Inspection·September 14, 2021

Agency for Health Care Administration PRINTED: 09/27/2021 FORM APPROVED STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING: ________ B. WING ________ (X3) DATE SURVEY COMPLETED 35961039 R 09/14/2021 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 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X6) COMPLETE DATE (N 000) INITIAL COMMENTS (N 000) A revisit to a recertification survey was conducted on September 14, 2021 at Villa Maria West Skilled Nursing Facility. Deficiencies were found to be corrected at the time of the survey. AHCA Form 3020-0001 LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X8) DATE Electronically Signed 09/23/21 STATE FORM 6809 LZ9H12 If continuation sheet 1 of 1 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES PRINTED: 09/27/2021 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING ______ (X3) DATE SURVEY COMPLETED 106080 B. WING ______ R 09/14/2021 NAME OF PROVIDER OR SUPPLIER VILLA MARIA WEST SKILLED NURSING FACILITY STREET ADDRESS, CITY, STATE, ZIP CODE 8850 NW 122 ST HIALEAH GARDENS, FL 33018 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE [F 000] INITIAL COMMENTS [F 000] An unannounced revisit survey was conducted on September 14, 2021 at Villa Maria West Skilled Nursing Facility. The facility was in substantial compliance with 42 CFR Part 483 requirements for Long Term Care Facilities. Previously cited deficiencies were found to be corrected. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Electronically Signed 09/23/2021 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 of survey these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:LZ9H12 Facility ID: 35961030 If continuation sheet Page 1 of 1