Inspection·June 20, 2024

PRINTED: 06/25/2024 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 R 06/20/2024 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 Fire & Life Safety follow up desk review was conducted on 06/20/2024 to the Fire & Life Safety relicensure survey that 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 deficiencies noted on the annual relicensure survey have been corrected and the facility is in substantial compliance with the requirements for nursing homes. AHCA Form 3020-0001 LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X8) DATE Electronically Signed 06/24/24 STATE FORM 6809 X3LW22 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 01 - MAIN FED (X3) DATE SURVEY COMPLETED 106080 B. WING R 06/20/2024 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 (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 000] INITIAL COMMENTS [K 000] A Fire & Life Safety follow up by desk review was conducted on 06/20/2024 to the Fire & Life Safety recertification survey that was conducted on 05/17/2024 at Villa Maria West Skilled Nursing Facility, a nursing home in Hialeah Gardens, Florida. under 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 The deficiencies noted on the annual recertification survey have been corrected and the facility is in substantial compliance with the requirements for nursing homes. 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: XSLW22 Facility ID: 35961030 If continuation sheet Page 1 of 1