Health inspection·January 5, 2024

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, review of policy and procedure, and record review, the facility failed to promptly notify the resident's responsible party of the resident's fall in the facility for 1 of 2 sampled residents (Resident #1). The findings included: Review of the facility policy and procedure, titled Change in a Resident's Condition or Status, revised February 2021, was provided by the Director of Nursing (DON) and it documented in the Policy Statement: Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status . Resident #1 was initially admitted to the facility on [DATE] with diagnoses which included Fusion of Spine, Lumbar Region, Basal Cell Carcinoma of Skin, Hypertension, Chronic Obstructive Pulmonary Disease, Unsteadiness on Feet, Difficulty with Walking, Need assistance with Personal Care, and Urinary Tract Infection (UTI). Resident #1 had a Brief Interview Mental Status (BIM) score of 13 (cognitively intact), and required one person assist with transfers and daily ADLs (activities of daily living). During a telephone interview conducted on 01/05/24 at 9:17 AM,with Resident #1's daughter and second emergency contact, she reported neither she nor the resident's first emergency contact, her sister, was ever notified of Resident #1 having had a fall in the facility on Tuesday 11/14/23. The resident's daughter stated that the resident was the one who called her to let her know that she had fallen in her room while getting up from her wheelchair. Resident #1's daughter went on to say that she didn't understand why the facility did not notify her nor her sister about the resident's fall, and why it was that she had to hear about this from her Mother, who was residing in the facility, for care. The resident's Fall care plan documented that on 11/14/23 Resident observed on floor, no injuries noted; 11/15/23 transfer to hospital and back after a few hours status post fall; no new orders. An interview was conducted with the Social Services Director on 01/05/24 at 3:11 PM, in which she acknowledged that Resident #1 was found sitting on the floor in her room on Tuesday 11/14/23 sometime well after lunch and she said that she reported this to Resident #1's assigned nurse, Staff A, a Registered Nurse (RN). A side-by-side computerized record review was conducted with the DON of the nurses' note effective date 11/14/23 at 4:45 PM by Staff A, in which it was documented Staff A was notified by the Social (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 2 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 01/05/2024 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)