Inspection visit
Health inspection
3 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 3 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0725
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in
charge on each shift.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
review of policy and procedure, record review, and interview, it was determined that the facility failed to
ensure that it maintained sufficient nursing staff, on a 24-hour basis to provide nursing and related services
to residents, in order to maintain the highest practicable physical, mental, and psychosocial well-being of
each resident, as determined by resident assessments and individual plans of care.
The findings included:
Review of the facility policy and procedure, titled Staffing, revised October 2017, provided by the
Administrator, documented in the Policy Statement: Our facility provides sufficient numbers of staff with the
skills and competency necessary to provide care and services for all residents in accordance with resident
care plans and the facility assessment. Policy Interpretation and Implementation: 1. Licensed nurses and
certified Nursing Assistants (CNAs) are available 24 hours a day to provide direct resident care services. 2.
Staffing numbers and the skill requirements of direct care staff are determined by the needs of the
residents based on each resident's plan of care 4. Direct care staffing information per day (including agency
and contract staff) is submitted to the Centers for Medicaid and Medicare Services (CMS) payroll-based
journal (PBJ) system on the schedule specified by CMS, but no less than a quarter .
On the Staffing Calculations Form for the three (3) months of April, May and June 2022, it was documented
that the licensed nursing staff hours reflected less than 1.0 hour on the following nine (9) days: Sunday
04/17/22, Monday 04/18/22, Thursday 04/28/22, Sunday 05/01/22, Monday 05/02/22, Friday 05/06/22,
Friday 05/13/22, Wednesday 05/18/22 and Wednesday 06/01/22.
Further record review revealed that, it was also documented the average combined hours (licensed nursing
staffing and certified nursing assistant), were less than 3.6 hours on the following twenty-two (22) days:
Sunday 04/03/22, Tuesday 04/05/22, Sunday 04/10/22, Sunday 04/17/22, Tuesday 04/19/22, Thursday
04/28/22, Sunday 05/01/22, Saturday 05/07/22, Tuesday 05/10/22, Friday 05/13/22, Saturday 05/14/22,
Tuesday 05/17/22, Thursday 05/26/22, Friday 05/27/22, Sunday 05/29/22, Friday 06/03/22, Monday
06/06/22, Thursday 06/09/22, Friday 06/10/22, Saturday 06/11/22, Saturday 06/18/22 and Saturday
06/25/22.
A side-by-side record review was conducted with the Administrator in which it was revealed for the three (3)
months of April, May and June 2022 the licensed nursing staff hours were less than 1.0 hour on nine (9)
days, and the average combined hours (licensed nursing staffing and certified nursing assistant) were less
than 3.6 hours on twenty-two (22) days.
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 4
Event ID:
105604
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
105604
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/16/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Covenant Village Care Center
9211 W Broward Blvd
Plantation, FL 33324
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 0725
Level of Harm - Minimal harm
or potential for actual harm
An interview was conducted with Resident #7 on 11/07/22 at 12:17 PM, in which she indicated that it does
bother her that on the weekends, the facility is sometimes short staffed affecting her overall care needs.
Resident #7 was re-admitted to the facility on [DATE] with diagnoses which included Coronary Artery
Disease, Hypertension, and Cerebrovascular Accident (CVA). She had a Brief Interview Mental Status
(BIM) score of 15 (cognitively intact).
Residents Affected - Few
An interview was conducted with Staff A, a CNA, on 11/16/22 at 10:29 AM, in which she verbalized that
sometimes the facility is short-staffed with only six (6) CNAs on the floor, when the facility would usually
have had seven (7) CNAs on the floor.
During an interview conducted on 11/16/22 at 1:10 PM with Staff E, a Registered Nurse (RN), in which she
was questioned as to how often that she is asked to stay late or come in early to provide additional nurse
staffing coverage, and she replied, at least on an almost bi-weekly basis.
On 11/16/22 at 10:40 AM, according to the Administrator, the staffing information provided during this
survey by their current Staffing Coordinator, was not the same information that was previously submitted to
the PBJ for the months of April, May, and June of 2022 by the facility's former Staffing Coordinator.
During an interview conducted on 11/16/22 at 10:49 AM with the Staffing Coordinator, she indicated that
she was aware of the Federal and State regulations for sufficient nurse staffing. She acknowledged the
licensed nursing staff hours were less than 1.0 hour on the following nine (9) days: Sunday 04/17/22,
Monday 04/18/22, Thursday 04/28/22, Sunday 05/01/22, Monday 05/02/22, Friday 05/06/22, Friday
05/13/22, Wednesday 05/18/22 and Wednesday 06/01/22.
She also acknowledged that the average combined hours (licensed nursing and certified nursing assistant)
were less than 3.6 hours on the twenty-two (22) days noted above.
An interview was conducted with the Director of Nursing (DON), on 11/16/22 at 11:47 AM regarding the
licensed nursing staff hours less than 1.0 hour, and the average combined hours less than 3.6 hours, and
she acknowledged that staffing is to be provided per the resident needs.
In fact, there were eleven (11) weekend days identified during this time frame, that were identified as having
either low licensed nursing staff hours or low combined hours (certified nursing assistant and licensed
nursing).
The Administrator further recognized and acknowledged on 11/16/22 at 12:15 PM that sufficient nursing
staff should have been maintained, on a 24-hour basis.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105604
If continuation sheet
Page 2 of 4
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
105604
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/16/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Covenant Village Care Center
9211 W Broward Blvd
Plantation, FL 33324
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 0755
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a
licensed pharmacist.
Based on observation, interview, record review, and policy review, it was determined the facility failed to
ensure accurate accountability and reconciliation of controlled medications for 1 of 6 sampled residents
(Resident #204).
The findings included:
Review of the facility policy titled Administering Medications dated 2001 documents, The individual
administering the medication initials the resident's MAR (Medication Administration Record) on the
appropriate line after giving each medication and before administering the next ones. As required or
indicated for a medication, the individual administering the medication records in the resident's medical
record: the date and time the medication was administered.
During an observation of the West-end Medication Cart on 11/08/22 at 2:22 PM, a review of the Percocet (a
controlled medication) was completed for Resident #204 with Staff B, a Licensed Practical Nurse (LPN).
Review of the number of Percocet taken from the medication cart as recorded on the Controlled Drug
Declining Inventory Sheet dated 11/01/22 through 11/08/22, compared to the number of Percocet
administered to Resident #204 as per the corresponding MAR, revealed the following discrepancies:
On 11/01/22 at 10:30 AM, 11/01/22 at 6:00 PM, 11/02/22 at 3:37 PM, 11/02/22 at 7:29 PM, 11/02/22 at
11:40 PM, and 11/05/22 at 9:00 PM, one Percocet was taken from the medication cart with no
corresponding documentation of administration to Resident #204 on the Medication Administration Record
(MAR). This revealed the record lacked documented administration of the medication 6 of 16 times between
11/01/22 at 10:30 AM and 11/08/22 at 9:42 AM.
On 11/16/22 at 7:30 AM a side-by-side review was done comparing the Controlled Drug Declining Inventory
Sheet and the MAR with the DON. The DON verified 6 doses of Percocet given between 11/01/22 at 10:30
AM and 11/08/22 at 9:42 AM, were not charted or incorrectly charted on the MAR for Resident #204.
On 11/16/22 at 8:10 AM Staff D stated she was aware she documented incorrectly the doses of Percocet
for Resident #204 on 11/02/22. The doses were documented under another medication on the electronic
MAR and she did not know how to correct it.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105604
If continuation sheet
Page 3 of 4
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
105604
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/16/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Covenant Village Care Center
9211 W Broward Blvd
Plantation, FL 33324
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 0849
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will
arrange for the provision of hospice services.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
records review and interviews, the facility failed to ensure that an interdisciplinary hospice comprehensive
care plan reflected the facility's responsibility for 1 of 2 sample residents (Resident #5).
The findings included:
Resident #5 was originally admitted to the facility in 2019, and recently readmitted on [DATE]. Her
diagnoses included: Syncope, Anxiety, Asthma, Dementia, shortness of breath (SOB), Hypertension (HTN),
Dysphagia, Peripheral Neuropathy, Major Depressive disorder; Contracture of left hand, and Gait
abnormality.
The Hospice Interdisciplinary Comprehensive Assessment and plan of care dated 2/29/2020, documented
additional diagnoses such as Chronic Obstructive Pulmonary Disease (COPD), Dependence on Oxygen,
Dementia in other diseases classified elsewhere with behavioral disturbances; Alzheimer's disease;
Dysphagia unspecified, and Cachexia.
The hospice Interdisciplinary Care Plans (ICP) dated 5/26/21 and 4/8/22 did not outline the facility's role in
the delivery of service. There was no indication of the starting date of services and no end date. It was
unclear whether the Facility staff was involved in the plan development. There was no facility staff signature
in the plan. The Integration tool dated 4/8/22 revealed that the resident terminal diagnosis was COPD.
Those who signed the Plan were all hospice representatives and their responsibilities (Nursing, Social
Worker, Certified Nursing Aides and Chaplain), but there was no indication as to what the nursing home
facility's responsibilities entailed.
The Facility's Plan of Care updated 10/21/2022 showed the goal for Resident #5 was to keep her
comfortable daily, throughout her end-of-life process, until the next review date. As interventions, the facility
would conduct 1:1 visit; observe any changes in Resident #5's mood and behavior.
During an interview with the Director of Nursing (DON) on 11/16/22 at 10:29 AM, she reported the facility's
DON, Social Worker, or the Minimum Data Set (MDS) Coordinator of the facility were responsible for
reviewing the Interdisciplinary Care Plan (ICP). However, they failed to recognize that their role was not
outlined in the ICP.
During an interview with the Hospice Case Manager on 11/16/22 at 10:59 AM, she said during the plan
development, they communicate with the facility's representatives and the facility knows what they are
responsible for. She ensued that they do not write down facility's responsibility on the ICP.
The Administrator provided no additional information during the Exit meeting held on 11/16/2022.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105604
If continuation sheet
Page 4 of 4
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Back to topCitations
3 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
F849 - Hospice services
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
F725 - Nursing Services
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
FAQ · About this visit
Common questions about this visit
What happened during the November 16, 2022 survey of COVENANT VILLAGE CARE CENTER?
This was a inspection survey of COVENANT VILLAGE CARE CENTER on November 16, 2022. The surveyor cited 3 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at COVENANT VILLAGE CARE CENTER on November 16, 2022?
Yes, 3 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharm..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.