Inspection·May 17, 2024

K 000 INITIAL COMMENTS

K 000 A re-licensure survey was conducted on 05/17/2024 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 (2021 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 (2021 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 6/15/24 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 06/07/24 STATE FORM 6809 X3LW21 35961039 05/17/2024 VILLA MARIA WEST SKILLED NURSING FACILITY 8850 NW 122 ST HIALEAH GARDENS, FL 33018 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE

K 353 Continued From page 1 system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25

K 353 This Statute or Rule is not met as evidenced by: Based on observation and staff interview, the facility failed to maintain the automatic sprinkler system in accordance with NFPA 101. Findings included: During the Life Safety Survey tour of the facility at 6:45 PM on 05/17/2024 with the Maintenance Director, it was observed in the Exterior Boiler Room that (1) there was no list posted in sprinkler cabinet, and (2) there was no spare dry sprinkler for freezer nor means to restore service. During the staff interview at 6:45 PM on 05/17/2024, the Maintenance Director acknowledged these findings. These findings were also discussed and acknowledged by the Administrator during the exit conference. NFPA 101 (2021 Edition) 19.7.6, 4.6.12, 4.6.12.1, 9.11 through 9.11.3.2 NFPA 25 (2020 Edition) 5.4.1.5.6, 5.4.1.5.6.1 (1-4), and 5.4.1.5.3 Class III STATE FORM notes XSLW21 SUMMARY OF DEFICIENCIES 106080 05/17/2024 VILLA MARIA WEST SKILLED NURSING FACILITY 8850 NW 122 ST HIALEAH GARDENS, FL 33018 ID PREFIX TAG PREFIX TAG COMPLETION DATE DEFICIENCY)

K 000 INITIAL COMMENTS

K 000 An unannounced Fire & Life Safety recertification survey was conducted 05/17/2024 at Villa Maria West Skilled Nursing Facility, a nursing home in Hialeah Gardens, 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: 2008 Existing NFPA 220 Construction Type: I (332) Number of beds: 27 Census: 22

K 353 Sprinkler System - Maintenance and Testing

K 353 6/15/24 SS=D CFR(s): NFPA 101 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 Maintenance 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 06/07/2024 LIST OF DEFICIENCIES 106080 05/17/2024 VILLA MARIA WEST SKILLED NURSING FACILITY 8850 NW 122 ST HIALEAH GARDENS, FL 33018 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETION DATE

K 353 Continued From page 1

K 353 This REQUIREMENT is not met as evidenced by: Based on observation and staff interview, the facility failed to maintain the automatic sprinkler system in accordance with NFPA 101. Findings included: During the Life Safety Survey tour of the facility at 6:45 pm on 05/17/2024 with the Maintenance Director, it was observed in the Exterior Boiler Room that (1) there was no list posted in sprinkler cabinet, and (2) there was no spare dry sprinkler for freezer nor means to restore service. During the staff interview at 6:45 PM on 05/17/2024, the Maintenance Director acknowledged these findings. These findings were also discussed and acknowledged by the Administrator during the exit conference. NFPA 101 (2012 Edition) 19.3.5.1, 9.7.5 NFPA 25 (2011 Edition) 5.4.1, 5.4.1.1, 5.4.1.4, and 5.4.1.4.2.1 PLAN OF CORRECTION 106080 05/17/2024 8850 NW 122 ST HIALEAH GARDENS, FL 33018 PREFIX PREFIX COMPLETION DATE

E 000 Initial Comments E 000 During an unannounced Fire & Life Safety recertification survey conducted on 05/17/2024 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. COMPLETED 05/17/2024 HIALEAH GARDENS, FL 33018 PREFIX PREFIX COMPLETE DATE

K 000 INITIAL COMMENTS K 000 A re-licensure survey was conducted on 05/17/2024 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 (2021 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 (2021 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 6/15/24 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 05/17/2024 VILLA MARIA WEST SKILLED NURSING FACILITY 8850 NW 122 ST HIALEAH GARDENS, FL 33018 PREFIX COMPLETE DATE

K 353 Continued From page 1 system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25 K 353 This Statute or Rule is not met as evidenced by: Based on observation and staff interview, the facility failed to maintain the automatic sprinkler system in accordance with NFPA 101. Findings included: During the Life Safety Survey tour of the facility at 6:45 PM on 05/17/2024 with the Maintenance Director, it was observed in the Exterior Boiler Room that (1) there was no list posted in sprinkler cabinet, and (2) there was no spare dry sprinkler for freezer nor means to restore service. During the staff interview at 6:45 PM on 05/17/2024, the Maintenance Director acknowledged these findings. These findings were also discussed and acknowledged by the Administrator during the exit conference. NFPA 101 (2021 Edition) 19.7.6, 4.6.12, 4.6.12.1, 9.11 through 9.11.3.2 NFPA 25 (2020 Edition) 5.4.1.5.6, 5.4.1.5.6.1 (1-4), and 5.4.1.5.3 Class III Corrective Action: A list of items was created and posted in the sprinkler cabinet. A replacement dry sprinkler was purchased for the freezer. Identification of Residents who have the potential to be affected All residents, visitors, and staff that enter the facility have the potential to be affected Systemic Changes/Preventive Measures: Engineering staff were in-serviced on K 353 with an emphasis on testing and maintaining the system in accordance with NFPA 25. A log was created to monitor the testing and maintenance of the sprinkler system. The log will be used weekly for 90 days. Monitoring: The Director of Engineering will monitor the sprinkler system and document in the log weekly for 90 days. The results of the audits will be submitted to the monthly Quality Assurance 35961039 05/17/2024 VILLA MARIA WEST SKILLED NURSING FACILITY 8850 NW 122 ST HIALEAH GARDENS, FL 33018 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE

K 353 Continued From page 2

K 353 Committee meeting for review STATE FORM ndss XSLW21 SUMMARY OF DEFICIENCIES 05/17/2024 VILLA MARIA WEST SKILLED NURSING FACILITY 8850 NW 122 ST HIALEAH GARDENS, FL 33018 PREFIX TAG MUST BE PRECEDED BY FULL ID PREFIX TAG DEFICIENCY) COMPLETION DATE

K 000 INITIAL COMMENTS

K 000 An unannounced Fire & Life Safety recertification survey was conducted 05/17/2024 at Villa Maria West Skilled Nursing Facility, a nursing home in Hialeah Gardens, 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: 2008 Existing NFPA 220 Construction Type: I (332) Number of beds: 27 Census: 22

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

K 353 6/15/24 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 Maintenance 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 06/07/2024 106080 05/17/2024 VILLA MARIA WEST SKILLED NURSING FACILITY 8850 NW 122 ST HIALEAH GARDENS, FL 33018 PREFIX TAG COMPLETION DATE DEFICIENCY)

K 353 Continued From page 1 This REQUIREMENT is not met as evidenced by: Based on observation and staff interview, the facility failed to maintain the automatic sprinkler system in accordance with NFPA 101. Findings included: During the Life Safety Survey tour of the facility at 6:45 pm on 05/17/2024 with the Maintenance Director, it was observed in the Exterior Boiler Room that (1) there was no list posted in sprinkler cabinet, and (2) there was no spare dry sprinkler for freezer nor means to restore service. During the staff interview at 6:45 PM on 05/17/2024, the Maintenance Director acknowledged these findings. These findings were also discussed and acknowledged by the Administrator during the exit conference. NFPA 101 (2012 Edition) 19.3.5.1, 9.7.5 NFPA 25 (2011 Edition) 5.4.1, 5.4.1.1, 5.4.1.4, and 5.4.1.4.2.1

K 353 The submission of this plan of correction does not constitute an admission by the Provider of any fact or conclusion set forth This plan of correction is being submitted because the law requires it. Corrective Action: A list of items was created and posted in the sprinkler cabinet. A replacement dry sprinkler was purchased for the freezer. Identification of Residents who have the potential to be affected All residents, visitors, and staff that enter the facility have the potential to be affected Systemic Changes/Preventive Measures: Engineering staff were in-serviced on K 353 with an emphasis on testing and maintaining the system in accordance with NFPA 25. A log was created to monitor the testing and maintenance of the sprinkler system. The log will be used weekly for 90 days. Monitoring: The Director of Engineering will monitor the sprinkler system and document in the log weekly for 90 days. The results of the audits will be submitted to the monthly Quality Assurance COMPLETED 05/17/2024 8850 NW 122 ST HIALEAH GARDENS, FL 33018 PREFIX PREFIX COMPLETION DATE

K 353 Continued From page 2 K 353 Committee meeting for review SUMMARY OF DEFICIENCIES 106080 05/17/2024 VILLA MARIA WEST SKILLED NURSING FACILITY 8850 NW 122 ST HIALEAH GARDENS, FL 33018 PREFIX PREFIX COMPLETION DATE

E 000 Initial Comments E 000 During an unannounced Fire & Life Safety recertification survey conducted on 05/17/2024 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.