Inspection·October 3, 2023

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident's #1 Psychotropic meds care plan dated 12/03/22 documented the resident was at risk for drug related side effects due to use of psychotropic meds for the diagnosis of: Depression, Insomnia, Schizophrenia, Psychosis; Goal: Resident will remain free of drug related side effects through next review date and Interventions: Medicate as ordered; Monitor behavior and mood changes. Review of the Demographic Face Sheet for Resident #2 documented the resident was admitted on [DATE] with a diagnosis of encephalopathy, diabetes mellitus, cerebral infarction, major depressive disorder, bipolar disorder, glaucoma, hypertension, anxiety disorder and psychosis. Review of the Minimum Data Set (MDS) Annual assessment dated [DATE] for Resident #2 documented the resident's Mental Status (BIMS) Summary Score was 03, indicating severe cognitive impairment and he required supervision with setup help only for adls (activities daily living). Review of the Physician's Order Sheets (POS) and Medication Administration Records (MAR) dated February 2023 for Resident #2 documented the resident was receiving the following medications: Divalproex Sodium DR 500mg tab 2 tabs PO HS for seizures; Risperidone 0.5mg tab 1 tab PO BID for psychosis; Haloperidol 0.5mg tab 1 tab PO in the morning for psychosis and Mirtazapine 7.5mg tab 1 tab PO HS for depression. Review of Resident's #2 Psychotropic meds care plan dated 7/14/22 documented the resident was at risk for drug related side effects due to use of psychotropic meds for the diagnosis of: Anxiety, Major Depressive Disorder, Bipolar Disorder, Psychosis; Goal: Resident will remain free of drug related side effects through next review date and Interventions: Medicate as ordered; Monitor behavior and mood changes. Review of Federal Immediate Report dated 2/15/23 documented the following: Date/Time of Incident: 2/15/2023 3:15 PM; Type of Incident: Abuse; Who has been notified: Resident Representative, Abuse Registry; Law enforcement not notified; Description of Incident: On 2/15/23 at 15:20 a resident who is alert and oriented times three reported to staff when passing by room [ ] he observed [ ] Resident #2 on top of resident [ ] Resident #1 hitting him in his face. Residents were immediately separated from each other and placed on one to one supervision. [ ] Resident #2 states that he hit his roommate because he called him a [ ] and this made him upset. [ ] Resident #1 said he gave [ ] Resident #2 the tv remote control and he was called a [ ]. [ ] Resident #1 told to not call him a [ ] and went to his bed. [ ] Resident #2 climbed on top of [ ] Resident #1 and hit him. [ ] Resident #2 suffered no injuries and [ ] Resident #1 has scratches on his face with minimal bleeding. First aide was given. [ ] Resident #1 voiced no concerns for his safety and exhibits no change in behavior related to the incident. Administrator was notified. Residents placed on a one to one. On 10/03/23 at 11:55 AM attempted to interview Resident #2 but the resident did not answer. On 10/03/23 at 1:10 PM interview with the Administrator/Abuse Coordinator. She stated, They were roommates at the time. [ ] Resident #1 called [ ] Resident #2 a [ ]. [ ] Resident #2 was on top of [ ] Resident #1 and started hitting him. Staff was walking by their room and saw them in action and broke them up. [ ] Resident #2 said he slapped the guy because he don't like the word. [ ] Resident #2 was sent to the hospital for aggressive behavior. [ ] Resident #1 said he didn't have any hard feelings but if he came back that he didn't want him to be his roommate. When [ ] Resident #2 came back they were placed in different rooms. [ ] Resident #1 was discharged to an ALF (assisted living facility). The Administrator/Abuse Coordinator reported I report abuse when I get them. Abuse is supposed to be reported in two hours. This was not reported to Law Enforcement. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106131 If continuation sheet Page 2 of 5 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 10/03/2023 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to report an alleged abuse incident to the abuse registry for allegation of abuse for one (Resident #1, Resident #2) out of six residents reviewed for abuse. The findings included: Record review of the facility's policy titled, Abuse, Neglect and Exploitation protocol implementation date was on 10/2019, the policy documented: The facility will provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect and exploitation. Abuse means the infliction of injury with resulting physical harm, pain or mental anguish. Law enforcement is the full range of potential responders to elder abuse, neglect and exploitation including police sheriffs, detectives and public safety officers. A prompt thorough investigation will be conducted by the facility immediately. Policy Explanation and Compliance Guidelines: 1) The facility will develop and implement written policies and procedures that: a) Prohibit and prevent abuse, neglect and exploitation of residents and misappropriation of resident property. VII. Reporting/Response of Abuse, Neglect and Exploitation: When abuse, neglect or exploitation is suspected: Immediately report all alleged violations to the Administrator, state agency, adult protective services and all other required agencies (law enforcement) within specified timeframes. Review of the Demographic Face Sheet for Resident #1 documented the resident was admitted on [DATE] with a diagnosis of chronic obstructive pulmonary disease, respiratory failure, anxiety disorder, major depressive disorder, schizophrenia, hypertension, emphysema, insomnia and blindness one eye. The resident was discharged from the facility on 4/10/23. Review of the Minimum Data Set (MDS) Quarterly assessment dated [DATE] for Resident #1 documented the resident's Mental Status (BIMS) Summary Score was 15, indicating no cognitive impairment and he was able to make his needs known and he required supervision with setup help only for adls (activities daily living). Review of the Physician's Order Sheets (POS) and Medication Administration Records (MAR) dated February 2023 for Resident #1 documented the resident was receiving the following medications: Quetiapine Fumarate 100mg (milligrams) tab (tablet) 200mg PO (by mouth) HS (at night) for schizophrenia; Zolpidem Tartrate 10mg tab 1 tab PO HS for insomnia; Percocet 5-325mg tab 1 tab PO every 8 hours PRN (as needed) for pain; -Trazodone HCL (hydrochloride) 50mg tab 1 tab PO HS for major depressive disorder and Divalproex Sodium DR (delayed release) 500mg tab 1 tab PO BID (twice a day) for other seizures. Review of Resident's #1 Psychotropic meds care plan dated 12/03/22 documented the resident was at risk for drug related side effects due to use of psychotropic meds for the diagnosis of: Depression, Insomnia, Schizophrenia, Psychosis; Goal: Resident will remain free of drug related side effects through next review date and Interventions: Medicate as ordered; Monitor behavior and mood changes. Review of the Demographic Face Sheet for Resident #2 documented the resident was admitted on [DATE] with a diagnosis of encephalopathy, diabetes mellitus, cerebral infarction, major depressive disorder, bipolar disorder, glaucoma, hypertension, anxiety disorder and psychosis. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106131 If continuation sheet Page 3 of 5 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 10/03/2023 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the Minimum Data Set (MDS) Annual assessment dated [DATE] for Resident #2 documented the resident's Mental Status (BIMS) Summary Score was 03, indicating severe cognitive impairment and he required supervision with setup help only for adls (activities daily living). Review of the Physician's Order Sheets (POS) and Medication Administration Records (MAR) dated February 2023 for Resident #2 documented the resident was receiving the following medications: Divalproex Sodium DR 500mg tab 2 tabs PO HS for seizures; Risperidone 0.5mg tab 1 tab PO BID for psychosis; Haloperidol 0.5mg tab 1 tab PO in the morning for psychosis and Mirtazapine 7.5mg tab 1 tab PO HS for depression. Review of Resident's #2 Psychotropic meds care plan dated 7/14/22 documented the resident was at risk for drug related side effects due to use of psychotropic meds for the diagnosis of: Anxiety, Major Depressive Disorder, Bipolar Disorder, Psychosis; Goal: Resident will remain free of drug related side effects through next review date and Interventions: Medicate as ordered; Monitor behavior and mood changes. Review of Federal Immediate Report dated 2/15/23 documented the following: Date/Time of Incident: 2/15/2023 3:15 PM; Type of Incident: Abuse; Who has been notified: Resident Representative, Abuse Registry; Law enforcement not notified; Description of Incident: On 2/15/23 at 15:20 a resident who is alert and oriented times three reported to staff when passing by room [ ] he observed [ ] Resident #2 on top of resident [ ] Resident #1 hitting him in his face. Residents were immediately separated from each other and placed on one to one supervision. [ ] Resident #2 states that he hit his roommate because he called him a [ ] and this made him upset. [ ] Resident #1 said he gave [ ] Resident #2 the tv remote control and he was called a [ ]. [ ] Resident #1 told to not call him a [ ] and went to his bed. [ ] Resident #2 climbed on top of [ ] Resident #1 and hit him. [ ] Resident #2 suffered no injuries and [ ] Resident #1 has scratches on his face with minimal bleeding. First aide was given. [ ] Resident #1 voiced no concerns for his safety and exhibits no change in behavior related to the incident. Administrator was notified. Residents placed on a one to one. Review of the Abuse Log dated February 2023-October 2023 documented the following: Dated 2/15/23, APS ID Date Called Time Called: 2/15/2023 6:15?, Accepted/Rejected: Answer Blank, Allegations: Resident to Resident. The abuse log dated for the incident on 2/15/23 documented the date, the time it was reported had a question mark and if the report was accepted or rejected, the answer was blank. All other abuse allegations on the abuse log were completed with the date, time, the person's name and ID (identification) number who took the report of the abuse and if the abuse report was accepted or rejected at the abuse registry. On 10/03/23 at 11:05 AM, interview with the Administrator/Abuse Coordinator. She stated, I called the abuse in because the abuse registry online was down. I don't have proof that the call was made. On 10/03/23 at 11:55 AM attempted to interview Resident #2 but the resident did not answer. On 10/03/23 at 12:13 PM via telephone with Administrator and local state abuse registry agency representative #1. She stated, I can't confirm or deny whether a call was received for abuse. I will transfer you to my supervisor. On 10/03/23 at 12:18 PM via telephone with Administrator and local state abuse registry agency supervisor representative #2. She stated, I can't confirm or deny whether a call was received for abuse. If an abuse report is accepted or rejected, it is put into the system. The Administrator was asked (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106131 If continuation sheet Page 4 of 5 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 10/03/2023 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete by the local state abuse registry agency supervisor representative #2 did she write down the person's name and ID number who took her report over the phone, and she stated, No, I didn't. On 10/03/23 at 1:10 PM interview with the Administrator/Abuse Coordinator. She stated, They were roommates at the time. [ ] Resident #1 called [ ] Resident #2 a [ ]. [ ] Resident #2 was on top of [ ] Resident #1 and started hitting him. Staff was walking by their room and saw them in action and broke them up. [ ] Resident #2 said he slapped the guy because he don't like the word. [ ] Resident #2 was sent to the hospital for aggressive behavior. [ ] Resident #1 said he didn't have any hard feelings but if he came back that he didn't want him to be his roommate. When [ ] Resident #2 came back they were placed in different rooms. [ ] Resident #1 was discharged to an ALF (assisted living facility). The administrator/abuse coordinator reported, I report abuse when I get them. Abuse is supposed to be reported in two hours. This was not reported to Law Enforcement. Event ID: Facility ID: 106131 If continuation sheet Page 5 of 5