Cycle 1
Health 2025-05-15 · Fire 2025-05-15
5 health deficiencies
Top issue: Pharmacy Service (4 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Plantation, FL
Covenant Village Care Center
5-star overall rating with 4-star inspections with 5 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
9211 W Broward Blvd, Plantation, FL
(954) 370-8982
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
60
Certified beds
Average residents
56
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Covenant Living
Operator or chain grouping
Approved since
1988-03-15
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
15 facilities
Chain averages 4 overall / 4 health / 4 staffing / 4 quality stars
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
1.32
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.25
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
2.62
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
4.19
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.57
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
3.82
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
1.09
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.18
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
1.31
CMS adjusted RN staffing hours
Adjusted total hours
4.15
CMS adjusted total nurse staffing hours
Case-mix index
1.38
Higher values indicate more complex resident acuity
RN turnover
27%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
19%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,727
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
28.93
Composite VBP score used to determine payment impact.
Payment multiplier
0.9852
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.20
Baseline 24.11% · Performance 22.91% · Measure score 1.20 · Achievement 0 · Improvement 1.20
Healthcare-associated infections
0
Baseline 6.00% · Performance 9.33% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
8.59
Baseline 41.51% · Performance 28.57% · Measure score 8.59 · Achievement 8.59 · Improvement 7.27
Adjusted total nurse staffing
1.79
Baseline 3.74 hours · Performance 3.59 hours · Measure score 1.79 · Achievement 1.79 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 16.64% |
10.72%
5.9 pts worse
|
Worse than the National Rate · Eligible stays 235 · Observed rate 20.43% · Lower 95% interval 13.58% |
| Discharge to community | 54.48% |
50.57%
3.9 pts better
|
No Different than the National Rate · Eligible stays 213 · Observed rate 50.23% · Lower 95% interval 47.05% |
| Medicare spending per beneficiary | 1.06 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 99.49% |
95.27%
4.2 pts better
|
Numerator 194 · Denominator 195 |
| Falls with major injury | 0.51% |
0.77%
0.3 pts better
|
Numerator 1 · Denominator 195 |
| Discharge self-care score | 28.57% |
53.69%
25.1 pts worse
|
Numerator 38 · Denominator 133 |
| Discharge mobility score | 27.82% |
50.94%
23.1 pts worse
|
Numerator 37 · Denominator 133 |
| Pressure ulcers or injuries, new or worsened | 1.54% |
2.29%
0.8 pts better
|
Numerator 3 · Denominator 195 · Adjusted rate 1.2% |
| Healthcare-associated infections requiring hospitalization | 9.33% |
7.12%
2.2 pts worse
|
No Different than the National Rate · Eligible stays 136 · Observed rate 11.03% · Lower 95% interval 5.55% |
| Staff COVID-19 vaccination coverage | 6.49% |
8.2%
1.7 pts worse
|
Numerator 5 · Denominator 77 |
| Staff flu vaccination coverage | 83.78% |
42%
41.8 pts better
|
Numerator 62 · Denominator 74 |
| Discharge function score | 30.83% |
56.45%
25.6 pts worse
|
Numerator 41 · Denominator 133 |
| Transfer of health information to provider | 99.07% |
95.95%
3.1 pts better
|
Numerator 107 · Denominator 108 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 71 · Denominator 71 |
| Resident COVID-19 vaccinations up to date | 52.21% |
25.2%
27 pts better
|
Numerator 59 · Denominator 113 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
97.8%
2.2 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 100.0% |
| 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 | 0.0% |
5.9%
5.9 pts better
|
5.4%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 0.0% |
15.7%
15.7 pts better
|
19.6%
19.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 0.0% |
9.8%
9.8 pts better
|
16.7%
16.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · 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 | 7.5% |
9.8%
2.3 pts better
|
14.9%
7.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 7.5% · 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 | 0.0% |
0.8%
0.8 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 5.4% |
12.5%
7.1 pts better
|
19.8%
14.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 5.4% |
| Percentage of long-stay residents with pressure ulcers | 3.1% |
5.1%
2 pts better
|
5.1%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 3.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.9% |
94.3%
5.6 pts better
|
81.7%
18.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.7% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.1% |
9.3%
0.2 pts better
|
12.0%
2.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.1% · Observed 8.7% · Expected 10.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.5% |
1.5%
1 pts better
|
1.6%
1.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 0.0% · Q3 0.0% · Q4 0.5% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.7% |
94.7%
2 pts better
|
79.7%
17 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 96.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 31.7% |
26.2%
5.5 pts worse
|
23.9%
7.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 31.7% · Observed 31.5% · Expected 23.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-29 · Fire 2024-02-29
4 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-11-16 · Fire 2022-11-16
4 health deficiencies
Top issue: Administration (1 deficiency)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-05-15
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 2025-06-12
D · Potential for more than minimal harm
2025-05-15
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-06-12
D · Potential for more than minimal harm
2025-05-15
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-06-12
D · Potential for more than minimal harm
2022-11-16
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-11-16
D · Potential for more than minimal harm
2022-11-16
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-11-16
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-05-15
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-06-12
D · Potential for more than minimal harm
2025-05-15
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 2025-06-12
D · Potential for more than minimal harm
2025-05-15
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-06-12
D · Potential for more than minimal harm
2025-05-15
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-06-12
D · Potential for more than minimal harm
2025-05-15
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-06-12
D · Potential for more than minimal harm
2024-02-29
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 2024-03-22
D · Potential for more than minimal harm
2024-02-29
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-03-22
D · Potential for more than minimal harm
2024-02-29
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-03-22
D · Potential for more than minimal harm
2024-02-29
F808 · Nutrition and Dietary Deficiencies
Health
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.
Corrected 2024-03-22
D · Potential for more than minimal harm
2024-01-05
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 2024-01-15
D · Potential for more than minimal harm
2022-11-16
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 2023-01-08
D · Potential for more than minimal harm
2022-11-16
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 2023-01-08
D · Potential for more than minimal harm
2022-11-16
F849 · Administration Deficiencies
Health
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.
Corrected 2023-01-08
Penalties and ownership
What sits behind the stars
Ownership
Covenant Living Communities & Services
5% Or Greater Direct Ownership Interest · Organization
Bentley, Sarah
Corporate Director · Individual
Buettner, Kathy
Corporate Director · Individual
Covenant Living Communities & Services
Operational/Managerial Control · Organization
Creaney, Janet
Corporate Director · Individual
Cunliffe, Terri
Corporate Officer · Individual
Cunliffe, Terri
W-2 Managing Employee · Individual
Eastburg, Mark
Corporate Director · Individual
Erickson, David
Corporate Officer · Individual
Manlove, Matt
Corporate Director · Individual
Peterson, Loann
Corporate Director · Individual
Reppe, Dixie
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Broward Oaks Nursing And Rehabilitation
Plantation, FL
2-star overall rating with 2-star inspections with $33,891 in total fines with 14 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Nspire Healthcare Plantation
Plantation, FL
3-star overall rating with 3-star inspections with $35,989 in total fines with 6 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Regents Park Of Sunrise
Sunrise, FL
3-star overall rating with 2-star inspections with 6 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
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