Inspection·May 15, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to initiate a care plan for monitoring behaviors and side effects for 2 of 5 sampled residents on psychotropic medications (Resident #268 and Resident #33). Facility also failed to initiate a care plan for monitoring pain for 1 of 5 sampled residents on narcotic medications (Resident #268). The findings included: 1. A record review showed that Resident #268 was admitted on [DATE] with diagnosis of Hemiplegia and hemiparesis following other nontraumatic intracranial hemorrhage affecting left non-dominant side and Epilepsy, not intractable, without status epilepticus. The Minimum Data Set (MDS) comprehensive dated 05/04/2025 revealed that the Brief Interview of Mental Status (BIMS) score is 14, which indicated intact cognition. A review of the orders revealed the following: 04/30/25: Divalproex 125 mg tablet, delayed release Every 12 Hours. 04/30/25: Tramadol 50 mg tablet as needed Every 4 Hours. 05/01/25: Enoxaparin 40 mg/0.4 mL subcutaneous syringe 1 Time Daily for 30 Days. 05/01/25: Pain Assessment 05/01/25: Behavior Monitoring 05/01/25: Side Effect Monitoring A review of Resident #268 medication administration record (MAR) indicated that the behaviors and side effects were being monitored. The pain assessment was also completed. A review of the comprehensive care plan dated 05/13/25 stated that Resident #268 is at risk for potential bleeding related to Anticoagulant Therapy. And monitoring of bruising and bleeding to put in place. A review of the comprehensive care plan dated 05/13/25 indicated that no care plan was put in place for monitoring behaviors or side effects related to the use of psychotropic medications or pain (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 6 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 05/15/2025 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)