Inspection·February 23, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm Observation of room [ROOM NUMBER] revealed the exterior of the 2 room chairs were heavily worn. The room floor was soiled and stained, the privacy curtain (A bed) was soiled and stained, and 1 of 2-bathroom lights was not working. Observation of room [ROOM NUMBER] revealed the Room floor was soiled and stained. Residents Affected - Some During observation of room [ROOM NUMBER], it was noted that the room floor was soiled and stained, the exterior of the 2 overbed tables were worn and wood exposed, and the privacy curtain (A bed) was soiled and stained. Observation of room [ROOM NUMBER] revealed the floor soiled and stained, a large area of the vinyl floor was becoming detached from floor. Observation of room [ROOM NUMBER]: The exterior of the tube feeding pole (A bed) was noted to be soiled and stained, the exterior of the 2 overbed tables were heavily worn with wood exposed, there was a large hole in the wall behind B bed, the room chair exteriors were heavily worn. Observation of room [ROOM NUMBER] revealed the footboard (A bed) was heavily worn with sharp wood exposed and the exteriors of the 2 overbed tables were worn and in disrepair. Observation of room [ROOM NUMBER] revealed the privacy curtain (A bed) was soiled and stained, the vinyl room floor was detached from the floor, and the exterior of the bathroom entry door was damaged and in disrepair. Observation of room [ROOM NUMBER]: The base boards were detached from the room walls, the exterior of the 2 room chairs were heavily worn, and the exterior of the entry door for the bathroom was damaged and in disrepair. Observation of room [ROOM NUMBER]: The privacy curtain (A bed) was soiled and stained, the base boards were falling off from the room walls, the exterior of the bathroom door was damaged and in disrepair, and 1 of 2-bathroom lights not working. Observation of room [ROOM NUMBER]: The armrest of the electric wheelchair (A bed) was heavily worn and torn and in need of replacement (resident requested replacement), the exterior of bathroom entry door was damaged and in disrepair, the base boards in the room were detached from the room wall, and there was no overbed light cord (B bed). Observation of room [ROOM NUMBER]: The privacy curtain was soiled and stained and the exterior of the overbed table (1) was heavily worn, and wood exposed. Observation of room [ROOM NUMBER]: The privacy curtain (1) was soiled and stained, the overbed table was heavily worn wood exposed. Observation of room [ROOM NUMBER]: The privacy curtain (a bed) was too short to flow around the bed and could not ensure privacy. Observation of room [ROOM NUMBER]: A large area of the ceiling in the room had peeling paint and was in disrepair. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106131 If continuation sheet Page 2 of 18 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 106131 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sierra Lakes Nursing & Rehabilitation Center 220 Sierra Drive Miami, FL 33179 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Observation of room [ROOM NUMBER]: The exterior of the 2 overbed tables were rust laden, and no television cable reception for A bed. Third Floor: Observation of the third-floor dining room revealed six large windows that were clouded over with a waxy substance and view to outside could not be seen by residents. Observation of the third-floor community shower room [ROOM NUMBER], noted the toilet seat not secured to toilet, and 1 of 3 room lights mot working. Observation of the third-floor community shower room [ROOM NUMBER]: The bathroom handrail was detached and falling from the wall in the shower stall, and the room entry door was noted to have large bolts protruding through door that could cause potential injury to residents. Fourth Floor: Observation of the fourth-floor dining room revealed, six large windows that were clouded over with waxy substance and view to outside could not be seen by residents. Observation of room [ROOM NUMBER]: The room floor was soiled and stained, the bathroom floor was soiled and stained, there was a large bolt protruding from the bottom of the bathroom door that was a potential accident hazard to the residents. Observation of room [ROOM NUMBER]: Bathroom light 1/2 was not working, the privacy curtain (A bed) was soiled and stained, and the exterior bathroom door was damaged and in disrepair, Observation of room [ROOM NUMBER]: The exterior of room entry door was damaged and in disrepair, the exterior of the bathroom door was damaged and in disrepair, the 2 overbed tables were heavily worn with wood exposed. On 02/21/2023 at approximately 2:00 PM following the environment tour the findings were again confirmed with the Administrator. It was stated that staff are failing to report the housekeeping/maintenance issues on the Maintenance Logbook that are located at all 3 nurses stations. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106131 If continuation sheet Page 3 of 18 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 106131 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sierra Lakes Nursing & Rehabilitation Center 220 Sierra Drive Miami, FL 33179 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, record review and policy review, the facility failed to provide adequate pain control management for 1 (Resident #102) out of 1 sampled resident for pain management. Residents Affected - Few The findings included: The facility's policy Pain Management issued 03/2020 reveals The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. On 02/20/2023 at 10:12 AM during the initial observation and interview Resident #102 stated he had pain in his right hip and left shoulder. He stated he had a patch on his left shoulder, but the shoulder especially was hurting. During observation and interview on 02/21/2023 at 9:00 AM, Resident #102 again stated he had pain in his left shoulder. Resident #102 was initially admitted to the facility on [DATE] with diagnoses that included Chronic Obstructive Pulmonary Disease, Pain in Left Shoulder, and Hyperlipidemia. The quarterly Minimum Data Set (MDS) with an assessment reference date of 01/11/2023 revealed a Brief Interview of Mental Status (BIMS) score of 14 out of 15 which indicated intact cognition. Review of the resident's care plan revealed Resident #102 has potential for alteration in comfort related to (r/t) limited mobility, Left Shoulder pain. Care plan with revised date of 10/27/2022 with an intervention of observe for effectiveness of pain intervention, report acute pain or pain that is not relieved with intervention to MD (Medical Doctor) as needed. A review of the Electronic Health Record (EHR) revealed the resident was being seen by a pain management nurse practitioner since 05/08/2021. Percocet 5/325 milligrams (mg) every 8 hours as needed (PRN) for pain had been on the Physician's orders as far back as 12/11/2020 when the EHR began on this resident. The most recent pain management note in the EHR which was dated 01/26/2023 revealed follow up pain management chronic pain Plan 1. Percocet 5/325 mg po (by mouth) q (every) 8 hours PRN 2. will continue to follow patient seen and examined by . A review of the resident's medications was done and there was no Physician order for Percocet. The Percocet was discontinued on 01/10/2023. Resident #102 has an order for acetaminophen 325 mg give 2 tablets orally every 6 hours as needed for temperature above 100 degrees/mild pain. Use for pain scale 1-3. On 02/23/2023 at 10:35 AM an interview was conducted with the Director of Nurses (DON). The DON stated the Percocet was discontinued because it was a pharmacy recommendation on 12/27/2022 to discontinue Oxycodone PRN because he did not use the medication and it did not have a stop date on it. The primary physician's nurse practitioner (NP) was consulted to discontinue the medication, not the pain management NP so the pain management NP was unaware that it was discontinued. Additional interview with Resident #102 on 02/23/2023 at 10:41 AM revealed the resident had pain in the left shoulder and the patch was not really helping. He stated he told the nurse the pain was a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106131 If continuation sheet Page 4 of 18 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 106131 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sierra Lakes Nursing & Rehabilitation Center 220 Sierra Drive Miami, FL 33179 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 level 4. Level of Harm - Minimal harm or potential for actual harm Interview with Staff A, Registered Nurse, on 02/23/2023 at 10:45 AM revealed she gave him Acetaminophen 325 mg, 2 tablets earlier for a pain level of 4, but has not had a chance to follow up with him yet to see if it relieved the pain. Residents Affected - Few On 02/23/2023 at 10:50 AM an interview was conducted with DON which revealed the resident had no medication available for a pain level of 4. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106131 If continuation sheet Page 5 of 18 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 106131 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sierra Lakes Nursing & Rehabilitation Center 220 Sierra Drive Miami, FL 33179 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview, and record review, it was determined that the facility failed to follow the approved menu for Regular Diets (94 residents), Mechanical Soft Diet (47 residents), No Added Salt Diet (26 residents), and Low Concentrated Sweets Diet (15 residents), and Pureed Diet (21 residents). The findings included: During the review of the approved menu for the lunch meal of 02/20/2023, the following were documented to be served: 1 Slice Bread and 1 teaspoon Margarine - Regular Diet, Mechanical Soft Diet, No Added Salt Diet, and Low Concentrated Sweets Diet and for Pureed Diets-(2 ounces) Scoop of Pureed Bread and 1 teaspoon Margarine. During the observation of the lunch meal in the second-floor dining room on 02/20/2023 at 12:00 PM, it was noted that bread, pureed bread, and margarine were not served to the 20 residents. Observation of the second and third floor dining rooms noted again that no bread, pureed bread, or margarine were included on the resident lunch trays. The concerns observed during the lunch meal was discussed with the facility's Registered Dietitian and Administrator for their review. Upon review by the facility's Registered Dietitian and Administrator, it was revealed that the bread and margarine were available to any residents however, dietary staff failed to serve the bread, pureed bread, and margarine as per the approved menu to the residents for the meal on 02/20/2023. During the review of the approved menu for the Breakfast meal on 02/21/2023 the following was documented to be served. 4 ounces (#8 scoop) Pureed Cream of [NAME] Cereal 4 ounces (#8 scoop) Pureed Pancakes 4 ounces (#8 scoop) Pureed Scrambled Eggs with Ham During the observation of the breakfast meal conducted in the main kitchen on 02/21/2023 at 7:15 AM it was noted that the steam table did not contain prepared portions of Pureed Cream of [NAME] Cereal, Pureed Pancakes, and Pureed Scrambled Eggs with Ham. Interview with the Food Service Supervisor at the time of the observation revealed that the cook (Staff C) failed to review the approved breakfast menu and the pureed foods were not prepared as per the approved breakfast menu. A review of the facility's diet census for 02/21/2023 noted that there were currently 11 residents with physician ordered Pureed Diets which included sampled Resident #2, Resident # 22, Resident #33, Resident #42, # Resident 79, Resident #80, and Resident #89. During review of the approved menu for the lunch meal on 02/23/2023 the following foods were documented to be served: 4 ounces (#8 scoop) Ground Turkey (Mechanical Soft Diet) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106131 If continuation sheet Page 6 of 18 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 106131 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sierra Lakes Nursing & Rehabilitation Center 220 Sierra Drive Miami, FL 33179 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0803 3 ounces Hot Dogs (Alternate Entree) Level of Harm - Minimal harm or potential for actual harm During the observation of the lunch meal in the Main Kitchen on 02/22/2023 at 11:30 AM the following were noted: Residents Affected - Some 2 ounce (#16 scoop) was served for Mechanical Soft Diets 1-ounce Hot Dog was served as the alternate entree Interview with the Registered Dietitian and Food Service Supervisor on 02/22/2023 at 11:45 AM during the time of the lunch meal observation it was revealed that staff were to review the approved menu and were unaware the approved menu documented a 4-ounce serving of Ground Turkey for Mechanical Soft Diet. It was also noted that the alternate entree of Hot Dog was to be a 3-ounce portion. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106131 If continuation sheet Page 7 of 18 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 106131 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sierra Lakes Nursing & Rehabilitation Center 220 Sierra Drive Miami, FL 33179 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on record review, observation, and interview it was determined that food was not prepared by following standardized recipes to ensure nutritive value, flavor, and appearance for Regular Diet, Mechanical Soft Diet, No Added Sugar Diet, No Concentrated Sweet Diets (141 facility residents) and Pureed Diet (21 Residents) to include sample Resident #2, Resident #22, Resident #32, Resident #42, Resident #79, Resident #80, and Resident #89. Residents Affected - Some The findings included: Review of Standardized Recipe for Scrambled Egg with Ham noted ingredients: 4 gallons, 2 cups of frozen scrambled eggs 1 gallon, 1/2 cup of 2% milk. 1 gallon, 1/2 cup of diced ham. Approved Portion Size = #8 scoop During observation of the breakfast meal in the Main Kitchen on 02/21/2023 at 7:15 AM, it was noted that portions of the entree contained ham pieces while other portions did not contain ham. The scrambled eggs with ham was observed in the steam table and it was noted that there were large/whole pieces of ham and no ground ham. When portioned some of the entree contained large ham pieces while others contained no ham. Interview with the [NAME] (Staff C) at the time of the observation revealed that she did not prepare the entree by use of the standardized recipe and did not utilize ground ham. The cook utilized whole pieced of ham and was not aware that each portion must contain a minimum 2 ounces of ground ham. Additional interview with the Food Service Supervisor also revealed that she was unaware of the recipe and that ground ham must be used for the preparation of the scrambled eggs with ham. Review of the Pureed Frosted Chocolate Cake recipe documented the following ingredients: Frosted Chocolate Cake (21 pieces) and 30 ounces of 2% Milk. During the observation of the lunch meal in the Main Kitchen on 02/22/2023 at 11:30 AM, accompanied by the Food Service Supervisor and Registered Dietitian, the surveyor requested to observe the pureed frosted cake. Upon opening the pureed cake was noted to be in a total liquid form. Interview with the Diet Aide (Staff D) who stated she prepared the cake, reported that she added too much water to the cake mix prior to pureeing. The surveyor asked if she reviewed the recipe for the cake that documented 30 ounces of 2 % milk and Staff D answered no. The Supervisor and Dietitian at the time of the observation stated that the pureed cake was too thin and would not be palatable for residents receiving pureed diet. A review of the Diet Census for 02/22/2023 revealed that there were currently 21 residents with physician ordered Pureed Diet. The 21 residents included sampled Resident #2, Resident #22, Resident #32, Resident #42, Resident #79, Resident #80, and Resident #89. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106131 If continuation sheet Page 8 of 18 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 106131 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sierra Lakes Nursing & Rehabilitation Center 220 Sierra Drive Miami, FL 33179 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) During observation of the lunch meal on 2/20/2023 at 12:00 PM in the third floor dining room, it was noted that Resident #33 was being fed by staff. Further observation noted that the resident's food plate contained only 2 servings of pureed spaghetti, 1 serving of mashed potatoes and 1 serving of pureed carrots. Further observation noted that there was no pureed entree (pureed meatballs) on the main plate. A review of the resident's tray card noted documentation of No Red Meats. During an interview with the Food Service Supervisor on 02/21/2023 at 11:45 AM it was revealed that only the entree stated on the approved pureed menu is prepared and no additional pureed entrees are prepared for the resident's personal preferences. On 02/22/2023 during an interview at 11:45 AM the facility's Registered Dietitian revealed that she was unaware that the resident personal preferences for 'No Red Meats was not followed and further stated that additional pureed entree should be available at all meals to follow residents food preferences. 3) During the lunch meal observation conducted in the main kitchen on 02/22/2023 at 11:30 AM and accompanied with the Food Service Supervisor and Registered Dietitian, it was noted that the lunch tray for Resident #104 did not contain a pureed turkey entrée. The resident was being served only pureed vegetable and mashed potatoes. A review of the resident's tray card documented food preference of no turkey. On 02/22/2023 at 11:30 AM during the lunch meal observation in the main kitchen, the cook (Staff C ) revealed that only the entree listed on the approved menu for pureed diet was prepared. It was further revealed that additional pureed entrees are not prepared for meals to meet resident's personal food preferences. The facility's Registered Dietitian at the time of the observation revealed that she was unaware that the resident was not going to receive a pureed entree of preference and unaware that an additional pureed entree was not being prepared for all meals to meet residents' personal food preferences. 4. During the resident council meeting on 02/21/23 at 03:05 PM, Resident #69 expressed that he asks for a fruit plate, and it is never available. There were 15 residents in attendance and 7 of the 15 agreed that they would like fresh fruit plates. An interview was conducted with the Registered Dietician (RD) on 02/22/23 at 10:23 AM. She stated that they do have fresh fruit plates, and it is on the substitute menu. There are different fruits which depend on the availability of obtaining the fruits from the vendor. They will get watermelon, honey dew, bananas, oranges, and/or strawberries. Upon review of the substitute list for dining, the choice documented indicated a cottage cheese fruit plate. On 02/22/2023 at 2:03 PM the Dietary Supervisor (Staff B) stated that they do not have the cottage cheese available unless a resident asks for a fruit plate before 10:00 AM, then someone can run to the store and buy cottage cheese. The RD and Staff B were asked if they ever attended Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106131 If continuation sheet Page 9 of 18 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 106131 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sierra Lakes Nursing & Rehabilitation Center 220 Sierra Drive Miami, FL 33179 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0806 Level of Harm - Minimal harm or potential for actual harm Council meetings and if they were aware that the residents would like more fresh fruit available. They stated that they were attending meetings for 3 months and were aware. Based on record review, observations and interviews, the facility failed to follow food preferences for 4 (Resident #12, Resident #33, Resident #104, and Resident #69) out of 12 residents reviewed for nutrition. Residents Affected - Some The findings included: Review of the facility's policy titled, Nutrition and Hydration with a revised date of 06/2021, revealed: The facility will provide a therapeutic diet taking into account the resident's clinical condition and preferences. 1) Review of Resident #12's clinical records revealed the resident was admitted on [DATE] with the most recent readmission dated 02/05/2020. Clinical diagnoses include but not limited to: Type 2 Diabetes Mellitus with Hyperglycemia, Anemia in other Chronic Diseases Classified Elsewhere, and Gastro-Esophageal Reflux Disease without Esophagitis. Review of Section C for cognitive pattern on the Minimum Data Set (MDS) dated [DATE] revealed that Resident #12 had a Brief Interview of Mental Status score of 15, indicating an intact cognitive response. Review of the Section G for functional status revealed that Resident #12 for bed mobility and dressing both had a self-performance of extensive assistance with support of one-person physical assist, eating had a self-performance of supervision with support of setup help only. Review of the Physician's orders for Resident #12 revealed an order dated 10/01/2020 for NAS/NCS (No Added Salt/No Concentrated Sweets) diet, regular texture, regular/thin consistency. Review of Care Plan for Resident #12 revealed a care plan dated 07/19/2021 with a focus indicating the resident has nutritional problem or potential nutritional problem related to non-compliant with NCS, NAS diet, Obesity, no significant weight change, BMI (Body Mass Index) 44.4, morbidly obese. not compliant with NAS, NCS diet, Buying food from outside. Resident continues to order food from outside frequently, complains about facility meals despite interventions to accommodate his food preferences, reports poor appetite. Goals included resident will not develop complications related to obesity, including skin breakdown, ineffective breathing pattern, altered cardiac output, diabetes, impaired mobility through review date. Interventions included: Monitor weights monthly, provide and serve NAS, NCS diet as ordered. Review of the Reaction Note for Resident #12 dated 02/01/2023 included: food allergy with Fish and Strawberries both give resident upset stomach. Review of the Dietary Consult Note for Resident #12 dated 07/08/2022 included: Resident reported he does not care for facility meals and at times will eat maybe one meal a day. Resident visited by dietary representative for meal preferences, however still verbalized dissatisfaction with meals. Staff reported that resident orders food from outside source. Resident reported he has not been doing that lately as he has no funds. Review of the Nutrition/Dietary Note for Resident #12 dated 10/25/2022 included: Visited resident, got grilled cheese sandwich from the kitchen for lunch, said that it is the only thing that he likes eating at the facility, reported that food is not appetizing, gives him diarrhea, orders food from (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106131 If continuation sheet Page 10 of 18 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 106131 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sierra Lakes Nursing & Rehabilitation Center 220 Sierra Drive Miami, FL 33179 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some outside frequently. Will speak with dietary and try to accommodate his food preferences as best as possible. During an interview conducted on 02/20/2023 at 3:40 PM with Resident #12, he stated he does not like a lot of the food the facility provides and often wants a cheeseburger, but the facility will not provide one, so he asks for a grilled cheese sandwich with a burger on it, but rarely gets what he asks for. Resident #12 stated that when he asks for the grilled cheese sandwich with a burger they tell him that they do not have any hamburgers, or they cannot make his request. During an observation conducted on 02/21/2023 at 12:53 PM, Resident #12 received 2 grilled cheese sandwiches with hamburger in each grilled cheese sandwich. During an interview conducted on 02/22/2023 at 2:00 PM with Staff B Dietary Supervisor, who stated she was promoted to Dietary Supervisor position from kitchen aid 1 year ago. Staff B stated she does the ordering for the facility twice weekly for delivery on Mondays and Wednesdays. She stated that the facility was always able to provide a hamburger to the residents, they have frozen hamburger patties or fresh hamburger and can make a hamburger patty. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106131 If continuation sheet Page 11 of 18 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 106131 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sierra Lakes Nursing & Rehabilitation Center 220 Sierra Drive Miami, FL 33179 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. Based on observation, interview, and record review, it was determined that the facility failed to follow physician ordered Double Portion Diet that were a nutrition intervention for weight loss for 17 out of 17 facility residents that included sampled Resident #20, Resident #80, Resident #124, Resident #137, and Resident #166. The findings included: During the observation of the lunch tray assembly line in the main kitchen on 02/22/2023 at 11:30 AM, accompanied by the facility's Registered Dietitian and Food Service Supervisor, it was noted that residents with physician ordered Double Portion Diet were not receiving a double portion of Oven Roasted Turkey (6 ounces protein), Mashed Potatoes, and Carrots. Specifically, the only double portion included on the main plate was a double portion of mashed potatoes. The turkey (3 ounces) and carrots (4 ounces) were all noted to only be a single portion. An interview at 02/22/2023 at approximately 11:35 AM with the cook (Staff D) at the time who was serving the foods on the tray line stated that she thought the only double portion to be served was the mashed potatoes. Staff D further stated that she had not been trained/in-serviced on the serving of Double Portion Diet. Interview with the facility's Registered Dietitian on 02/22/2023 at at approximately 11:38 AM at the time of the meal observation stated that the Double Portions are ordered for residents with weight loss (high calorie, high protein). The Registered Dietitian further stated that the Double Portion Diet included 2 portions of entree, 2 portions of starch, and 2 portions of vegetables for all lunch and dinner meals. The Registered Dietitian also stated that she was unaware that the only double portion being served for lunch and dinner meals was the was the starch portion. A review of the facility's Diet Census for 02/22/23 documentation noted there were currently 17 facility residents with physician ordered Double Portion Diet' that included 5 sampled residents that had nutrition risk/weight loss Resident #20, Resident #80, Resident #124, Resident #137, and Resident #166. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106131 If continuation sheet Page 12 of 18 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 106131 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sierra Lakes Nursing & Rehabilitation Center 220 Sierra Drive Miami, FL 33179 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0810 Provide special eating equipment and utensils for residents who need them and appropriate assistance. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to provide physician ordered adaptive equipment for 1 out of 35 sampled residents (Resident #17). Residents Affected - Few The findings included: Review of the facility's policy titled, Restorative Dining with a revised date of 10/2022 included: Assistive eating devices are utensils people use when they have difficulty eating or drinking independently. These devices are typically used for people with disabilities or people that have low dexterity. The device is placed on each tray or table setting and is available for the resident to use when eating. Record of Resident #17's clinical records revealed the resident was originally admitted to the facility on [DATE] with the most recent readmission date of 10/05/2022; clinical diagnoses included but not limited to Parkinson's Disease and feeding difficulties. Review of Section C for cognitive pattern on the Minimum Data Set (MDS) dated [DATE] revealed that Resident #17 had a Brief Interview for Mental Status of 13, which indicated that she had an intact cognitive response. Review of Section G for functional status of the MDS revealed that Resident #17 had a bed mobility, transfer self-support of limited assistance with support of one-person physical assist, dressing self-performance of extensive assistance with support of one-person physical assist, eating self-performance of supervision with support of setup help only. Review of the Physician's Orders revealed that Resident #17 had an order dated for 10/11/2022 for patient to use double handled sippy cup, weighted utensil, and scoop plate during meals in order to facilitate self-feeding skills. Review of the Care Plan for Resident #17 dated 01/17/2023 revealed a care plan with a focus on the resident is at risk for nutritional and or hydration deficits as evidenced by: at risk for weight loss, due to fair intake of meals and skipping meals. Goals were to meet 75-100% of nutritional and hydration needs over the next review date. Interventions included: Assess/record nutritional status. Encourage/assist to eat as needed. Observe meal consumption. During an observation conducted on 02/20/2023 at 12:30 PM, Resident #17 was in the 4th floor dining room having lunch. On her lunch tray was a scoop plate, and weighted utensils. There was no sippy cup provided to resident with lunch tray, nor did staff offer to obtain a sippy cup for the resident. During an interview conducted on 2/20/2022 at 12:40 PM with Resident #17 when asked about her adaptive equipment for meals, she stated she has Parkinson's and shakes a lot, so they send me a scoop plate and weighted utensils with each meal. She then stated they are supposed to send me a sippy cup, but they don't always send the sippy cup. When asked how often they send the sippy cup, she said less than 50% of the time. During an interview conducted on 02/20/2023 at 12:45 PM with Staff E Licensed Practical Nurse (LPN) when asked if Resident #17 is supposed to have a sippy cup provided with her meals, she replied (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106131 If continuation sheet Page 13 of 18 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 106131 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sierra Lakes Nursing & Rehabilitation Center 220 Sierra Drive Miami, FL 33179 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0810 Level of Harm - Minimal harm or potential for actual harm only if it is ordered for the resident. Staff E verified the meal ticket that revealed Adaptive Devices: Scoop Plate, Sippy Cup, Weighted Utensils. Staff E stated that she would call the kitchen to have a sippy cup sent up for the resident to use with her lunch. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106131 If continuation sheet Page 14 of 18 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 106131 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sierra Lakes Nursing & Rehabilitation Center 220 Sierra Drive Miami, FL 33179 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation and interview, it was determined that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety as evidenced by failure to maintain refrigeration/freezer units in proper working order, failure to properly clean and sanitize food preparation and serving equipment, and failure to hold hot and cold foods at regulatory temperatures. The findings included: During the initial kitchen/food service observation tour conducted on 02/20/23 at 9:00 AM, accompanied with the Food Service Supervisor (FSS), the following were noted: (a) Observation of the walk-in freezer noted the entrance frame to have black organic matter and rust laden, and the door gasket was heavily torn. The door was also noted to have a heavy build-up of ice. Upon entering it was noted that the motor and fan were encased in ice. The motor was noted to be spraying ice throughout the unit. Cases of unidentifiable foods were noted to be covered and encased in ice. The surveyor requested to the FSS that foods be removed from the freezer and be located in alternate refrigeration units and requested that a licensed refrigeration vendor assess the refrigeration issue. (b) During the observation of the walk-in refrigerator it was noted that the internal motor unit was dripping condensation heavily onto foods located below the motor. It was also noted that the motor was spewing condensation onto other foods stored within the unit. Cases of foods were noted to be drenched in condensation. The surveyor informed the FSS that the foods located within the unit were becoming contaminated by the condensation. The surveyor requested to the FSS that foods be removed from the freezer and be located in alternate refrigeration units and requested that a licensed refrigeration vendor assess the refrigeration issue. (c) Observation of reach-in #1 refrigerator noted that the interior of the unit was pitting and the motor dripping condensation heavily. Foods located within the unit were noted to be wet with the dripping condensation. The surveyor requested that the unit not be utilized until repairs could be made. (d) Observation of food preparation skillets (frying pans = 9) were noted to be covered in a thick layer of carbon. The surveyor informed the FSS that the carbon could possibly result in food contamination when the pans a heated. The surveyor requested that the skillets/pans be discarded as soon as possible. (e) Observation of the [brand] industrial food chopper and blender was reported by the FSS to be clean and ready for use however, further observation noted approximately an inch of fluid in the bottom of the unit. The surveyor informed the FSS that the unit must be turned upside down after cleaning/sanitizing and air dried prior to next use. The surveyor requested that the unit not be used until it is properly cleaned, sanitized, and internal dried. (f) Observations of the kitchen noted 3 cleaning rags left on food preparation and serving surfaces. The surveyor requested that the rags be store in a chemical sanitizing solution when not in use. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106131 If continuation sheet Page 15 of 18 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 106131 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sierra Lakes Nursing & Rehabilitation Center 220 Sierra Drive Miami, FL 33179 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many (g) A container located within the reach-in #2 refrigerator was noted to have a yellow food substance. The container was dated 02/15/2023 and did not contain documentation of what the food was. The FSS stated that she thought the food was pudding, however, should have been discarded with 72 hours. (h) The utility drawer observed contained food portioning equipment. Further observation noted that the serving spoons and scoops were placed in all directions and not placed in a sanitary manner to ensure that staff would handle only by the handles. The surveyor requested that the serving utensils be rewashed and sanitized and placed in the drawer in a sanitary manor. (i) Observation revealed Staff G had three packed bags on foods. Upon further investigation it was revealed that the 3 bags contained sandwiches for residents leaving the facility for medical appointments. The bags were noted to contain egg salad sandwiches (2) and cheese sandwich (1) It was revealed that the perishable sandwiches were to be transported with the residents were not in an insulated container with commercial ice packs to ensure that the sandwiches maintained the regulatory 41 degrees F or below. Staff G stated that the sandwiches would be transported at room temperature in a zip lock bag. (j) Observation of the commercial slicer revealed the unit was not properly cleaned after the last use. The unit was noted to have areas of dried food matter around the blade's exterior and base. The surveyor requested that the unit be properly cleaned and sanitized prior to the next use. 2) During a second observation tour of the main kitchen on 02/21/2023 at 7:00 AM, accompanied with the FSS, the following were noted: (k) Food temperatures were taken by the Food Service Supervisor with the facility's calibrated bayonet food thermometer. The results of the temperature testing revealed that hot foods were not being held at the regulatory temperature of 135 degrees Fahrenheit (F) or higher and cold foods were not being held at the regulatory temperature of 41 degrees F or below. The following was noted: Waffles (40 portions) = 110 degrees F Pancakes (40 portions) = 115 degrees F Orange Juice (50 - 4-ounce portions) = 55 degrees F Thickened Orange Juice (10 - 4-ounce portions) = 50 degrees F (l) During the observation it was noted that the walk-in freezer, walk-in refrigerator, and reach in refrigerator continues to drip condensation and spray and spew condensation and ice throughout the units. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106131 If continuation sheet Page 16 of 18 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 106131 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sierra Lakes Nursing & Rehabilitation Center 220 Sierra Drive Miami, FL 33179 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. During the QAPI review and interview on 02/23/23 at 10:11 AM it was revealed that the QAPI meeting is conducted on the third Friday of the month. The risk manager is the Administrator. The QAPI members are committee chairperson, administrator, Director of Nursing, Medical Director, Dietary, Pharmacy representative, Social Service, Activities, Environmental representative, Infection control, Rehab, Staff Development, Safety representative and Medical records representative. Based on record review, observations, and interview it was determined that the facility's Quality Assurance and Performance Improvement Activities (QAPI/QAA) failed to demonstrate effective plan of actions were implemented to correct identified quality deficiencies in the problem area as evidenced by repeated deficient practices for F 812- Food Procurement, Store/Prepare/Serve-Sanitary and F 908- Essential Equipment, Safe operating condition. There were 178 residents residing in the facility at the time of this survey. The findings include: Review of the facility's survey history revealed during the recertification and relicensure survey with exit dated 10/29/2021 the facility was cited F 812 and F 908 due to the facility's failure to ensure the proper washing of the dishes and utensils by not having an operable wash tank temperature gauge on the high temperature dish machine. This had the potential to affect 141 out of 169 residents who eat orally residing in the facility at the time of the survey. During this survey with exit dated 02/23/2023 the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety as evidenced by failure to maintain the refrigeration/freezer units in proper working order, failure to properly clean and sanitize food preparation and serving equipment, and failure to hold hot and cold foods at regulatory temperatures. (Reference: F 812 and F 908) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106131 If continuation sheet Page 17 of 18 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 106131 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sierra Lakes Nursing & Rehabilitation Center 220 Sierra Drive Miami, FL 33179 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm . Residents Affected - Some Based on observations and interviews the facility failed to maintain refrigeration/freezer units in proper working order The findings include: During the initial kitchen/food service observation tour conducted on 02/20/23 at 9:00 AM, accompanied with the Food Service Supervisor (FSS), the following were noted: (a) Observation of the walk-in freezer noted the entrance frame to have black organic matter and rust laden, and the door gasket was heavily torn. The door was also noted to have a heavy build-up of ice. Upon entering it was noted that the motor and fan were encased in ice. The motor was noted to be spraying ice throughout the unit. Cases of unidentifiable foods were noted to be covered and encased in ice. The surveyor requested to the FSS that foods be removed from the freezer and be located in alternate refrigeration units and requested that a licensed refrigeration vendor assess the refrigeration issue. (b) During the observation of the walk-in refrigerator it was noted that the internal motor unit was dripping condensation heavily onto foods located below the motor. It was also noted that the motor was spewing condensation onto other foods stored within the unit. Cases of foods were noted to be drenched in condensation. The surveyor informed the FSS that the foods located within the unit were becoming contaminated by the condensation. The surveyor requested to the FSS that foods be removed from the freezer and be located in alternate refrigeration units and requested that a licensed refrigeration vendor assess the refrigeration issue. (c) Observation of reach-in #1 refrigerator noted that the interior of the unit was pitting and the motor dripping condensation heavily. Foods located within the unit were noted to be wet with the dripping condensation. The surveyor requested that the unit not be utilized until repairs could be made. During a second observation tour of the main kitchen on 02/21/23 at 7:00 AM, accompanied with the FSS; it was noted that the walk-in freezer, walk-in refrigerator, and reach in refrigerator continues to drip condensation and spray and spew condensation and ice throughout the units. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106131 If continuation sheet Page 18 of 18