Inspection·May 17, 2024

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 AHCA Form 3020-0001 LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE Electronically Signed TITLE (X6) DATE 06/07/24 STATE FORM 6809 X3LW21 If continuation sheet 1 of 2 Agency for Health Care Administration PRINTED: 06/12/2024 FORM APPROVED 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 05/17/2024 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

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 AHCA Form 3020-0001 STATE FORM notes XSLW21 if continuation sheet, 2 of 2 DEPARTMENT OF HEALTH AND HUMAN SERVICES PRINTED: 06/12/2024 CENTERS FOR MEDICARE & MEDICAID SERVICES FORM APPROVED OMB NO. 0938-0391 SUMMARY OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION IDENTIFICATION NUMBER: A. BUILDING 01 - MAIN FED (X3) DATE SURVEY COMPLETED 106080 B. WING 05/17/2024 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 PREFIX TAG PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH DEFICIENCY MUST BE PRECEDED BY FULL (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 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 LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Electronically Signed 06/07/2024 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: XSLW21 Facility ID: 35961030 If continuation sheet Page 1 of 2 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES PRINTED: 06/12/2024 FORM APPROVED OMB NO. 0938-0391 LIST 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 05/17/2024 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) (X5) 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 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:XSLW21 Facility ID: 35961030 If continuation sheet Page 2 of 2 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES PLAN OF CORRECTION AND SUMMARY OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION IDENTIFICATION NUMBER: A. BUILDING (X3) DATE SURVEY COMPLETED 106080 05/17/2024 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

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. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Electronically Signed 06/07/2024 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:XSLW21 Facility ID: 35961030 If continuation sheet Page 1 of 1 PRINTED: 06/12/2024 FORM APPROVED Agency for Health Care Administration STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 35961039 (X2) MULTIPLE CONSTRUCTION A. BUILDING: 05 - MAIN LIC B. WING ____ (X3) DATE SURVEY COMPLETED 05/17/2024 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 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 AHCA Form 3020-0001 LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Electronically Signed 06/07/24 STATE FORM 6809 X3LW21 If continuation sheet 1 of 3 Agency for Health Care Administration PRINTED: 06/12/2024 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 35961030 A. BUILDING: 05 - MAIN LIC B. WING __ (X3) DATE SURVEY COMPLETED 05/17/2024 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 PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG 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 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 The submission of this plan of correction does not constitute an admission by the Provider of any fact or conclusion set forth in the summary statement of deficiencies. 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 AHCA Form 3020-0001 STATE FORM notes XSLW21 if continuation sheet, 2 of 3 Agency for Health Care Administration PRINTED: 06/12/2024 FORM APPROVED STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 35961039 (X2) MULTIPLE CONSTRUCTION A. BUILDING: 05 - MAIN LIC B. WING _ (X3) DATE SURVEY COMPLETED 05/17/2024 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 353 Continued From page 2

K 353 Committee meeting for review AHCA Form 3020-0001 STATE FORM ndss XSLW21 If continuation sheet, 3 of 3 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES SUMMARY OF DEFICIENCIES AND PLAN OF CORRECTION PRINTED: 06/12/2024 FORM APPROVED OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING 01 - MAIN FED (X3) DATE SURVEY COMPLETED 05/17/2024 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 SUMMARY STATEMENT OF DEFICIENCIES 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

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 LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE Electronically Signed TITLE (X6) DATE 06/07/2024 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: XSLW21 Facility ID: 35961030 If continuation sheet Page 1 of 3 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES PRINTED: 06/12/2024 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 05/17/2024 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 (X5) COMPLETION DATE SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE 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 in the summary statement of deficiencies. 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 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: XSLW21 Facility ID: 35961030 If continuation sheet Page 2 of 3 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION PRINTED: 06/12/2024 FORM APPROVED OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 106080 (X2) MULTIPLE CONSTRUCTION A. BUILDING 01 - MAIN FED (X3) DATE SURVEY COMPLETED 05/17/2024 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

K 353 Continued From page 2 K 353 Committee meeting for review FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:XSLW21 Facility ID: 35961030 If continuation sheet Page 3 of 3 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES SUMMARY OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING (X3) DATE SURVEY COMPLETED 106080 05/17/2024 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) (X5) 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. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Electronically Signed 06/07/2024 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: XSLW21 Facility ID: 35961030 If continuation sheet Page 1 of 1