Health inspection·December 29, 2022

F 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some calendar is provided to the residents. The Resident council meeting is held on a monthly basis. Due to the short length of stay of our patients, each meeting held has new residents therefore we are unable to have an elected president. The Activities Calendar provided by the facility and posted at the nurse's station showed that there was only one activity per day, which consisted of: Sundays at 11:00 AM - 'Mass (Channel 11)' Mondays at 11:30 AM - 'Sensory activity' on 12/05/22 and 12/19/22 - 'Crossword Packets' on 12/12/22 and 12/26/22 Tuesdays - on 12/06/22 at 1:00 PM - 'Resident Council' (it was stated during the entrance conference that the facility did not have a Resident Council) - on 12/13/22 at 11:30 AM - 'Sensory Activity' - on 12/20/22 and 12/27/22 at 11:00 AM - 'Arts & Crafts 1:1' Wednesdays at 11:00 AM - 'Mass (Channel 11) Thursdays - On 12/01/22 and 12/29/22 at 11:30 AM 'Sensory Activity' - On 12/08/2, 12/15/22 and 12/22/22 at 11:00 AM 'Arts & Crafts 1:1' Fridays at 11:30 AM - 'Crossword Packets' Saturdays 'Crossword Packets Available in Dining room' Resident #175 was admitted on [DATE]. A care plan date dated 12/23/22 indicate [Resident's name] is alert, able to make needs known and engages in activities of choice daily. The goal of the care plan was documented as, Will continue to engage in activities of choice daily through next review date as evidenced by staff observations and daily participation records. With a target date of 01/22/23. Interventions to the care plan included: * Provide arts/crafts material books-for-the-blind crossword puzzles deck of cards large print reading material magazines pen/pencil stress ball television channel listing word search for in-room activities PRN and encourage family to bring favorite games, books or leisure items from home if requested. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106080 If continuation sheet Page 2 of 7 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 106080 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/29/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Maria West Skilled Nursing Facility 8850 NW 122 St Hialeah Gardens, FL 33018 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 0679 * Provide spiritual assistance, refer to pastoral care for support and comfort measures. Level of Harm - Minimal harm or potential for actual harm * Invite and escort if needed to group programs, social events daily. Residents Affected - Some * Establish their likes and dislikes and what is most important to them through the activity assessment and assist to achieve personal goals related to activities during their stay. * Provide/post monthly recreation calendar of events. During an observation and interview with Resident #175, on 12/27/22 at 11:23 AM, when asked about participation in activities, Resident #175 replied, Today is the first day that I have done anything, and it was therapy. I had an operation on 12/19/22 and came here on the 21st. Every morning, They start at about 5:30 AM in the morning. at 6:00 AM they came with breakfast. Then I asked for a bath .I had breakfast today at 7:00 AM and then they took me to the bathroom. at about 9:30 AM they took me down to therapy. I was in my room for about an hour, and they took me back down again to therapy. I would like to do table games. I cannot walk. During an interview, on 12/27/22 at 12:33 PM, Staff B, OTA (Occupational Therapy Assistant) was asked about activities, Staff B replied, I walk around and go from room to room I ask them if they would like items that they can do in their room, paint things or craft things, books, word search, activity books, playing cards. Since the COVID, we haven't used the activity room. The patients could come on their own (to the Activity Room). Staff B stated that there was no Activities Director. The director left in October, they are looking for someone, but they haven't found anybody. Nobody has been asking me to take them to the Activities Room. The schedule for mealtimes showed that lunch is served to the residents from 12:00 PM to 1:00 PM. On 12/27/22 at 11:48 AM, lunch was being served to the residents in their rooms. During an interview, on 12/29/22 at approximately 9:00 AM, with the Human Resource Manager, when asked about Activities staff, the Human Resources Manager replied, We have an OTA that does activities. We had an Activities Director a long time ago and that switched over to the therapy department. During an interview, on 12/29/22 at 9:39 AM, the Administrator revealed the department went through the transition to the new therapy contractor, our OT (Occupational Therapy) ran the activities. There was no documentation of resident's participation in an activities program. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106080 If continuation sheet Page 3 of 7 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 106080 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/29/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Maria West Skilled Nursing Facility 8850 NW 122 St Hialeah Gardens, FL 33018 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 0740 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident must receive and the facility must provide necessary behavioral health care and services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview, the facility failed to act on a resident's request for psychiatry consultation for 1 (Resident # 176) of 1 resident reviewed for Behavioral Health. The findings included: Resident #176 was admitted to the facility on [DATE]. Resident #176's care plan, initiated on 12/27/22, documented, [Resident Name] is at risk for side effects, adverse reaction related to use of antidepressant medication required for diagnosis of depression. The goal of the care plan was documented as, Will have no side effects or adverse reaction to use of antidepressant over the next 30 days. Interventions to the care plan included * Psychiatrist to evaluate and treat for mood state and medication review as indicated. * Maintain fall precautions. * Instruct staff on daily interventions that will respect, understand, and manage the resident's condition and support their safety and rights. * Observe for side effects, adverse reaction: dry mouth, constipation, changes in appetite, insomnia, fatigue, increased agitation or irritability, and falls. * Monitor and document moods and behaviors if they persist with treatment. * Discuss side effects of medication with resident and/or health care surrogate. Resident #176's Orders included: (Eliquis) Apixaban 2.5 mg tablet - by mouth twice a day for DVT Prophylaxis - 12/17/22 Sertraline HCI 100 Mg tablet by mouth daily for Major depressive disorder - 12/17/22 Tramadol HCI 50 mg tablet by mouth every 6 hours as needed - 12/17/22 During an interview with Resident #176 and the resident's son, on 12/27/22 at 12:53 PM, Resident #176's son stated, I think that we need to have someone see him. I told the nurse about a week ago. I believe the person for psychiatry is out for the holidays. Resident #176's son further stated, He came in here . for about a week and was feeling very nauseous and was sent to the hospital and then came back. He is a very independent person, he drives, cooks and cleans and now that he is in this state, he has been very depressed. Resident #176 echoed the statements made by his son and stated that he was feeling 'depressed' and wished to be seen by a psychiatrist/psychologist. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106080 If continuation sheet Page 4 of 7 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 106080 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/29/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Maria West Skilled Nursing Facility 8850 NW 122 St Hialeah Gardens, FL 33018 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 0740 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview, on 12/28/22 at 12:08 PM with Staff C, LPN, when asked about the psychiatrist services, Staff C replied, She comes every Monday. She wasn't here this week because of the holiday. Usually when we put the order, we give the secretary the order and she call to make to make the appointment. During an interview, on 12/28/22 at 12:27 PM, with Staff D, LPN, when asked of the process when a resident requests psychiatry consult, Staff D replied, in that case, I notify the psychiatry doctor right away and then and she would give an order for medication, and she would tell me that she would see him. If the doctor is out for vacation, we notify the facility doctor, and he passes by to evaluate the patient until the psychiatrist is back. On 12/28/22 at 12:34 PM, Staff C called the psychiatrist and was answered by answering service and reported that she was waiting for a call back. When it was reported to Staff C and Staff D that Resident #176 had stated that he felt 'depressed' Staff D replied, He had an order put in on 12/18/22 (as a new admission). She has not seen the patient yet. The order is for one month. His brother asked about seeing a psychiatrist, but sometimes he will wake up with a little headache. They told me about two weeks ago. I told the secretary. On 12/28/22 at 1:36 PM Medical Records reported that there was no documentation of the resident stating that he was depressed and requested to see psychiatry. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106080 If continuation sheet Page 5 of 7 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 106080 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/29/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Maria West Skilled Nursing Facility 8850 NW 122 St Hialeah Gardens, FL 33018 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined that the facility failed to follow the approved menu to ensure that the nutritional needs of 17 of 17 facility residents (Includes sampled Resident #4, Resident #30, Resident #36, Resident #75, Resident #76, Resident #77, and Resident #78) were being met. The findings included. During the observation of the lunch tray line in the main kitchen on 12/28/22 at 11:30 AM, it was noted that the serving portion of the Chili -Texas Cowboy (entree) was a 4-ounce ladle portion and the pureed Chili was a 4-ounce scoop for Regular, Carbohydrate Controlled, Mechanical Soft, and No Added Salt diets. It was noted that bot entrees were being served in a 4-ounce dessert/vegetable dish which could not include the 3 once protein portion and 4-ounce carbohydrate portion,. A review of the approved menu production sheets and resident menus for the lunch meal on 12/28/22 both documented an 8-ounce portion to be served. At the request of the surveyor a copy of the standardized recipe for the Texas Cowboy Chili was obtained. A review of the recipe documented that the entree portion to be served was 1-1/2 cups (12 ounces). Interview with the Food Service Director and [NAME] (Staff A) during the observation revealed that they were unaware the recipe documented a 12-ounce portion, and the approved menu/production sheet documented an 8-ounce portion. it was further discussed with the FSD and Registered Dietitian that the residents were receiving an insufficient serving of the Chili entree. it was noted during the interview that the Chili portion size did not meet the minimum 3-ounce cooked protein as per the approved menu. A review of the facility diet census for 12/28/22 indicated that all 17 facility residents were affected by the entree for the lunch meal of 12/28/22. The 17 residents included sampled Resident #4, Resident #30, Resident #36, Resident #75, Resident #76, Resident #77, and Resident #78. Further review of Resident #30's clinical record indicated the resident was admitted to the facility on [DATE] clinical diagnoses included but not limited to Congested Heart Failure (CHF), Diabetes, Rectal Bleeding and Hypertension. Physician orders dated 12/22/2022 included: Daily Weights, Pureed Diet with -Nectar Consistency Liquids. Order Dated 12/23/2022 - Diabetes Snack BID (twice daily), Vitamin C 500 mg daily for vitamin deficiency, Folic Acid 1 mg at bedtime (Q HS) for vitamin deficiency. Active Critical Care Sugar Free 30 ml BID - Protein Wound healing. Glucerna 240 ml QD - Diabetic Supplement. Order dated 12/28/2022- Stage II Pressure Ulcer Coccyx. Review of the resident's weight history indicated: 12/27/22 - 141.1 pounds 12/26/22 -Refused (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106080 If continuation sheet Page 6 of 7 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 106080 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/29/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Maria West Skilled Nursing Facility 8850 NW 122 St Hialeah Gardens, FL 33018 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 0803 12/24/22 - Refused Level of Harm - Minimal harm or potential for actual harm 12/23/22- Refused 12/22/22 - Refused Residents Affected - Some Review of Dietary Notes dated 12/23/22 documented the resident states appetite has decreased, PO (by mouth) intake 50-75%, Active Critical Care BID for wound healing, MNA (The Mini Nutritional Assessment) scores indicate Risk For Malnutrition, BMI (Body Mass Index) =21.8 (Malnutrition). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106080 If continuation sheet Page 7 of 7