Cycle 1
Health 2025-07-18 · Fire 2025-07-18
17 health deficiencies
Top issue: Administration (7 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Maitland, FL
Ansley Cove Healthcare And Rehabilitation
2-star overall rating with 1-star inspections with abuse icon flag with $87,552 in total fines with 17 recent health deficiencies
1301 W Maitland Blvd, Maitland, FL
(407) 645-3990
Overall
2 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
39
Certified beds
Average residents
29
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1995-06-16
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.81
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.72
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
2.29
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
3.82
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.53
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
3.63
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.57
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.45
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.88
CMS adjusted RN staffing hours
Adjusted total hours
4.14
CMS adjusted total nurse staffing hours
Case-mix index
1.26
Higher values indicate more complex resident acuity
RN turnover
83%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
51%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,252
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
27.35
Composite VBP score used to determine payment impact.
Payment multiplier
0.9845
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.79
Baseline 20.63% · Performance 20.60% · Measure score 1.79 · Achievement 1.79 · Improvement 0
Healthcare-associated infections
0
Baseline 9.16% · Performance 9.19% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
4.65
Performance 44.68% · Measure score 4.65 · Achievement 4.65 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
4.50
Baseline 4.06 hours · Performance 4.36 hours · Measure score 4.50 · Achievement 4.50 · Improvement 1.23
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.55% |
10.72%
1.8 pts worse
|
No Different than the National Rate · Eligible stays 109 · Observed rate 15.6% · Lower 95% interval 8.55% |
| Discharge to community | 64.2% |
50.57%
13.6 pts better
|
Better than the National Rate · Eligible stays 95 · Observed rate 57.89% · Lower 95% interval 53.46% |
| Medicare spending per beneficiary | 0.93 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 82.22% |
95.27%
13 pts worse
|
Numerator 37 · Denominator 45 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 45 |
| Discharge self-care score | 47.22% |
53.69%
6.5 pts worse
|
Numerator 17 · Denominator 36 |
| Discharge mobility score | 50% |
50.94%
0.9 pts worse
|
Numerator 18 · Denominator 36 |
| Pressure ulcers or injuries, new or worsened | 2.22% |
2.29%
0.1 pts better
|
Numerator 1 · Denominator 45 · Adjusted rate 1.76% |
| Healthcare-associated infections requiring hospitalization | 9.19% |
7.12%
2.1 pts worse
|
No Different than the National Rate · Eligible stays 53 · Observed rate 15.09% · Lower 95% interval 5.43% |
| Staff COVID-19 vaccination coverage | Not Available |
8.2%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 52.78% |
56.45%
3.7 pts worse
|
Numerator 19 · Denominator 36 |
| Transfer of health information to provider | 83.33% |
95.95%
12.6 pts worse
|
Numerator 20 · Denominator 24 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 87.3% |
97.8%
10.5 pts worse
|
93.4%
6.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 87.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
2.6%
2.6 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
3.7%
3.7 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 5.9% |
5.9%
About the same
|
5.4%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 5.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 33.3% |
15.7%
17.6 pts worse
|
19.6%
13.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 33.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 14.6% |
9.8%
4.8 pts worse
|
16.7%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 14.6% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.8% |
9.8%
3 pts worse
|
14.9%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 12.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.4%
0.4 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 5.3% |
0.8%
4.5 pts worse
|
1.7%
3.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 5.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.6% |
12.5%
12.1 pts worse
|
19.8%
4.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 24.6% |
| Percentage of long-stay residents with pressure ulcers | 2.1% |
5.1%
3 pts better
|
5.1%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 2.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 75.3% |
94.3%
19 pts worse
|
81.7%
6.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 90.2% · Q2 73.1% · Q3 50.8% · Q4 77.0% · 4Q avg 75.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 2.3% |
9.3%
7 pts better
|
12.0%
9.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 2.3% · Observed 2.3% · Expected 11.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.5% |
1.5%
About the same
|
1.6%
0.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.9% · Q3 2.5% · Q4 2.2% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 66.0% |
94.7%
28.7 pts worse
|
79.7%
13.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 66.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.6% |
26.2%
5.6 pts better
|
23.9%
3.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.6% · Observed 20.9% · Expected 24.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-09-19 · Fire 2024-09-19
16 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2023-09-28 · Fire 2023-09-28
8 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-09-19
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-10-19
E · Potential for more than minimal harm
2023-09-28
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2023-10-30
E · Potential for more than minimal harm
2023-09-28
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-10-30
Inspection history
Recent health citations
E · Potential for more than minimal harm
2026-01-29
F569 · Resident Rights Deficiencies
Health
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Corrected 2026-02-16
J · Immediate jeopardy
2025-12-19
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2026-01-26
J · Immediate jeopardy
2025-12-19
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2026-01-26
J · Immediate jeopardy
2025-12-19
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2026-01-26
E · Potential for more than minimal harm
2025-12-19
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2026-01-26
E · Potential for more than minimal harm
2025-12-19
F895 · Administration Deficiencies
Health
Have a Compliance and Ethics Program.
Corrected 2026-01-26
G · Actual harm
2025-10-16
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-11-29
G · Actual harm
2025-10-16
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-11-29
E · Potential for more than minimal harm
2025-10-16
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2025-11-29
E · Potential for more than minimal harm
2025-10-16
F895 · Administration Deficiencies
Health
Have a Compliance and Ethics Program.
Corrected 2025-11-29
D · Potential for more than minimal harm
2025-10-16
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-11-29
E · Potential for more than minimal harm
2025-07-18
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-08-18
E · Potential for more than minimal harm
2025-07-18
F847 · Administration Deficiencies
Health
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Corrected 2025-08-18
E · Potential for more than minimal harm
2025-07-18
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2025-08-18
E · Potential for more than minimal harm
2025-07-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-08-18
D · Potential for more than minimal harm
2025-07-18
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2025-08-18
D · Potential for more than minimal harm
2025-07-18
F778 · Administration Deficiencies
Health
Help the resident make transportation arrangements to and from radiology services.
Corrected 2025-08-18
G · Actual harm
2025-02-15
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-03-21
G · Actual harm
2025-02-15
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-03-21
F · Potential for more than minimal harm
2025-02-15
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2025-03-21
D · Potential for more than minimal harm
2025-02-15
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-03-21
D · Potential for more than minimal harm
2025-02-15
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-03-21
D · Potential for more than minimal harm
2025-02-15
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-03-21
E · Potential for more than minimal harm
2025-01-23
F576 · Resident Rights Deficiencies
Health
Ensure residents have reasonable access to and privacy in their use of communication methods.
Corrected 2025-02-23
F · Potential for more than minimal harm
2024-09-19
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-10-19
D · Potential for more than minimal harm
2024-09-19
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2024-10-19
D · Potential for more than minimal harm
2024-09-19
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-10-19
D · Potential for more than minimal harm
2024-09-19
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-10-19
D · Potential for more than minimal harm
2024-09-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-19
D · Potential for more than minimal harm
2024-06-13
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-07-13
D · Potential for more than minimal harm
2024-06-13
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2024-07-13
D · Potential for more than minimal harm
2024-06-13
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-07-13
D · Potential for more than minimal harm
2024-06-13
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-07-13
E · Potential for more than minimal harm
2023-09-28
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2023-10-30
E · Potential for more than minimal harm
2023-09-28
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-10-30
E · Potential for more than minimal harm
2023-09-28
F847 · Administration Deficiencies
Health
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Corrected 2023-10-30
E · Potential for more than minimal harm
2023-09-28
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-10-30
G · Actual harm
2023-03-16
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-04-17
E · Potential for more than minimal harm
2023-03-16
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2023-04-17
D · Potential for more than minimal harm
2023-03-16
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-04-17
D · Potential for more than minimal harm
2023-03-16
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-04-17
Penalties and ownership
What sits behind the stars
$87,552
2025-01-23
Fine
Fine · fine $87,552
Fine
Ownership
Garrard, Louis
5% Or Greater Direct Ownership Interest · Individual
Barr, Dylan
Operational/Managerial Control · Individual
Garrard, Louis
Operational/Managerial Control · Individual
Smith, Alvis
Operational/Managerial Control · Individual
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