Inspection·December 28, 2022

E 000 During an unannounced Fire & Life Safety recertification survey conducted on 12/28/2022 at Villa Maria West Skilled Nursing Facility, a nursing home in Hialeah Gardens, Florida, Emergency Preparedness was reviewed. Villa Maria West Skilled Nursing Facility is in compliance with Emergency Preparedness per Code of Federal Regulations (CFR) 42, Part 483.73, Requirement for Long-Term Care Facilities. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Electronically Signed 01/06/2023 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DEZ321 Facility ID: 35961030 If continuation sheet Page 1 of 1 PRINTED: 01/18/2023 FORM APPROVED Agency for Health Care Administration STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING: 05 - MAIN LIC B. WING _ (X3) DATE SURVEY COMPLETED 35961039 12/28/2022 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) (X6) COMPLETE DATE

K 000 INITIAL COMMENTS K 000 An unannounced Fire & Life Safety re-licensure survey was conducted on 12/28/2022 at Villa Maria West Skilled Nursing Facility, a nursing home in Hialeah Gardens, 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 facility was found to be in substantial compliance at the time of this survey. AHCA Form 3020-0001 LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Electronically Signed 01/06/23 STATE FORM 6809 DEZ321 If continuation sheet 1 of 1 DEPARTMENT OF HEALTH AND HUMAN SERVICES PRINTED: 01/18/2023 CENTERS FOR MEDICARE & MEDICAID SERVICES FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING 01 - MAIN FED (X3) DATE SURVEY COMPLETED 106080 B. WING 12/28/2022 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 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID (X5) PREFIX TAG (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE COMPLETION REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY)

K 000 INITIAL COMMENTS

K 000 An unannounced Fire & Life Safety recertification survey was conducted on 12/28/2022 at Villa Maria West Skilled Nursing Facility, a nursing home in Hialeah Gardens, Florida. Villa Maria West Skilled Nursing Facility is not in compliance with 42 CFR 483.90 (a) & (b), and National Fire Protection Association (NFPA) 101(2012 edition) and Tentative Interim Amendments (TIA's) 12-1, 12-2, 12-3, and 12-4. NFPA 99(2012 edition) and Tentative Interim Amendments TIA's 12-2, 12-3, 12-4, 12-5 and 12-6 requirements for nursing homes. Initial Plan Review date: 2008 Existing NFPA 220 Construction Type: I (332) Square Footage: 14,310 Generator: Diesel 1600 kilowatt (kW) Number of licensed beds: 27 Census: 20 The facility was found to be in substantial compliance at the time of this survey. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Electronically Signed 01/06/2023 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: DEZ321 Facility ID: 35961030 If continuation sheet Page 1 of 1