Inspection·June 17, 2024

Agency for Health Care Administration PRINTED: 06/25/2024 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 R 06/17/2024 35961039 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 PROVIDER'S PLAN OF CORRECTION PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X6) COMPLETE DATE (N 000) INITIAL COMMENTS (N 000) A revisit to a Licensure survey that was conducted at Villa Maria West Skilled Nursing Facility on 6/17/24. Previously cited deficiencies were found to be corrected. AHCA Form 3020-0001 LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X8) DATE Electronically Signed 06/24/24 STATE FORM 6809 X3LW12 If continuation sheet 1 of 1 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES SUMMARY OF DEFICIENCIES AND PLAN OF CORRECTION PRINTED: 06/25/2024 FORM APPROVED OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING (X3) DATE SURVEY COMPLETED 106080 B. WING R 06/17/2024 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 [F 000] INITIAL COMMENTS [F 000] An unannounced revisit to a recertification was conducted on June 17, 2024 at Villa Maria West Skilled Nursing Facility. The facility was in compliance with CFR 42, 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 06/24/2024 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: XSLW12 Facility ID: 35961030 If continuation sheet Page 1 of 1