #2 during the 3 PM to 11 PM shift and did not provide a reason. CNA G verbalized that she felt pressured by the Nursing Home Administrator (NHA) and DON to give false witness statements, and she feared retaliation if she did not do so.Review of the Transfer Form dated [DATE] revealed the most recent documented vital signs for resident #2 included a blood pressure of 138/64 recorded on [DATE] at 12:06 AM and a pulse oximetry of 95% recorded on [DATE] at 7:04 PM. Additional vital signs including a pulse of 78, respirations of 20, and temperature of 98.0 ? were documented on [DATE] at 10:34 PM.On [DATE] at 4:34 PM, during a telephone interview, LPN F acknowledged she was the assigned nurse for resident #2 on the 3:00-11:00 PM shift on [DATE]. She stated she administered medications via g-tube and observed resident #2 with eyes closed. On [DATE] at 4:58 PM, LPN F verified the vital signs were not taken at 12:06 AM. She stated she took resident #2's vital signs early during the 3 PM to 11 PM shift at 4:45 PM but documented them later which resulted in documentation times not accurately reflecting when vital signs were taken. During a follow up interview on [DATE] at 3:57 PM, LPN F was presented with findings from the hospital and EMS reports. LPN F stated she observed resident #2 and noted the feeding pump running without alarms. LPN F indicated during medication administration via g-tube, she did not physically touch the resident and did not verify if the resident was breathing. She said she believed the resident's eyes were closed and did not check for any change in condition. LPN F verified she did not check if the resident received any care during her shift, she primarily ensured the head of the bed was elevated for the tube feeding. Review of the resident #2's medical record revealed LPN F documented a skilled evaluation on [DATE] at 10:35 PM, noting the resident was oriented times three (to person, time, and place), communicated verbally, had clear speech, a flat abdomen with bowel sounds present, and was taking nutrition and medications orally. The documentation also indicated skin issues had not been evaluated. This was in contradiction to the MDS assessments that noted the resident was dependent, with severe cognitive impairment and received all nutrition and hydration via gastric tube and not orally. This was also in contradiction to the family stating the resident was mostly non verbal. Review of resident #2's medical record revealed a Nurse Practitioner note dated [DATE]. The physical examination documented the resident did not open her eyes but was able to respond and verbalize her name.On [DATE] at 11:03 PM, during a telephone interview, the Medical Director stated dependent residents were to be checked every two hours. He said he expected nurses to initiate CPR for full code residents when indicated. The medical director stated he was informed of (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 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] 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] revealed an intent to based it on the resident's comprehensive assessment and consistent with the resident's needs and choices.Review of the facility's policy and procedure titled Documentation in Medical Record revised on [DATE] read, Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. 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 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 F600, F684, F610, and F895On [DATE] just after midnight, resident #2 was found unresponsive and staff initiated cardiopulmonary resuscitation (CPR). The resident was transferred to the hospital by Emergency Medical Services (EMS). The EMS and hospital records noted resident #2 was very rigid with stiff extremities and core body temperature of 90.7 degrees Fahrenheit. The records indicated the resident displayed signs and symptoms of rigor mortis indicating the resident had been deceased for some time, before staff had identified the resident to be unresponsive and initiated CPR. On [DATE] at 2:41 PM, the Nursing Home Administrator (NHA) stated he was responsible for the monthly QAPI meetings with the Director of Nursing and the Medical Director. He said that all incidents such as neglect, falls and abuse were brought forth to the meetings. He noted the QAPI program was intended to look at any systemic breakdowns and trends.The NHA spoke about the incident when resident #2 was found unresponsive on [DATE]. He stated that witness statements were collected related to the CPR event and they were used to conduct an internal investigation. He explained the investigation was intended to ensure staff provided timely and effective CPR. The Administrator did not address any timelines of the event or conclusive times the resident was last cared for. He explained the investigation was not brought to QAPI because there were no concerns with staff performance during the code blue event where CPR was performed.Review of witness statements, hospital records, and staff interviews related to resident #2 being found deceased revealed inconsistencies with timelines, CPR recordings, documentation and false witness statements On [DATE] at 11:05 AM, the Medical Director confirmed he attended monthly QAPI meetings. He stated he reviewed resident #2's hospital record, which noted resident #2 had arrived at the hospital with stiff extremities, hyperthermia, and exhibited signs of rigor mortis. The Medical Director said he provided this information to the NHA and DON but did not participate in any QAPI meetings related to the incident nor inquired why the incident was not brought to QAPI.On [DATE] at 1:43 PM, the DON said she was aware resident #2's assigned Certified Nursing Assistant (CNA) had documented, resident #2 was not in the facility during the 3 PM to 11 PM shift on the evening of [DATE]. She did not explain why the CNA documented the resident was not in the facility. Interviews with other staff disclosed the CNA told them she did not provide care to resident #2 as she thought the resident was in the hospital. The Administrator and DON could not provide an explanation for how the facility's investigation demonstrated resident #2 received quality care and timely CPR when the hospital's findings noted the resident had been deceased for some time and was in rigor mortis. The Administrator did not explain how resident #2 was left unattended, died and was in rigor mortis without staff noticing. The Administrator said the facility received a text, alleging the 3 PM to 11 PM CNA had neglected resident #2 by not providing any care to her during the entire shift. The Administrator indicated he was aware of this text and the allegation of neglect on [DATE]. Although the NHA was aware of the neglect allegation, there was no QAPI meeting held to ensure identified concerns were addressed. 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 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 Have a Compliance and Ethics Program. 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 all staff adhered to ethical practices and professional standards by providing inconsistent and misleading statements related to a resident's death in the facility, failed to provide high-level personnel oversight to ensure adherence to ethical standards, and failed to develop effective lines of communication to encourage immediate reporting of violations without fear of retaliation. These failures contributed to the inadequate investigation of resident #2's death. Findings:Cross Reference F600, F684, F610According to the facility's Compliance and Ethics Program policy revised [DATE], the facility is committed to compliance and has designated, implemented, and enforced a compliance and ethics program for promoting quality of care and preventing and detecting criminal, civil and administrative violations. The program's compliance guidelines included compliance activities such as monitoring, auditing, reporting systems, and data integrity. The facility would review the program annually with staff to improve performance in deterring, reducing and detecting violations and promote quality of care.Review of resident #2's medical record, revealed a progress note by Registered Nurse (RN) B dated [DATE] at 12:30 AM which read, was notified by the nurse to look at resident as she was unresponsive to sternal rub. Code blue initiated and 911 called, cardiopulmonary (CPR) performed until police and Emergency Medical Services (EMS) arrived. EMS arrived and transferred resident to (name of hospital). DON (Director of Nursing), on-call provider, and emergency contact were notified.According to the EMS report and hospital records dated [DATE], resident #2 had rigid extremities and hyperthermia consistent with prolonged time of death which indicated she had been deceased for some time prior to staff initiating CPR. The record indicated that facility staff told EMS resident #2 was last observed well by staff at 11:00 PM on [DATE].A discrepancy existed between the time staff reported to EMS resident #2 was last observed well and the time staff provided their witness statements and interviews. The 3-11 PM nurse reported she last saw resident #2 between 10:15 PM and 10:30 PM, however she did not assess resident #2 and the last set of vital signs were taken at 4:45 PM according to Licensed Practical Nurse (LPN) F's witness statement. Based on these findings it was unknown whether resident #2 was well or even observed at 11:00 PM.On [DATE] at 4:34 PM, LPN F, the 3 PM to 11 PM nurse, reported when she arrived for her shift, she did rounds and noted resident #2 was asleep. She obtained vital signs, which she stated were within normal limits, but documented them at 10:35 PM. LPN F confirmed she last saw resident #2 between 10:15 PM and 10:30 PM asleep and in no distress, however LPN F did not assess her to determine if she was even breathing. LPN F documented in the resident's chart at 10:35 PM that resident was alert and oriented X3, communicated verbally, and had warm skin. This documentation was inconsistent with LPN F's statement that she did not do an assessment on resident #2.On [DATE] at 5:33 PM, Certified Nursing Assistant (CNA) C was assigned to resident #2 from 3-11 PM. She said she checked on resident #2 three times during her shift, and she was asleep except when she emptied her urinary catheter bag and the resident opened her eyes slightly and smiled. CNA C's statement contradicted what she documented at 10:59 PM on [DATE] which noted the resident was unavailable for all care tasks throughout the shift including incontinence care. CNA C alleged she confused resident #2 with a resident next door who had been hospitalized for a few days, however the facility's Admissions and Discharges from [DATE] to [DATE], revealed the resident in the next room was at the facility and not in the hospital on [DATE].On [DATE] at 11:30 AM, and during a follow up interview, CNA G stated she arrived for her shift late at 11:30 PM on [DATE] and learned resident #2 was deceased . She said the resident was cold to the touch and her urinary catheter bag was full. CNA G said that during report CNA C revealed she had not provided care for resident #2 the whole shift as she Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete 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 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 thought the resident was in the hospital. She explained the Administrator and the DON told her to provide false witness statements or she would lose her job. On [DATE] at 2:09 PM, RN B was the assigned nurse for resident #2 from 11 PM to 7 AM on [DATE]. She stated LPN E assisted with rounds that night and stocked the tube feed supplies for resident #2. RN B said LPN E found resident unresponsive at around 12:00 AM. RN B said LPN E attempted a sternal rub on resident #2 to arouse her, however in a follow up interview she retracted her statement alleging LPN E never touched the resident. She maintained that other staff members did not assist with CPR but was unable to explain how she was able to dial 911 and call the DON while performing chest compressions. RN B noted CPR started at 12:25 AM, EMS report showed the call came in at 12:33 AM, the DON reported she received a call from RN B at 12:30 AM, and RN B documented in the resident's chart at 12:30 AM. Based on the timeline of events, it would have been implausible for RN B to complete these tasks on her own while attempting CPR.On [DATE] at 3:05 PM, LPN E confirmed she assisted RN B with rounds and stocking tube feed supplies during the 11 PM- 7 AM shift. She denied any involvement during the code blue on resident #2. She explained she stocked tube feeds for resident #2 at around midnight and noticed the resident had ashy lips and dry mouth, which could have indicated a lack of oxygen, but she did not intervene. LPN E said she reported her findings to RN B and continued with her other duties. Review of LPN E's witness statement dated [DATE] revealed she entered resident #2's room at approximately 12:20 AM.On [DATE] at 3:45 PM, LPN A verified she worked the 11 PM to 7 AM shift on [DATE]. She stated some time between 11:30 PM and 11:45 PM, she heard LPN E tell RN B resident #2 was deceased . LPN A mentioned LPN E stated the resident was in rigor mortis when she found her and she added that LPN E assisted with the code blue by calling the DON, and placing the crash cart in resident #2's room prior to EMS arrival. This contradicted LPN E's statement that she did not assist with CPR. LPN A said the DON was contacted by LPN E and RN B prior to CPR initiation. She was unable to hear the conversation but based on LPN E and RN B's actions she believed the DON instructed them to place the crash cart in resident #2's room prior to EMS arrival to give the impression CPR was in progress. LPN A stated she was not asked to provide a witness statement.Review of LPN E's witness statement dated [DATE], revealed she rounded on resident #2 at approximately 12:20 AM and the resident did not look well. She then reported her findings to the assigned nurse, RN B and went to the nurses' station. RN B returned to the nurses' station to ask LPN E the code status for resident #2 prior to starting CPR. LPN E added that RN B immediately called a code blue after learning the resident was a full code. LPN E's witness statement conflicted with RN B's statement, which stated that after she determined resident #2 had no pulse, she immediately started CPR. LPN E's statement suggested CPR was delayed since RN B left the resident's room to verify the code status.On [DATE] at 2:40 PM, the DON denied the allegation that she instructed staff to give impression of doing CPR when EMS arrived. She confirmed she received a call from RN B to inform her resident #2 had been found unresponsive and CPR was initiated. The DON said she instructed staff to collect witness statements from the staff involved. She explained the witness statements were used to ensure staff had followed appropriate procedure during the code. She confirmed that witness statements were not part of their CPR process in the past. She maintained that staff provided timely and appropriate CPR to resident #2 and that she was not aware the resident had been deceased when staff found her.On [DATE] at 2:40 PM, the Administrator said LPN A refused to write a statement because she was upset about not getting paid but there was no documentation to show her refusal. He stated he was not aware resident #2 had been deceased prior to CPR because the medical director had not shared that information after review of resident #2's hospital record.On [DATE] at 11:03 AM, the medical director explained the nurse practitioner saw resident #2 on [DATE] and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete 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 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] but there were no recommendations made related to hospice care.On [DATE] at 1:20 PM, the staffing coordinator confirmed LPN A had texted her on [DATE] related to not receiving her paycheck. She said LPN A made allegations of neglect for resident #2 related to CPR event. The Staffing Coordinator stated she forwarded the message to the Administrator and Human Resources (HR) manager.On [DATE] at 1:55 PM, the HR manager confirmed she received the text message from staffing coordinator but did not report the allegations of neglect because she was not clinical.On [DATE] at 3:08 PM, the Administrator confirmed he received the text message with LPN A's allegations of neglect and acknowledged he did not report the allegations.On [DATE] an email was sent to the State Agency (SA) field office from the Administrator that noted, just wanted to give a heads up we had a very disgruntled employee that the facility terminated today. The employee indicated that they would be contacting the SA to get the facility shut down. The employee in question was listed as LPN A.On [DATE] at 1:52 PM, the compliance officer who handled the hotline when employees called with concerns stated it was the expectation that all staff conducted themselves in an ethical manner and avoided falsifying documentation or providing false information related to residents. She defined ethical behavior as having good moral character. Event ID: Facility ID: 105886 If continuation sheet Page 15 of 15