Inspection·September 11, 2025

F0655 SS = D | Baseline Care Plan | F0655 | | 10/11/2025 INITIAL COMMENTS A recertification survey was conducted at Villa Maria West skilled Nursing Facility September 9, 2025, to September 11, 2025. The facility was not in compliance with 42 CFR 483. Requirements for Long Term Care Facilities. Baseline Care Plan CFR(s): 483.21(a)(1)-(3) $483.21 Comprehensive Person-Centered Care Planning $483.21(a) Baseline Care Plans $483.21(a)(1) The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must: (i) Be developed within 48 hours of a resident's admission. (ii) Include the minimum healthcare information necessary to properly care for a resident including, but not limited to- (A) Initial goals based on admission orders. (B) Physician orders. (C) Dietary orders. (D) Therapy services. (E) Social services. (F) PASARR recommendation, if applicable. $483.21(a)(2) The facility may develop a comprehensive care plan in place of the baseline care plan if the comprehensive care plan- 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 of deficiencies. This plan of correction is being submitted because the law requires it. Corrective Action -Comprehensive Care Plan for Shortness of Breath and the use of respiratory treatment was added for resident # 49. -Baseline Care Plans were audited for all residents to ensure compliance. -Nursing staff in-service was initiated. Identification of Residents who have the potential to be affected -All residents admitted to facility with orders for respiratory treatments have the potential to be affected. Systemic Changes/Preventive Measures -RNs/LPNs were in-serviced on the importance of initiating a Baseline Care Plans for residents on respiratory treatments. -Respiratory treatment was added as an intervention to the Baseline Care Plan for residents at risk for Shortness of Breath. -Facility implemented a tracking tool to ensure compliance with the developing of a Baseline Care Plan for residents on respiratory treatments. Monitoring 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 reverse for further 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 were made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE | TITLE | (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete | Event ID: 1D2BB3-H1 | Facility ID: 35961030 | If continuation sheet Page 1 of 8 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES PRINTED: 10/23/2025 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTIONS (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 106080 (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING (X3) DATE SURVEY COMPLETED 09/11/2025 NAME OF PROVIDER OR SUPPLIER VILLA MARIA WEST SKILLED NURSING FACILITY STREET ADDRESS, CITY, STATE, ZIP CODE 8850 NW 122 ST , HIALEAH GARDENS, Florida, 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

F0655 SS = D Continued from page 1 (i) is developed within 48 hours of the resident's admission. (ii) Meets the requirements set forth in paragraph (b) of this section (excepting paragraph (b)(2)(i) of this section). $483.21(a)(3) The facility must provide the resident and their representative with a summary of the baseline care plan that includes but is not limited to: (i) The initial goals of the resident. (ii) A summary of the resident's medications and dietary instructions. (iii) Any services and treatments to be administered by the facility and personnel acting on behalf of the facility. (iv) Any updated information based on the details of the comprehensive care plan, as necessary. This REQUIREMENT is NOT MET as evidenced by: The facility failed to develop a baseline care plan that included respiratory care for Resident #49, as evidenced by: Resident #49, was admitted on 09/04/2025 and receiving multiple respiratory treatments, did not have a baseline care plan developed until six days after admission." The findings included: On 09/09/2025 at 9:45 AM, Resident #49 was observed seated in a wheelchair watching television. The resident reported no concerns and revealed she had two weeks remained in rehabilitation following a fall at home. On 09/10/2025 at 8:34 AM, the resident actively participated in therapy, with no concerns noted or reported. During the observation on 09/11/2025 at 10:15 AM, the resident was again seated in a wheelchair, and no concerns were noted or reported. A review of the medical record for Resident #49 showed an admission date of 09/04/2025, with diagnoses including "Encounter for other specified aftercare" and Chronic Obstructive Pulmonary Disease (COPD). The Admission Minimum Data Set (MDS) was in progress at the time of review. The Entry MDS was completed on 09/08/2025, and the Assessment Reference Date (ARD) was set for 09/10/2025.

F0655 Continued from page 1 - A Tracking tool will be completed for all admissions with respiratory treatment orders by DON/Supervisor/Designee for every admission for 90 days, then monthly for 90 days, and randomly thereafter. -The results of this audit tool will be submitted to monthly Quality Assurance Committee Meeting for review for the next three months. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: 1D2BB3-H1 Facility ID: 35961030 If continuation sheet Page 2 of 8 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES PRINTED: 10/23/2025 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTIONS (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 106080 (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING (X3) DATE SURVEY COMPLETED 09/11/2025 NAME OF PROVIDER OR SUPPLIER VILLA MARIA WEST SKILLED NURSING FACILITY STREET ADDRESS, CITY, STATE, ZIP CODE 8850 NW 122 ST , HIALEAH GARDENS, Florida, 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

F0655 SS = D Continued from page 2 Review of Physician orders dated between 09/04/2025 and 09/09/2025 indicated that the resident received multiple active respiratory treatments. These included Budesonide (Pulmicort) 0.5 mg/2mt (0.5 milligrams per 0.5 milliliters) via nebulizer 0.5 mg twice daily, Formoterol Tartrate (Forvana) 5 mcg/2 ml (5 micrograms per 2 milliliters) nebulization solution twice daily, and ipratropium-Albuterol solution every six hours via nebulizer. A pulmonology consultation was ordered on 09/08/2025 for pneumonia. Additional orders included Prednisone 10 mg daily for five days, Cefuroxime 250mg orally twice daily for pneumonia, and an order dated 09/04/2025 to check oxygen saturation. Review of Progress notes from 09/07/2025 and 09/08/2025 documented treatment for pneumonia and COPD. On 09/10/2025 at 11:30 AM, the Manager of Clinical Reimbursement, MDS Registered Nurse confirmed that although the ARD was set for 09/10/2025 and baseline care plan initiation was scheduled for that day, the resident had been receiving multiple respiratory interventions since 09/04/2025. The MDS RN acknowledged that the baseline care plan had not been completed and lacked interim documentation outlining essential respiratory treatments or goals. Despite clear orders for multiple inhaled and oral medications, consults, and respiratory monitoring, the facility failed to develop or implement a baseline care plan within 48 hours of admission that addressed the resident's respiratory needs. Following the interview, on 09/10/2025 at 12:40 PM, the Director of Nursing (DON) entered the conference room and hand-delivered a newly created baseline care plan. This plan had been developed only after the surveyor's inquiry, confirming that the baseline care plan was not completed within the regulatory time frame and was created in response to surveyor involvement. A review of the facility's Policy and Procedures for Baseline Care Plan for Care Planning, effective 12/03/2004, revised 02/22/2026, and reviewed 10/16/2024, revealed the following: The policy indicated that care, treatment, and services are planned to ensure appropriateness to the resident's needs. The facility provides an individualized, interdisciplinary plan of care addressing all resident needs, strengths, limitations, and goals. Care planning is implemented through integration of assessment findings, prescribed treatment plans, and development

F0655 FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: 1D2BB3-H1 Facility ID: 35961030 If continuation sheet Page 3 of 8 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES PRINTED: 10/23/2025 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTIONS | (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 106080 | (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING | (X3) DATE SURVEY COMPLETED 09/11/2025 NAME OF PROVIDER OR SUPPLIER: VILLA MARIA WEST SKILLED NURSING FACILITY STREET ADDRESS, CITY, STATE, ZIP CODE: 8850 NW 122 ST , HIALEAH GARDENS, Florida, 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 --- | --- | --- | --- | ---

F0655 SS = D | Continued from page 3 of reasonable and measurable goals. Documentation is completed using computerized care planning. The procedure specified that an interim care plan must be completed no later than 72 hours after admission. | F0655 | |

F0867 SS = D | QAPI/QAA Improvement Activities CFR(s): 483.75(c)(1)-(4)d)(1)(2)e)(1)-3(g)(2)(ii)(iii) $483.75(c) Program feedback, data systems and monitoring. A facility must establish and implement written policies and procedures for feedback, data collections systems, and monitoring, including adverse event monitoring. The policies and procedures must include, at a minimum, the following: $483.75(c)(1) Facility maintenance of effective systems to obtain and use of feedback and input from direct care staff, other staff, residents, and resident representatives, including how such information will be used to identify problems that are high risk, high volume, or problem-prone, and opportunities for improvement. $483.75(c)(2) Facility maintenance of effective systems to identify, collect, and use data and information from all departments, including but not limited to the facility assessment required at §483.71 and including how such information will be used to develop and monitor performance indicators. $483.75(c)(3) Facility development, monitoring, and evaluation of performance indicators, including the methodology and frequency for such development, monitoring, and evaluation. $483.75(c)(4) Facility adverse event monitoring, including the methods by which the facility will systematically identify, report, track, investigate, analyze and use data and information relating to adverse events in the facility, including how the facility will use the data to develop activities to prevent adverse events. $483.75(d) Program systematic analysis and systemic action. | F0867 | Corrective Action: An emergency meeting of the Safety committee was held to review the AHCA findings, and to discuss the plan of correction. Plan of correction that was submitted for 05/15/2024 was reviewed and an ad hoc QAA Meeting was conducted. Identification of residents who have the potential to be affected. All residents admitted to the facility have the potential to be affected. Systemic Change/Preventive Measures 1.) QAPI Team was in-serviced by the Vice President of Operational Excellence; Performance Improvement; on the QAPI Process. 2.) QAPI Five Elements. 3.) QAPI Self-Assessment. 4.) QAPI Policy, and 5.) QAPI Education. An in-service focused on Care Plans and the care planning process will occur on 10/9/2025. The in-service will be provided by an outside consultant. Administrative Staff will monitor the developing of the care plans and the completion of the log; a weekly meeting will occur between Director of Nursing, Risk Manager, Executive Assistant; MDS Coordinator and the Administrator/Designee to discuss all aspects of resident care. These meetings occur weekly for ninety days. All aspects of resident care that arise will be discussed in the morning meeting that includes all department heads. All results of the meeting will be reported to the safety committee monthly and then to QAPI Committee for ninety days. An ad hoc QAA Meeting was conducted to determine the reason that the deficient practice was repeated. | 10/11/2025 FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: 1D2BB3-H1 Facility ID: 35961030 If continuation sheet Page 4 of 8 DEPARTMENT OF HEALTH AND HUMAN SERVICES PRINTED: 10/23/2025 CENTERS FOR MEDICARE & MEDICAID SERVICES FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTIONS (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 106080 (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING (X3) DATE SURVEY COMPLETED 09/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VILLA MARIA WEST SKILLED NURSING FACILITY 8850 NW 122 ST., HIALEAH GARDENS, Florida, 33018 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION PREFIX TAG (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) PREFIX TAG (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE

F0867 Continued from page 4 F0867 Continued from page 4 SS = D $483.75(d)(1) The facility must take actions aimed at performance improvement and, after implementing those actions, measure its success, and track performance to ensure that improvements are realized and sustained. $483.75(d)(2) The facility will develop and implement policies addressing: (i) How they will use a systematic approach to determine underlying causes of problems impacting larger systems. (ii) How they will develop corrective actions that will be designed to effect change at the systems level to prevent quality of care, quality of life, or safety problems; and (iii) How the facility will monitor the effectiveness of its performance improvement activities to ensure that improvements are sustained. $483.75(e) Program activities. $483.75(e)(1) The facility must set priorities for its performance improvement activities that focus on high-risk, high-volume, or problem-prone areas; consider the incidence, prevalence, and severity of problems in those areas; and affect health outcomes, resident safety, resident autonomy, resident choice, and quality of care. $483.75(e)(2) Performance improvement activities must track medical errors and adverse resident events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the facility. $483.75(e)(3) As part of their performance improvement activities, the facility must conduct distinct performance improvement projects. The number and frequency of improvement projects conducted by the facility must reflect the scope and complexity of the facility's services and available resources, as reflected in the facility assessment required at §483.71. Improvement projects must include at least annually a project that focuses on high risk or problem-prone areas identified through the data Staff awareness – In-service. Monitoring – Extended monitoring period. Respiratory treatment was not a choice as an intervention – Choice was added as an intervention. These factors played a major role in the reoccurrence of the deficient practice. Staff was re-educated/re-trained by the DON on the deficient practice to prevent reoccurrences. Monitoring: Random audits will be conducted by the Administrator/designee for ninety days; monthly for 90 days, and then randomly thereafter. The audit results will be reported to the QAPI Committee monthly for their review, input, and guidance and then forwarded to QMC. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: 1D2BB3-H1 Facility ID: 35961030 If continuation sheet Page 5 of 8 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES PRINTED: 10/23/2025 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTIONS (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 106080 (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING (X3) DATE SURVEY COMPLETED 09/11/2025 NAME OF PROVIDER OR SUPPLIER VILLA MARIA WEST SKILLED NURSING FACILITY STREET ADDRESS, CITY, STATE, ZIP CODE 8850 NW 122 ST., HIALEAH GARDENS, Florida, 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

F0867 SS = D Continued from page 5 collection and analysis described in paragraphs (c) and (d) of this section.

F0867 $483.75(g) Quality assessment and assurance. $483.75(g)(2) The quality assessment and assurance committee reports to the facility's governing body, or designated person(s) functioning as a governing body regarding its activities, including implementation of the QAPI program required under paragraphs (a) through (e) of this section. The committee must: (ii) Develop and implement appropriate plans of action to correct identified quality deficiencies; (iii) Regularly review and analyze data, including data collected under the QAPI program and data resulting from drug regimen reviews, and act on available data to make improvements. This REQUIREMENT IS NOT MET as evidenced by: Based on observations, staff interviews, and records review, the facility failed to implement effective corrective actions to address previously identified deficiencies. This is evidenced by the repeated citation of F655 – Development of a Baseline Care Plan. Despite prior citations and the opportunity for corrective action, the facility did not demonstrate sustained compliance. At the time of the survey, 22 residents were residing in the facility. The findings included: Review of the facility's survey history revealed, during a recertification survey with exit date 05/15/ 2024, F655 Development of a baseline care plan was cited related to facility's failure to develop a baseline care plan for oxygen use for one resident. During this survey with exit dated 09/11/2025, the facility did not develop Resident #49's baseline care plan for respiratory care. On 09/11/2025, at 12:30 PM, a Quality Assurance and Performance Improvement (QAPI) review was conducted with the Director of Nursing and the Administrator. The facility's Quality Assurance and Performance Improvement (QAPI) policy and procedure dated February 14, 2025, was reviewed with no concerns noted. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: 1D2BB3-H1 Facility ID: 35961030 If continuation sheet Page 6 of 8 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES PRINTED: 10/23/2025 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTIONS (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 106080 (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING (X3) DATE SURVEY COMPLETED 09/11/2025 NAME OF PROVIDER OR SUPPLIER VILLA MARIA WEST SKILLED NURSING FACILITY STREET ADDRESS, CITY, STATE, ZIP CODE 8850 NW 122 ST., HIALEAH GARDENS, Florida, 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

F0867 SS = D Continued from page 6 The facility has a Quality Assurance and Assessment (QAA) Committee that meets every month on the second Wednesday. The most recent meeting was on September 13, 2025. Sign-in sheets showed that all required team members attended, including representatives from nursing, therapy, social services, dietary, and environmental services. The committee's primary objective is to ensure a safe, person-centered care environment, through data-driven analysis, collaborative problem-solving. The team uses data, teamwork, and improvement plans to fix problems. Every day at 9:02 AM, staff meet to find and solve issues early. Staff can also report concerns in other ways, like talking to supervisors. The committee chooses projects based on risk and how much they affect residents and prioritizes projects based on risk and resident impact, using structured tools to help the team decide what to focus on. Progress is tracked through audits and staff feedback. Current improvement plans focus on hospital transfers and nutrition services. Other top issues include pressure ulcer prevention and fall reduction. All actions are checked and updated to make sure they work and stay in place and follow-up action revisions are conducted systematically to ensure accountability and sustained improvement. Review of the facility's Policy titled: "Quality Assurance and Performance Improvement" reviewed on 02/14/25 I. Mission As part of Catholic Health Services, Our Mission is to provide health care and services to those in need, to minimize human suffering, to assist people to wholeness and to nurture an awareness of their relationship with God. II. Vision Our vision is to strive to improve the health, independence and spiritual life of the elderly, the poor, and the needy in the Archdiocese, through innovative and proactive approaches to: Managing care and providing services.Facilitating transitions across levels of care.Community partnerships and collaboration.Advocacy efforts.III. QAPI Objectives The primary objectives of Quality Assurance & FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: 1D2BB3-H1 Facility ID: 35961030 If continuation sheet Page 7 of 8 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES PRINTED: 10/23/2025 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTIONS (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 106080 (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING (X3) DATE SURVEY COMPLETED 09/11/2025 NAME OF PROVIDER OR SUPPLIER VILLA MARIA WEST SKILLED NURSING FACILITY STREET ADDRESS, CITY, STATE, ZIP CODE 8850 NW 122 ST., HIALEAH GARDENS, Florida, 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

F0867 SS = D Continued from page 7 Performance Improvement (QAP) is to monitor, assess and improve performance of critical focus areas, improve healthcare outcomes and reduce and prevent medical/health care errors on a continuous basis throughout the facility.

F0867 FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: 1D2BB3-H1 Facility ID: 35961030 If continuation sheet Page 8 of 8 PRINTED: 10/23/2025 FORM APPROVED Florida Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTIONS (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING (X3) DATE SURVEY COMPLETED 130471041 09/11/2025 NAME OF PROVIDER OR SUPPLIER VILLA MARIA WEST SKILLED NURSING FACILITY STREET ADDRESS, CITY, STATE, ZIP CODE 8850 NW 122 ST., HIALEAH GARDENS, Florida, 33018 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) ID PROVIDER'S PLAN OF CORRECTION PREFIX (EACH CORRECTIVE ACTION SHOULD BE TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE

N0000 INITIAL COMMENTS N0000 09/26/2025

N0071 A re-licensure survey was conducted at Villa Maria West SS = D Skilled Nursing Facility September 9, 2025, to September 11, 2025. Deficiencies were identified at the time of the survey. Components of Care Plan CFR(s): 59A-4.109(1), FAC (1) Each resident admitted to the nursing home facility must have a plan of care. The plan of care must consist of: (a) Physician's orders, diagnosis, medical history, physical exam and rehabilitative or restorative potential. (b) A preliminary nursing evaluation with physician's orders for immediate care, completed upon admission. (c) A complete, comprehensive, accurate and reproducible assessment of each resident's functional capacity which is standardized in the facility, and is completed within 14 days of the resident's admission to the facility and every twelve months, thereafter. The assessment must be: 1. Reviewed no less than once every 3 months; 2. Reviewed promptly after a significant change, which is a need to stop a form of treatment because of adverse consequences (e.g., an adverse drug reaction), or commence a new form of treatment to deal with a problem, in the resident's physical or mental condition; and, 3. Revised as appropriate to assure the continued accuracy of the assessment. This LICENSURE REQUIREMENT IS NOT MET as evidenced by: The facility failed to develop a baseline care plan that included respiratory care for Resident #49, as

N0071 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 of deficiencies. This plan of correction is being submitted because the law requires it. Corrective Action -Comprehensive Care Plan for Shortness of Breath and the use of respiratory treatment was added for resident # 49. -Baseline Care Plans were audited for all residents to ensure compliance. -Nursing staff in-service was initiated. Identification of Residents who have the potential to be affected -All residents admitted to facility with orders for respiratory treatments have the potential to be affected. Systemic Changes/Preventive Measures -RNs/LPNs were in-serviced on the importance of initiating a Baseline Care Plans for residents on respiratory treatments. -Respiratory treatment was added as an intervention to the Baseline Care Plan for residents at risk for Shortness of Breath. -Facility implemented a tracking tool to ensure compliance with the developing of a Baseline Care Plan for residents on respiratory treatments. 10/11/2025 Office of Primary Care and Health Systems Management LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM Event ID: 1D2BB3-H1 Facility ID: 35961030 If continuation sheet Page 1 of 3 Florida Department of Health PRINTED: 10/23/2025 FORM APPROVED STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTIONS (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 130471041 (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING (X3) DATE SURVEY COMPLETED 09/11/2025 NAME OF PROVIDER OR SUPPLIER VILLA MARIA WEST SKILLED NURSING FACILITY STREET ADDRESS, CITY, STATE, ZIP CODE 8850 NW 122 ST , HIALEAH GARDENS, Florida, 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

N0071 SS = D Continued from page 1 evidenced by: Resident #49, admitted on 09/04/2025 and receiving multiple respiratory treatments, did not have a baseline care plan developed until six days after admission. The findings included: On 09/09/2025 at 9:45 AM, Resident #49 was observed seated in a wheelchair watching television. The resident reported no concerns and revealed she had two weeks remained in rehabilitation following a fall at home. On 09/10/2025 at 8:34 AM, the resident actively participated in therapy, with no concerns noted or reported. During the observation on 09/11/2025 at 10:15 AM, the resident was again seated in a wheelchair, and no concerns were noted or reported. A review of the medical record for Resident #49 showed an admission date of 09/04/2025, with diagnoses including "Encounter for other specified aftercare" and Chronic Obstructive Pulmonary Disease (COPD). The Admission Minimum Data Set (MDS) was in progress at the time of review. The Entry MDS was completed on 09/08/2025, and the Assessment Reference Date (ARD) was set for 09/10/2025. Review of Physician orders dated between 09/04/2025 and 09/09/2025 indicated that the resident received multiple active respiratory treatments. These included Budesonide (Pulmicort) 0.5 mg/2ml (0.5 milligrams per 0.5 milliliters) via nebulizer twice daily, Formoterol Fumarate Tarrate (Brovana) 5 mcg/2 ml (5 micrograms per 2 milliliters) nebulization solution twice daily, and Ipratropium-Albuterol solution every six hours via nebulizer. A pulmonology consultation was ordered on 09/08/2025 for pneumonia. Additional orders included Prednisone 10 mg daily for five days, Cefuroxime 250mg orally twice daily for pneumonia, and an order dated 09/04/2025 to check oxygen saturation. Review of Progress notes from 09/07/2025 and 09/08/2025 documented treatment for pneumonia and COPD. On 09/10/2025 at 11:30 AM, the Manager of Clinical Reimbursement (MDS Registered Nurse) confirmed that although the ARD was set for 09/10/2025 and baseline care plan initiation was scheduled for that day, the resident had been receiving multiple respiratory interventions since 09/04/2025. The MDS RN acknowledged that the baseline care plan had not been completed and lacked interim documentation outlining essential respiratory treatments or goals. Despite clear orders for multiple inhaled and oral medications, consults, and respiratory monitoring, the N0071 Continued from page 1 Monitoring - A Tracking tool will be completed for all admissions with respiratory treatment orders by DON/Supervisor/Designee for every admission for 90 days, then monthly for 90 days, and randomly. -The results of this audit tool will be submitted to monthly Quality Assurance Committee Meeting for review for the next three months. STATE FORM Event ID: 1D2BB3-H1 Facility ID: 35961030 If continuation sheet Page 2 of 3 Florida Department of Health PRINTED: 10/23/2025 FORM APPROVED STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTIONS (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 130471041 (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING (X3) DATE SURVEY COMPLETED 09/11/2025 NAME OF PROVIDER OR SUPPLIER VILLA MARIA WEST SKILLED NURSING FACILITY STREET ADDRESS, CITY, STATE, ZIP CODE 8850 NW 122 ST , HIALEAH GARDENS, Florida, 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

N0071 SS = D Continued from page 2 facility failed to develop or implement a baseline care plan within 48 hours of admission that addressed the resident's respiratory needs. N0071 Following the interview, on 09/10/2025 at 12:40 PM, the Director of Nursing (DON) entered the conference room and hand-delivered a newly created baseline care plan. This plan had been developed only after the surveyor's inquiry, confirming that the baseline care plan was not completed within the regulatory time frame and was created in response to surveyor involvement. A review of the facility's Policy and Procedures for Baseline Care Plan for Care Planning, effective 12/03/2004, revised 02/22/2026, and reviewed 10/16/2024, revealed the following: The policy indicated that care, treatment, and services are planned to ensure appropriateness to the resident's needs. The facility provides an individualized, interdisciplinary plan of care addressing all resident needs, strengths, limitations, and goals. Care planning is implemented through integration of assessment findings, prescribed treatment plans, and development of reasonable and measurable goals. Documentation is completed using computerized care planning. The procedure specified that an interim care plan must be completed no later than 72 hours after admission. Class III STATE FORM Event ID: 1D2BB3-H1 Facility ID: 35961030 If continuation sheet Page 3 of 3