Inspection·January 23, 2023

K 000 INITIAL COMMENTS

K 000 A re-licensure survey was conducted on 01/23/2023 at VI at Aventura, a nursing home in Aventura, Florida in accordance with National Fire Protection Association (NFPA) 1 and 101 (2018 edition) and applicable requirements of Florida State Fire Marshal's Rules and Regulations, Florida Administrative Code (F.A.C) 69A-3, F.A.C. 69A-53, F.A.C. 59A-4, and Florida Statutes (F.S.) 400 Part II, and F.S. 633.0215, adopting National Fire Protection Association (NFPA) 1 and 101 (2018 edition) known as the Florida Fire Prevention Code and all NFPA referenced standards and requirements adopted per NFPA 101, Chapter 2. The following is description of the deficiencies found at the time of the visit.

K 353 NFPA 101 Sprinkler System - Maintenance and SS=D Testing

K 353 2/26/23 Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked b) Who provided system test c) Water system supply source Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 02/10/23 STATE FORM 6809 KX2E21 35961002 01/23/2023 VI AT AVENTURA 19333 WEST COUNTRY CLUB DRIVE AVENTURA, FL 33180 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE

K 353 Continued From page 1

K 353 9.7.5, 9.7.7, 9.7.8, and NFPA 25 This Statute or Rule is not met as evidenced by: Based on observations and staff interview, the facility failed to maintain the automatic sprinkler system in accordance with NFPA 101. Findings included: During the records review process of the facility between 11:00 AM and 4:00 PM on 01/23/2023 with the Assistant Maintenance Director, it was revealed that there was no documentation for the performance of Fire Department Connection (FDC) 5-year hydrostatic test. During the Life Safety Survey tour of the facility at 4:45 PM on 01/23/2023 with the Assistant Maintenance Director, it was observed that (1) there was no list posted in sprinkler cabinet at the Pump Room/Electrical Room, and (2) there was no hydraulic calculation information sign at the risers. During the staff interview between 11:00 am and 4:45 PM on 01/23/2023, the Assistant Maintenance Director acknowledged these findings. These findings were also discussed and acknowledged by the Administrator during the exit conference. NFPA 101 (2018 Edition) 19.3.5, 9.7.5 NFPA 25 (2017 Edition) 6.3.2.1, 5.4.1.5.6, and 5.2.5 Class III This plan of correction is submitted as required under Federal and State regulations and statues applicable to long term care providers. This plan of correction does not constitute an admission of liability on the part of the facility, and such liability is hereby specifically denied. The submission of this plan does not constitute agreement by the facility that the surveyors findings or conclusion are accurate, that the finds constitute a deficiency or that the scope or severity regarding any of these deficiencies cited are correctly applied. In order to ensure that the services provided at Vi at Aventura meet the professional standards of quality, the team has initiated the following plan or correction. A. Facility has contracted with a Fire Sprinkler vendor to perform the Fire Department Connection 5-year hydrostatic test. B. A work order was created to flag the 5-year hydrostatic test of the Fire Department Connection recurring every five years. C. Facility posted a listing of fire sprinklers in the sprinkler cabinet located in the Pump Room. D. Fire Sprinkler vendor will install a hydraulic calculation plate at the riser. E. A semi-annual work order has been created to visually inspect that the listing of sprinkler heads and hydraulic calculation plates are posted and will be STATE FORM notes KX2E21 VI AT AVENTURA 19333 WEST COUNTRY CLUB DRIVE AVENTURA, FL 33180 |---|---|---|---|---| | K 353 | Continued From page 2 | K 353 | reported to the community's QAPI committee. | | STATE FORM SUMMARY OF DEFICIENCIES 106076 01/23/2023 VIA AT AVENTURA 19333 WEST COUNTRY CLUB DRIVE AVENTURA, FL 33180 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETION DATE

K 000 INITIAL COMMENTS

K 000 An unannounced Fire & Life Safety recertification survey was conducted 01/23/2023 at VI at Aventura, a nursing home in Aventura, Florida. The facility is not in compliance with 42 CFR 483.90 (a), and National Fire Protection Association (NFPA) 101 (2012 edition), NFPA 99 (2012) requirements for nursing homes. Initial Plan Review: 2003 Existing NFPA 220 Construction Type: I (332) Number of beds: 40 Census: 32

K 353 Sprinkler System - Maintenance and Testing SS=D CFR(s): NFPA 101

K 353 2/26/23 Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-Based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked b) Who provided system test c) Water system supply source Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25 THIS REQUIREMENT IS NOT MET as evidenced 02/10/2023 106076 01/23/2023 VIA AT AVENTURA 19333 WEST COUNTRY CLUB DRIVE AVENTURA, FL 33180 PREFIX PREFIX TAG TAG DEFICIENCY) COMPLETION DATE

K 353 K 353 Continued From page 1 by: This plan of correction is submitted as required under Federal and State regulations and statues applicable to long term care providers. This plan of correction does not constitute an admission of liability on the part of the facility, and such liability is hereby specifically denied. The submission of this plan does not constitute agreement by the facility that the surveyors findings or conclusion are accurate, that the finds constitute a deficiency or that the scope or severity regarding any of these deficiencies cited are correctly applied. In order to ensure that the services provided at VI at Aventura meet the professional standards of quality, the team has initiated the following plan or correction. A. Facility has contracted with a Fire Sprinkler vendor to perform the Fire Department Connection 5-year hydrostatic test. B. A work order was created to flag the 5-year hydrostatic test of the Fire Department Connection recurring every five years. C. Facility posted a listing of fire sprinklers in the sprinkler cabinet located in the Pump Room. D. Fire Sprinkler vendor will install a hydraulic calculation plate at the riser. E. A semi-annual work order has been created to visually inspect that the listing of sprinkler heads and hydraulic calculation plates are posted and will be Based on observations and staff interview, the facility failed to maintain the automatic sprinkler system in accordance with NFPA 101. Findings included: During the records review process of the facility between 11:00 AM and 4:00 PM on 01/23/2023 with the Assistant Maintenance Director, it was revealed that there was no documentation for the performance of Fire Department Connection (FDC) 5-year hydrostatic test. During the life safety survey tour of the facility at 4:45 PM on 01/23/2023 with the Assistant Maintenance Director, it was observed that (1) there was no list posted in sprinkler cabinet at the Pump Room/Electrical Room, and (2) there was no hydraulic calculation information sign at the risers. During the staff interview between 11:00 AM and 4:45 PM on 01/23/2023, the Assistant Maintenance Director acknowledged these findings. These findings were also discussed and acknowledged by the Administrator during the exit conference. NFPA 101 (2012 Edition) 19.3.5, 9.7.5 NFPA 25 (2011 Edition) 6.3.2.1, 5.4.1, and 5.2.6 01/23/2023 VIA AT AVENTURA 19333 WEST COUNTRY CLUB DRIVE AVENTURA, FL 33180 COMPLETION DATE

K 353 Continued From page 2 K 353 reported to the community's QAPI committee. VI AT AVENTURA 19333 WEST COUNTRY CLUB DRIVE AVENTURA, FL 33180

E 000 Initial Comments E 000 During an unannounced Fire & Life Safety recertification survey conducted on 01/23/2023 at VI at Aventura, a nursing home in Aventura, Florida, Emergency Preparedness was reviewed. VI at Aventura is in compliance with Emergency Preparedness per Code of Federal Regulations (CFR) 42, Part 483.73, Requirement for Long-Term Care Facilities. VI AT AVENTURA 19333 WEST COUNTRY CLUB DRIVE AVENTURA, FL 33180 DEFICIENCY)

K 000 INITIAL COMMENTS K 000 A re-licensure survey was conducted on 01/23/2023 at VI at Aventura, a nursing home in Aventura, Florida in accordance with National Fire Protection Association (NFPA) 1 and 101 (2018 edition) and applicable requirements of Florida State Fire Marshal's Rules and Regulations, Florida Administrative Code (F.A.C) 69A-3, F.A.C. 69A-53, F.A.C. 59A-4, and Florida Statutes (F.S.) 400 Part II, and F.S. 633.0215, adopting National Fire Protection Association (NFPA) 1 and 101 (2018 edition) known as the Florida Fire Prevention Code and all NFPA referenced standards and requirements adopted per NFPA 101, Chapter 2. The following is description of the deficiencies found at the time of the visit.

K 353 NFPA 101 Sprinkler System - Maintenance and K 353 2/26/23 SS=D Testing Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked b) Who provided system test c) Water system supply source Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 35961002 01/23/2023 VIA AT AVENTURA 19333 WEST COUNTRY CLUB DRIVE AVENTURA, FL 33180 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE

K 353 Continued From page 1

K 353 9.7.5, 9.7.7, 9.7.8, and NFPA 25 This Statute or Rule is not met as evidenced by: Based on observations and staff interview, the facility failed to maintain the automatic sprinkler system in accordance with NFPA 101. Findings included: During the records review process of the facility between 11:00 AM and 4:00 PM on 01/23/2023 with the Assistant Maintenance Director, it was revealed that there was no documentation for the performance of Fire Department Connection (FDC) 5-year hydrostatic test. During the Life Safety Survey tour of the facility at 4:45 PM on 01/23/2023 with the Assistant Maintenance Director, it was observed that (1) there was no list posted in sprinkler cabinet at the Pump Room/Electrical Room, and (2) there was no hydraulic calculation information sign at the risers. During the staff interview between 11:00 am and 4:45 PM on 01/23/2023, the Assistant Maintenance Director acknowledged these findings. These findings were also discussed and acknowledged by the Administrator during the exit conference. NFPA 101 (2018 Edition) 19.3.5, 9.7.5 NFPA 25 (2017 Edition) 6.3.2.1, 5.4.1.5.6, and 5.2.5 Class III STATE FORM notes KX2E21 |---|---|---|---| |---|---| | VI AT AVENTURA | 19333 WEST COUNTRY CLUB DRIVE AVENTURA, FL 33180 | |---|---|---|---|---| | K 000 | INITIAL COMMENTS | K 000 | | | | | An unannounced Fire & Life Safety recertification survey was conducted 01/23/2023 at VI at Aventura, a nursing home in Aventura, Florida. | | | | | | The facility is not in compliance with 42 CFR 483.90 (a), and National Fire Protection Association (NFPA) 101 (2012 edition), NFPA 99 (2012) requirements for nursing homes. | | | | | | Initial Plan Review: 2003 | | | | | | Existing | | | | | | NFPA 220 Construction Type: I (332) | | | | | | Number of beds: 40 | | | | | | Census: 32 | | | | | K 353 SS=D | Sprinkler System - Maintenance and Testing CFR(s): NFPA 101 | K 353 | | 2/26/23 | | | Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. | | | | | | a) Date sprinkler system last checked _____________ | | | | | | b) Who provided system test _____________________ | | | | | | c) Water system supply source __________________ | | | | | | Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. | | | | | | 9.7.5, 9.7.7, 9.7.8, and NFPA 25 | | | | | | This REQUIREMENT is not met as evidenced | | | | 106076 01/23/2023 VIA AT AVENTURA 19333 WEST COUNTRY CLUB DRIVE AVENTURA, FL 33180 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETION DATE

K 353 Continued From page 1

K 353 by: Based on observations and staff interview, the facility failed to maintain the automatic sprinkler system in accordance with NFPA 101. Findings included: During the records review process of the facility between 11:00 AM and 4:00 PM on 01/23/2023 with the Assistant Maintenance Director, it was revealed that there was no documentation for the performance of Fire Department Connection (FDC) 5-year hydrostatic test. During the life safety survey tour of the facility at 4:45 PM on 01/23/2023 with the Assistant Maintenance Director, it was observed that (1) there was no list posted in sprinkler cabinet at the Pump Room/Electrical Room, and (2) there was no hydraulic calculation information sign at the risers. During the staff interview between 11:00 AM and 4:45 PM on 01/23/2023, the Assistant Maintenance Director acknowledged these findings. These findings were also discussed and acknowledged by the Administrator during the exit conference. NFPA 101 (2012 Edition) 19.3.5, 9.7.5 NFPA 25 (2011 Edition) 6.3.2.1, 5.4.1, and 5.2.6 VIA ATVENTURA 19333 WEST COUNTRY CLUB DRIVE AVENTURA, FL 33180 PREFIX PREFIX COMPLETION DATE

E 000 | Initial Comments | E 000 | | During an unannounced Fire & Life Safety recertification survey conducted on 01/23/2023 at VI at Aventura, a nursing home in Aventura, Florida, Emergency Preparedness was reviewed. VI at Aventura is in compliance with Emergency Preparedness per Code of Federal Regulations (CFR) 42, Part 483.73, Requirement for Long-Term Care Facilities.