Ansley Cove Healthcare and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Ansley Cove Healthcare and Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Dec 19, 2025

  Based on interview, and record review, the facility failed to protect the resident's right to be free from neglect by not providing necessary care and services for a totally dependent resident and failed to assess, recognize and intervene for changes in condition for 1 of 3 residents reviewed for neglect, 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). […]

• Immediate jeopardy, isolatedF610Dec 19, 2025

  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. […]

• Immediate jeopardy, isolatedF684Dec 19, 2025

  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). […]

• Actual harm, isolatedF600Oct 16, 2025

  Based on observation, interview and record review, the facility neglected to identify and implement appropriate fall prevention interventions for a resident with a high risk for falls who also received a combination of high-risk medications, resulting in the resident experiencing a fall with injury.This failure resulted in actual harm to 1 of 4 residents reviewed for Quality of Care, (#1).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… […]

• Actual harm, isolatedF689Oct 16, 2025

  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… […]