Inspection·July 18, 2024

F 0583 Level of Harm - Minimal harm or potential for actual harm are in electronic format. 10. Technical safeguards will be implemented to allow access of EPHI only to those employees or software programs that have been granted access rights. C. Automatic logoff: electronic sessions will be terminated after a predetermined time of inactivity depending on the systems housed on the workstation. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106131 If continuation sheet Page 2 of 10 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 07/18/2024 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview facility failed to coordinate with the appropriate State authority to ensure an accurate Level I Preadmission Screening and Resident Review (PASRR) was completed in a timely manner for one resident (Resident #46) with a major mental disorder out of nine residents sampled as evidenced by Level I PASRR dated 2/19/24 omitted diagnosis of Schizophrenia, Bipolar disorder and Anxiety. There were 172 residents residing in the facility at the time of survey. The findings included: Record review of Preadmission Screening and Resident Review (PASRR) dated 2/19/24 Section I: PASRR Screen Decision-Making: Depressive Disorder and Psychosis was checked, Section IV: PASRR Screen Completion: No diagnosis or suspicion of Serious Mental Illness or Intellectual Disability indicated. Level II PASRR evaluation not required, signed on 2/19/24 by DON at the facility Record review of demographic sheet for Resident #46 revealed an admission date of 2/19/24 with diagnoses that included Major Depressive disorder, Psychosis, Bipolar, Anxiety, and Schizophrenia. Record review of admission Minimum Data Set (MDS) dated [DATE] Section A (Identification) revealed No level II PASRR Is the resident currently considered by the State process to have serious mental illness and/or intellectual disability or a related condition. Preadmission Screening and Resident Review (PASRR). Section I (active diagnosis) revealed Depression and Psychotic disorder. Further record review of electronic health record revealed a Significant Change MDS dated [DATE], Section I showed Anxiety disorder, Depression (other than bipolar), Bipolar Disorder, Psychotic disorder, and Schizophrenia. Section N indicated Antidepressant and Antipsychotic medications were received in the last 7 days. Section O indicated Psychological Therapy with total minutes of zero. Record review of Care Plan date initiated on 2/19/24 indicated R#46 was at risk for drug related side effects due to use of psychotropic meds for the diagnosis of Major Depressive Disorder and Psychosis. Interventions included: Notify Social Worker about any change in behavior pattern. Record review of physician orders revealed orders dated 4/26/24 for Quetiapine Fumarate Tablet 50 MG (milligrams) one tablet by mouth two times a day related to Psychosis and an order dated 6/18/22 for Lorazepam Tablet 0.5 MG one tablet by mouth every 12 hours for Anxiety. Record review of a Psychiatric Consult dated 2/19/24 revealed diagnosis of Major depression disorder. On 07/18/2024 at 11:24 AM, the Social Services Director stated, the process for completing PASSR is to evaluate all diagnosis upon admission, discuss in the morning meeting, and review current Level I to determine need for Level II. For residents who are currently residing in the facility we complete a resident review that includes clinicals and a Level I to determine if there is a need for a Level II to be sent to Kepro. The nurses are to update me about any new behaviors so I can ensure an accurate PASRR. For [Resident #46] I was notified last week by the resident's previous case worker via email about new diagnosis last week. I immediately completed a new PASSR and submitted it to Kepro for Level II determination on 7/16/24. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106131 If continuation sheet Page 3 of 10 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 07/18/2024 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Record review of an email given to the surveyor by the Social Services Director revealed a date of 4/8/2024 from case worker from a healthcare company regarding Resident #46, revealed a comprehensive care plan dated 4/1/24 that included diagnoses of Schizophrenia, Bipolar and Attention Deficit Hyperactivity Disorder Anxiety and Depression. Record review of the facility's Policy for PASRR dated 3/2021 Policy: It is the of the facility to assure that all residents admitted to the facility receive a Pre-admission Screening and Resident Review, in accordance with State and Federal Regulations. Procedure: 5. A nursing facility must notify the state mental health authority or state intellectual disability authority, as applicable, promptly after a significant change in the mental or physical condition of a resident who has a mental illness or intellectual disability for resident review. Event ID: Facility ID: 106131 If continuation sheet Page 4 of 10 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 07/18/2024 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observations and interviews, the facility failed to accurately reconcile two controlled medications on one medication cart out of seven medications carts reviewed. There were 172 residents residing I the facility at the time of survey. The findings included: On 07/17/24 at 12:52 PM on the 4th floor cart a controlled medication count was completed with Staff E, Licensed Practical Nurse (LPN) on the East medication cart. Two Medication Monitoring/ Control Records were inaccurate when compared to the corresponding bingo card. (photo evidence) On 07/17/24 at 12:52 PM Staff E, LPN stated: The correct procedure for signing out narcotics is to sign out the narcotic at the time it was given. I administered the medication to the resident but did not sign due to getting busy with other nursing tasks. On 07/18/24 at 2:26 PM the Director of Nursing (DON) stated: Nurses are to sign out controlled medications once it is popped out of the bingo card. Record review of the facility's policy: Controlled Substance Administration and Accountability date implemented June 2021. Policy: It is the policy of this facility to promote safe, high quality patient care, compliant with state and federal regulations regarding monitoring the use of controlled substances. The facility will have safeguards in place in order to prevent loss, diversion or accidental exposure. Policy Explanation and Compliance Guidelines: h. The Controlled Drug Record (or other specified form) serves the dual purpose of recording both narcotic disposition and patient administration. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106131 If continuation sheet Page 5 of 10 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 07/18/2024 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observations and interview the facility failed to properly store and label medications in one medication room and one medication cart out of three medication rooms and seven medication carts reviewed as evidenced by an observation of an unlabeled vial and medication left unattended. There were 172 residents residing I the facility at the time of survey. The findings included: On 07/16/24 at 4:35 PM a review of a medication storage room on the second floor revealed a vial Labeled Lorazepam injection with no open date observed on the vial. On 07/16/24 at 4:45 PM Staff D, Registered Nurse (RN) stated: I counted the controlled medications with the off going nurse. I received the Ativan in the fridge. I did not notice there was not an open date. The vial should be labeled with an open date. On 07/17/24 at 8:47 AM on the second floor an observation was made of crushed medication in a transparent medicine cup unattended, on top of the middle medication cart. (photo evidence) 07/17/24 08:52 AM Staff F, Registered Nurse (RN) returned to medication cart and stated: It is not okay to leave the medication on top of the cart. The reason I left the medication unattended was because I went to call the other nurse to open the fridge. On 07/18/24 at 2:26 PM the Director of Nursing (DON) stated: All open vials of medications should be labeled with an open and expiration date. No medication should be left unattended. Record review of the facility's policy Labeling of Medications Storage of drugs and Biologicals dated 11/28/2019. Policy: It is the policy of this facility to ensure that all medications and biologicals used in the facility will be labeled and stored in accordance with current state, federal regulations. Policy Explanation and Compliance Guidelines: 9. Labels for multi-use vials must include: a. The date the vial was initially opened or accessed (needle-punctured); with specified timeframes for usage once opened that are outside of the manufacturers expiration date. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106131 If continuation sheet Page 6 of 10 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 07/18/2024 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and Interview the facility failed to follow infection prevention protocol for one resident (Resident #118) out of seven sampled as evidenced by; the wound care nurse not wearing gown while providing wound care to Resident #118 who is under enhanced barrier precaution. There were 172 residents in the facility at the time of survey. Residents Affected - Few The findings included: On 07/17/24 at 10:40 AM, during a wound care observation with the wound care nurse. The Licensed Practical Nurse (LPN wound care nurse performed wound care for Resident#118. Prior to wound care, the LPN wound care nurse donned gloves. Record review of demographic sheet for Resident #118 revealed an admission date of 7/4/2022 and readmission date of 9/29/2022 with diagnosis that included: Stage 4 Pressure Ulcer of right buttock and other site. Record review of Quarterly Minimum Data Set (MDS) dated [DATE] Section C (cognitive status) revealed a Brief Interview for Mental Status score of score 13 out of 15 indicated cognition was intact, Section GG (Functional status) revealed Resident #118 dependent for ADLs. Section H (bowel and bladder) revealed Resident #118 had an indwelling catheter. Section M (skin) revealed the resident had a 1 Stage IV unhealed pressure ulcer. Record review of CARE PLAN start date 10/16 /23 and revision date 5/10/24 revealed Resident #118 had a pressure injury on admission [DATE] and interventions included: Enhanced based precaution (EBP) due to wounds and wound care as ordered. On 07/17/24 at 1:37 PM the LPN wound care nurse stated: [Resident #118] is under EBP due to his wound and catheter, and I did not wear a gown while performing wound care and that was a mistake. According to Protocol for EBP I should wear a disposable gown during wound care. Record review of the facility's Policy Enhanced Barrier Precautions issued 8/16/2022 revised 4/1/2024 Enhanced Barrier Precautions dated 8/16/2022 revised 4/1/2024 Policy: It is the policy of this facility that Enhanced Barrier Precautions, in addition to Standard and Contact Precautions will be implemented during high-contact resident care activities when caring for residents that have an increased risk for acquiring a multidrug resistant organism (MDRO) such as a resident with wounds, indwelling medical devices or residents with infection or colonization with an MDRO. Enhanced Barrier Precautions (EBP) consists of the use of gowns and gloves for high contact care activities which include but may not be limited to wound care: any skin opening requiring a dressing. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106131 If continuation sheet Page 7 of 10 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 07/18/2024 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation, interview and record review the facility failed to ensure lint screens were cleaned for two out of three dryers as evidenced by two out of three dryers lint screens observed full of lint. There were 172 residents residing in the facility at the time of the survey. The findings included: On 07/18/24 at 1:25 PM a Laundry Tour was conducted with the Housekeeping Director. The clean room contained three 87-pound capacity dryers. Two dryers were in progress and the lint screens were filled with lint. (photo evidence) When asked to view the lint log, the Housekeeping Director responded that the lint log was upstairs. On 07/18/2024 at 3:15 PM the surveyor was approached by the Housekeeping Director and given a lint log. Review of the Lint Log revealed July 18: 1:00 AM, 3:00 AM and 5:00 AM the log was not signed. The Housekeeping Director stated: The staff will sign for 1:00 AM, 3:00 AM and 5:00AM July 18 on July 19 overnight shift. Record review of the facility's Laundry Policy date implemented July 2020 Policy: The facility launders linens and clothing in accordance with current CDC guidelines to prevent transmission of pathogens. 10. Dryer filter will be checked, and lint removed every three hours while being used and PRN (as needed). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106131 If continuation sheet Page 8 of 10 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 07/18/2024 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review the facility failed to maintain an effective pest control program so that the environment is free of flies. This was evident throughout the facility in the kitchen, conference room, second floor, third floor and fourth floor where resident's reside. This has the potential to affect the entire resident population (one-hundred and seventy-two residents) residing in the facility at the time of this survey. Residents Affected - Many The findings included: Record review of the facility's policy titled Pest Control (issued date 3/2020) documented: Policy-It is the policy of the facility to maintain an effective pest control program that eradicates and contains common household pests and rodents; Definition of an Effective pest control program is defined as measures to eradicate and contain common household pests (flies); Policy Explanation and Compliance Guidelines: 1) Facility will maintain a written agreement with a qualified outside pest service to provide comprehensive pest control services on a regular and scheduled basis and 3) Facility will report issues that may arise in between scheduled visits with the outside pest service and treat as indicated. Observation of the facility's conference room on 7/15/24 at 7:35 AM revealed a swarm of flies in the conference room, flying around and landing on the tables. A fly repellent with a blue light was noted in the conference room. Observation during the initial kitchen tour on 7/15/24 at 8:08 AM with the Dietary Supervisor and the Registered Dietitian (RD) revealed flies were noted flying around the kitchen around the steam table and throughout the kitchen. A fly repellent with a blue light was noted in the kitchen. On 7/15/24 at 8:09 AM, interview with the Dietary Supervisor confirmed the flies in the kitchen. Observation of the second floor nurses' station on 7/16/24 at 8:58 AM revealed flies were flying and landed on the nurses' station. (Photographic evidence submitted) Observation of the second floor nurses' station on 7/17/24 at 7:35 AM revealed flies were flying and landed on the nurses' station. During observation of the lunch tray line on 7/17/24 at 11:39 AM revealed flies were noted in the kitchen, flying around the tray line. The flies were noted on top of the shelf on tray line and on the plate warmers. Dietary staff were observed fanning the flies away while on the tray line. (Photographic evidence submitted) On 7/17/24 at 11:41 AM, interview with the Dietary Supervisor confirmed the flies in the kitchen. On 7/17/24 at 2:05 PM, interview with the Regional Director of Maintenance. He stated, We are aware of the flies and have had the pest control company come out. On 7/17/24 at 2:28 PM, interview with the Administrator. She confirmed that the facility has a pest control contract and that the pest control company comes on a regular basis to the facility. On 7/17/24 at 2:47 PM, interview with the Director of Maintenance via Spanish translator. He (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106131 If continuation sheet Page 9 of 10 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 07/18/2024 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 0925 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many revealed the pest control company comes to the facility every single week. They fumigate the whole building and when they come they do a specific area. Review of the Pest Control contract documented dated and signed on 6/05/24, with an effective date of 5/01/24; Contract covers American Roaches, [NAME] Banded Roaches, Oriental Roaches, Smoky [NAME] Roaches, German Roaches, House Ant, Rat/Mice. The contract did not list flies as a part of the interior pest control treatment. Review of the Pest Management Invoices dated from 1/02/24-6/04/24 revealed the facility had received pest control treatment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106131 If continuation sheet Page 10 of 10