Health inspection·February 29, 2024

F 0677 stated the resident's care plan was revised on 01/24/24. Level of Harm - Minimal harm or potential for actual harm On 02/26/24 at 9:32 AM, observation revealed Resident #30 sitting up in bed with her breakfast tray set up in front of her. Further observation revealed the resident was dozing off, her eyes were closed. Attempted to interview the resident but she was not answering questions. The resident stared at the surveyor while attempting to interview her. The resident was asked if she wanted to be fed and nodded her head up and down (positive sign). The resident had her arms flexed up to her chest and in a cross position. Further observation revealed Staff F, Certified Nursing Assistant (CNA) in the resident's room feeding the roommate. Subsequently, an interview was conducted with Staff F who stated Resident #30 was able to feed herself. Residents Affected - Few On 02/26/24 from 9:32 AM to 9:46 AM, observation revealed Resident #30 continues to have her breakfast tray in front of her, food was untouched. On 02/26/24 at 9:46 AM, observation revealed Staff E, Activities Aide, entered Resident #30's room and Staff F, CNA was in the room feeding the roommate. Further observation revealed no assistance or encouragement was provided by Staff E nor Staff F from 9:32 AM to 9:46 AM. On 02/26/24 at 1:00 PM, observation revealed lunch tray cart was parked by Resident #30's room. At 1:23 PM, observation revealed Resident #30's tray delivered by Staff F, CNA. Subsequently, an interview was conducted with Staff F who stated that she was helping a resident in another room. Staff F stated Resident #30 fed herself and added the resident did not eat anything for breakfast and wanted lunch. Observation revealed Staff F setting up Resident #30's lunch tray. The resident was asked if she wanted to eat and nodded her head up and down (meaning yes). On 02/26/24 at 1:30 PM, observation revealed Resident #30 feeding herself using her right hand with difficulty, unable to grab puree food on the fork. Observation revealed the resident kept moving her fork side to side on the plate and the plate edges to grab some of the pureed food with very little amount noted on the fork. The resident kept her left arm under the cover. The resident's napkin was soaked wet with food dropped into the napkin. Observation revealed no staff assisting, or providing cues nor encouraging Resident #30 during her meal. On 02/28/24 at 9:01 AM, observation revealed Staff F, CNA delivered Resident #30's tray. Staff F asked the resident if she was ready to eat and she nodded her head up and down. Staff F added I will set you up to eat. On 02/28/24 at 9:18 AM, observation revealed Resident #30 feeding herself, putting the fork into the cup of juice and bringing it to her mouth. The resident had a napkin over her chest that was soaked wet. Staff F, CNA was feeding her roommate and acknowledged Resident #30 was trying to drink her juice with a fork. Staff F from the across the room asked Resident #30 to use the straw. Observation revealed the resident was able to put the straw into the cup but removed it immediately, did not use it. Further observation revealed the resident again tried to drink the juice with a fork. The resident was observed attempting to get her pureed food on the fork and was able to get very little amount. The resident did not touch her (enhanced) oatmeal. The tray contains thin liquid, pureed food, a carton of whole milk, a cup of coffee, a glass of cranberry juice and a glass of water. By 9:21 AM, observation revealed Resident #30 had taken approximately 10% of the pureed food, and 25 % of the cranberry juice. On 02/28/24 at 9:21 AM, during an interview, Staff F, CNA stated again that Resident #30 fed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105604 If continuation sheet Page 2 of 11 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 02/29/2024 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)

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few herself all meals and eats everything. Observation revealed a thick red liquid dripping out of the resident's mouth. The resident was able to retrieve a very small amount of the pureed food on the fork and into her mouth. Observation revealed the resident had a chunk of white piece of food in her mouth. Continued observation at 9:27 AM, revealed Resident #30 grabbed a small unopened butter container with her right hand attempting to open it with one hand and was not able to. The resident left arm was under the cover. At 9:30 AM, observation revealed the resident putting the fork inside the cup of cranberry juice multiple times and bringing it to her mouth. During the observation, Staff F, CNA continues to feed Resident # 30's roommate without providing encouragement, nor supervision to Resident #30, who had a physician order to be fed and supervised. Furthermore, Staff E, Activity Aide entered Resident #30's room to deliver an I-Pad and did not encouraged the resident to eat nor offer assistance. At 9:35 AM, observation revealed Resident #30 attempted to get food from the plate and was not able to. The resident's napkin over her chest was noted soaked wet with a reddish color. Continued observation revealed the resident was moving her straw from the table to the tray back and forth, the spilled half of the cup of cranberry juice over her tray and pushed her tray away from her. On 02/28/24 at 9:44 AM, observation revealed Staff F, CNA came to Resident #30's bedside and asked her if she wanted help, the resident shook her head from side to side (meaning no). At the time, Staff F smashed the resident's pureed biscuit that was 75% untouched. The resident then got a spoon full of pureed meat and biscuit smashed by Staff F. The resident was not swallowing and Staff F had to remind her to chew and swallow. At 9:50 AM, Staff F asked Resident #30 if she would like another juice and the resident nodded her head up and down (meaning yes). The resident continues to attempt to get more of the smashed pureed biscuit and meat into her mouth without swallowing. The resident kept putting spoonfuls of food into her mouth. At 9:51 AM, Staff F returned to Resident #30 with a second container of cranberry juice. The resident was pushing the tray away. Surveyor asked the resident if she would like Staff F to help her and nodded her head up and down. Staff F asked the resident if she wanted help and the resident nodded her head up and down. Observation revealed the resident open her mouth multiple times to be fed by Staff F. Further observation revealed Staff F had to repeatedly tell the resident to chew and swallow. At 9:56 AM, Staff F was feeding the resident and stated, I can't give it to you unless you swallow. At 9:58 AM, Staff F stated the resident was pocketing her food and stated the resident had never taken so long to eat. At 10:01 AM, continued observation revealed Resident #30 pouring milk over her pureed biscuit. At 10:04 AM, the resident decline more food. The resident ate 75% of her food after assistance was provided. On 02/28/24 at 10:24 AM, an interview was conducted with the Speech Pathologist, (SP) who stated that Resident #30 received therapy until 01/31/24 because of Dysphagia (difficulty swallowing). The ST stated the resident needs supervision with meals. The ST was apprised that Resident #30 did not eat breakfast on 02/26/24, and with the 02/28/24 breakfast meal, the resident spilled her food and juice all over her napkin, was attempting to drink juice with a fork and was pocketing her food in her mouth. The ST was apprised there was no staff close to the resident to assist and supervise her, the staff across the room was not assisting nor supervising Resident #30. On 02/28/24 at 1:38 PM, observation revealed Resident #30 sitting up in bed and Staff G, CNA next (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105604 If continuation sheet Page 3 of 11 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 02/29/2024 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)

F 0677 to the resident. An interview was conducted with Staff G who stated the resident needed to be fed. Level of Harm - Minimal harm or potential for actual harm 2) A record record review revealed that Resident #1 was admitted on [DATE] with diagnoses of major depression, dysphagia, and heart failure. A review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed that Resident #1 had a Brief Interview of Mental Status (BIMS) score of 99, which indicated the resident is cognitively impaired. Residents Affected - Few An observation was conducted on 02/26/24 at 12:10 PM. Resident #1 was noted in her room. Closer observation showed that Resident #1 had long, unkept fingernails on both hands, with a brown, unidentified matter underneath the pointer finger of her right hand. Photographic evidence obtained. In an observation conducted on 02/28/24 at 12:50 PM, Resident #1 was noted eating her lunch in the assisted dining hall. Closer observation showed that Resident #1 had long, unkept fingernails on both hands with a brown, unidentified matter underneath the pointer finger of her right hand. The care plan for Resident #1 under the Activities of Daily Livings (ADLs) section revealed that Resident #1 has a self-care deficit and requires assistance with self-care and her ADLs. Intervention included clean and manicured fingernails as needed. An interview was conducted on 02/28/24 at 4:00 PM with Staff B, Certified Nursing Assistant (CNA), who said she usually cleans and trims residents' fingernails before dinner. She was then asked to accompany Surveyors into Resident #1's room. She said yes when asked if Resident #1's fingernails needed trimming and cleaning. Staff B stated that it was not her Resident and that Staff E, Activity Aid, usually cuts and trims the Resident's fingernails. In an interview conducted on 02/28/24 at 4:10 PM, the facility's Director of Nursing (DON) stated that fingernail grooming is part of the overall grooming and that the Certified Nursing Assistants do not have a specific place in the electronic system that is just for fingernail grooming. The DON said that Resident #1 likes her fingernails long and that when staff tries to cut or trim her fingernails, she refuses. The DON stated that the Activity Director would know more about Resident #1 since she usually cuts and trims her fingernails during activities. An interview conducted on 02/28/24 at 4:17 PM with Staff C, Certified Nursing Assistant, stated that after dinner, they dress the residents, brush their teeth, and put them to prepare the resident for bed. Nail grooming is done when the showers are done, which is usually twice a week. When she looks at the fingernails, she makes the judgment of whether to trim the fingernails or cut the fingernails. They do it; and sometimes, the activity staff members trim and cut the fingernails. Staff C said that sometimes she works with Resident #1 and has her today and yesterday. In this interview, the Surveyors asked Staff C to accompany them to Resident #1's room. When asked if Resident #1's fingernails needed cutting and trimming, she said, It needs to be trimmed down. An interview conducted on 02/28/24 at 4:56 PM with the Activity Director, she stated that she trims and cuts Resident #1's fingernails during Monday activities that are dedicated to pampering hands and nail polish. She further noted that Resident #1 usually likes it and that it is unusual for Resident #1 to refuse or not want staff to cut or trim her fingernails. When asked by the Surveyors how long they keep the fingernails, she said just enough to be able to put nail polish but not too long. In this interview, the Activity Director was asked by Surveyors to accompany them to Resident #1's room. When asked to look at Resident #1's fingernails, she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105604 If continuation sheet Page 4 of 11 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 02/29/2024 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)

F 0677 confirmed that some of the fingernails needed to be trimmed, shaped, and cleaned underneath, especially the thumb on the right hand. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105604 If continuation sheet Page 5 of 11 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 02/29/2024 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)

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interviews, the facility failed to practice appropriate infection prevention and control and failed to follow wound care physician orders during wound care observation for 1 of 1 resident sampled for wound care review (Resident #45). Residents Affected - Few The findings included: Review of the facility's policy provided by the administrator titled, Hand Hygiene with no revision date and without the facility's name listed documented .additional considerations: the use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves and immediately after removing gloves. Review of Resident #45's clinical record documented an admission on [DATE]. The resident diagnoses included a fracture to the Right Femur, Muscle Weakness and Retention of Urine. Review of Resident #45's Minimum Data Set (MDS) 5 days admission assessment dated [DATE] documented a Brief Interview of the Mental Status (BIMS) score of 12, indicating that the resident had moderate cognition impairment. The assessment documented under Functional Abilities and Goals that the resident needed substantial/maximum assistance for most of his Activities of Daily Living (ADL's). Review of Resident #45's care plan titled, At risk for skin breakdown related to incontinence, impaired mobility . initiated on 01/10/24 and revised on 01/18/24. The care plan documented that on 02/09/24 the resident was observed with a right heel open area and a non-blanchable redness to the left heel as per nurses observation. Review of Resident #45's physician order dated 02/20/24 documented Clean right heel with Dakin's solution, pat dry, skin prep to the peri wound, apply Santyl, alginate calcium, cover with bordered island dressing daily and when soiled. On 02/27/24 at 2:43 PM, observation revealed Resident # 45 in a bed with an air mattress lying flat on his back. An interview was conducted with the resident in Spanish who stated he was cold and did not want to get out of bed. Observation revealed the resident was wearing bilateral heel booties. On 02/27/24 at 3:30 PM, a telephone interview was conducted with the MDS Coordinator who stated that as per Resident #45's initial assessment done 01/15/24, the resident did not have pressure wounds reported on admission. The MDS Coordinator stated that on 02/09/24 the nurse observed right heel open area and a non-blanchable redness to the left heel and treatment was started. The Coordinator stated the resident was receiving daily Physical therapy. On 02/28/24 at 8:04 AM, an interview was conducted with Staff D, Registered Nurse (RN). Staff D stated Resident #45 had a wound to his right heel and she will do his wound care sometime this shift. On 02/28/24 at 11:27 AM, wound care observation for Resident #45 performed by Staff D, RN started. Observation revealed Staff D reviewed the physician orders and gather the following supplies: a Derma Wound Cleanser bottle, a red bag, one bordered island gauze, three gauze packages, a package of calcium alginate, two skin prep pads, resident labeled Santyl ointment tube and a pair of scissors. At 11:36 AM, Staff D entered Resident #45's room, placed the supplies on top of the resident's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105604 If continuation sheet Page 6 of 11 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 02/29/2024 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)

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few dresser, donned gloves and cleaned his over the bed table with two dry paper towel, then placed three paper towels as a barrier on the table. Staff D then removed her gloves, performed hand hygiene and donned gloves. Observation revealed Staff D retrieved the scissors and without disinfecting the scissors, cut up a piece of the whole calcium alginate dressing and placed the scissors on top of the dresser. Staff D then poured a small amount of Santyl ointment into a medication cup and placed all supplies including the cut up piece of calcium alginate on top of the barrier. Staff D removed the resident's non-skid socks and the right heel dressing, removed her gloves, performed hand hygiene and donned gloves. Staff D retrieved the wound cleanser bottle and proceeded to spray the wound, dried up the wound and spray it with wound cleanser again and pat dry the wound. Observation revealed Staff D continues to wear the pair of gloves she used to clean the wound. Staff D proceeded to applied skin prep to the peri wound, then inserted her gloved index finger into the medication cup to retrieve the Santyl ointment and pasted into Resident #45's open right heel wound and covered with the bordered island dressing. Observation revealed Staff D removed her gloves and without hand hygiene, donned gloves and reached to her uniform pocket and retrieved an ink pen to date the dressing. Continued observation at 11:48 AM, revealed the wound cleanser fell to the floor and Staff D picked the bottle from the floor and placed it back on the table. Staff D put the resident non-skid socks back on and the bootie. Staff D then applied skin prep to Resident #45's left heel scab, removed her gloves and without hand hygiene donned gloves and put on the resident's non-skid sock and the bootie. Observation revealed Staff D removed her gloves, performed hand hygiene, returned to the treatment cart and placed the opened cut up calcium alginate dressing in the top drawer, and without disinfecting, Staff D placed the wound cleanse bottle that fell on the floor and the scissors back in the treatment cart. On 02/28/24 at 11:56 AM, an interview was conducted with Staff D, RN who stated she cleans her hand before and after working with the residents. Staff D was asked if she washes her hands between gloves changes, and replied if she touches something contaminated or dirty. Staff D confirmed she put the opened calcium alginate package, the wound cleanser bottle and the scissors back in the cart. Staff D stated she was supposed to clean the scissors and the wound cleanser bottle that was contaminated before putting those back in the treatment cart and did not. Staff D was apprised that she did not change gloves before applying Santyl ointment to the open wound with her finger. On 02/28/24 at 1:22 PM, an interview was conducted with the Director of Nursing (DON) who was apprised of Resident #45's wound care observations findings. The DON stated the nurses have applicators in the treatment cart to apply Santyl ointment to the wound. On 02/29/24 at 11:02 AM, a side by side review of Resident #45's wound care order was conducted with the DON. The DON was apprised Staff D did not use Dakin's solution, as per physician order, rather used Derma Wound Cleanser spray to clean the resident's wound. Subsequently, a side by side review of the wound cleanser ingredients was conducted with the DON. The DON acknowledged the Derma Wound Cleanser and Dakin's solution did not have the same ingredients. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105604 If continuation sheet Page 7 of 11 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 02/29/2024 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)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure that a Gradual Dose Reduction (GDR) for Psychotropic medication was being followed as per the Physician's orders for 1 of 5 residents reviewed for unnecessary medications (Resident #32). The findings included: A review of the facility's policy titled, Psychotropic Medication Use, dated 2001, revealed that the use of psychotropic medications is not increased when efforts to decrease antipsychotic medicines are being implemented. The medication management process will include an indication of use, dose, and duration. A record review revealed that Resident #32 was admitted on [DATE] with diagnoses of Anxiety Disorder and Major Depressive Disorder. The care plan, which was initiated on 11/14/23, revealed the following: Resident #32 is on routine antianxiety medication and administers medication as indicated. A review of the Physician's orders in the paper chart revealed an order to discontinue Ativan (Lorazepam) 0.5 milligrams (mg)once a day and start Ativan 0.25 mg once a day, which was dated 12/21/23. A review of the Physician's orders in the electronic system revealed the following: Lorazepam 0.5 mg, 0.25 mg oral one time a day for anxiety and agitation. The February 2024 Medications report revealed an order for Lorazepam 0.5 mg (0.25 mg) once a day starting on 12/21/23, which was discontinued on 02/28/24. In an interview conducted on 02/27/24 at 2:27 PM with Staff A, a Registered Nurse, she was asked to clarify the Physician's order for Lorazepam. She stated that Resident #32 receives 0.5 milligrams of Lorazepam daily at 5:00 PM. Staff A proceeded to show the Surveyors the printed order in the electronic system. When asked by Surveyors how she would interpret the above electronic order, she said, I see what you are saying, and then said, It needs to be looked at. Staff A further stated that when she was looking at the order, what stood out was the 0.5 mg of Lorazepam and not the 0.25 mg. An observation of Resident #32's Bingo Medication Dispenser card revealed that he was receiving a Lorazepam 0.5 mg tablet, which was provided by Staff A, taken from the locked medication cart. Photographic evidence obtained. An interview was conducted on 2/28/24 at 5:17 PM with Staff D, a Registered Nurse, who stated that she was supposed to give Resident #32 his order for Lorazepam 0.25 mg, but she did not because they did not have any in-house and that she contacted the Unit Manager to let her know. A review of the Psychiatry Subsequent Note dated 01/03/24 revealed the following: Resident #32 mood has been stable and has no behavioral concerns. Stable symptoms of depression and anxiety, and the staff reported that the behavior has been appropriate. In this note, the Psychiatrist documented that Resident #32 receives Lorazepam 0.25 mg once a day. A review of the care plan note dated 01/17/24 revealed the following: Resident #32 is receiving (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105604 If continuation sheet Page 8 of 11 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 02/29/2024 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)

F 0758 Lorazepam 0.25 mg once a day, and no medications that have failed GDR at this time. Level of Harm - Minimal harm or potential for actual harm An interview conducted on 02/28/24 at 6:00 PM with the facility's Director of Nursing stated that the Psychiatrist decided to change the order back to Lorazepam 0.5 mg and called the Pharmacy to ask for the higher dosage. The surveyor requested documentation regarding the above dosage change, which was not provided. Residents Affected - Few An interview conducted on 02/29/24 at 1:20 PM with the Psychiatrist Nurse Practitioner stated that he wanted Resident #32's Lorazepam decreased to 0.25 mg as he prescribed on 12/21/23. He was not aware that Resident #32 was receiving 0.5 mg of Lorazepam and not the Gradual Dose Reduction of 0.25 mg. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105604 If continuation sheet Page 9 of 11 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 02/29/2024 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)

F 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide the appropriate diet consistency per the Physician ' s orders for 1 of 5 sampled residents reviewed for nutrition (Resident #308). The findings included: A record review revealed that Resident #308 was admitted on [DATE] with diagnoses of Dementia and Hypertension. The Comprehensive Minimum Data Set (MDS) dated [DATE] revealed that Resident #308 had a Brief Interview of Mental Status (BIMS) score of 11, which was mild cognitive impairment. Record review showed a Diet Order and Communication yellow slip noted with a regular/pureed diet, which was dated 02/24/24. The Physician's order revealed an order for a pureed diet, which was dated 02/24/24. The care plan initiated on 02/24/24 revealed the following: allow time to eat and provide encouragement and assistance. Monitor dietary tolerance and symptoms of coughing or choking when eating or taking fluids. The nutrition progress note dated 02/26/24 revealed that Resident #308 was admitted under hospice to the facility for a short respite stay. History of dementia and dysphagia and is on a pureed diet consistent with thin liquids. In an observation conducted on 02/26/24 at 9:30 AM, Resident #308 was noted in her bed with a breakfast tray in front of her. Closer observation revealed a meal choice ticket: orange/apple/cranberry juice, scrambled eggs, sliced bacon, corn beef hash, mini croissant, oatmeal, milk, and coffee. The bottom of the meal choice ticket revealed Resident #308 diet crossed out, and underneath was written regular diet with the Resident's last name and room number. In this observation, Resident #308 said, this does not look like my tray; it seems like someone was eating from my breakfast meal. Resident #308 then picked up her tablespoon and ate from the breakfast tray. The meal tray was noted with scrambled eggs, milk, oatmeal, and coffee. Photographic evidence obtained. An observation conducted on 02/26/24 at 12:43 PM revealed Resident #308 in her bed. Closer observation showed a menu food selection sheet for the next day with meal choices for breakfast, lunch, and dinner dated 02/27/24. The menu food selection sheet had Resident #308's name and room number written on the bottom. The menu food selection sheet showed a regular diet meal choice and not the appropriate puree meal choices. Photographic evidence obtained. An interview conducted on 02/28/24 at 12:17 PM with the facility's Registered Dietitian stated that the daily menu is printed on paper with the food menu choice and placed on the breakfast trays for all residents. Residents can pick their food choices for the next day, and nurses will pick up the menus and give them to the dietary department. This is done daily and taken to the main kitchen for the dietary aides to review. The menu food choices forms have the diet listed with the name of the resident and the room number for each Resident. The meal trays should have a white diet slip attached to the menu food choices paper on each meal tray. The dietary service aides oversee placing the menu selection paper on the meal trays every morning and making sure that it has the correct Resident name and diet order and that the menu will match the right food choices. The Certified Nursing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105604 If continuation sheet Page 10 of 11 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 02/29/2024 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)

F 0808 Level of Harm - Minimal harm or potential for actual harm Assistants are also responsible for ensuring that the diet orders are accurate for the specific residents. The surveyor showed the Registered Dietitian the picture of the breakfast meal for regular consistency that was taken on 02/26/24, and she said, I do not know how that happened. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105604 If continuation sheet Page 11 of 11