Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Sierra Lakes Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
A resident with serious mental illness and a documented need for supervised smoking became upset after being denied an OTC antacid, lit a cigarette in the hallway, and was returned to her room unsupervised after staff confiscated the cigarette and lighter. She had previously obtained cigarettes and lighters during a supervised outing, and she later admitted setting her room on fire, leading staff to find smoke and flames in the room and evacuate nearby residents.
Unsecured housekeeping carts were observed unattended on multiple hallways with keys left in the locks, and staff were able to open the carts without a key while disinfectant chemicals were inside. A resident with seizures, moderate cognitive impairment, and fall risk was also observed in bed with the bed left in a high position while staff were away, despite a care plan intervention to keep the bed in the lowest position. In addition, a fully operational hand sanitizer dispenser was mounted directly above a light switch in a conference room.
A nurse failed to maintain accurate narcotic counts on a medication cart, with multiple controlled medication counts not matching the log. One resident’s tramadol was dropped, flushed, and replaced without a witness for the waste, and the nurse did not sign the medication out when it was removed. The RN supervisor confirmed the witness and sign-off requirements for controlled substances.
Food storage and dishwashing practices were deficient when two reach-in refrigerators lacked inside thermometers and the high-temp dish machine had an inoperable final rinse temp gauge. Staff and the Dietary Supervisor confirmed the missing thermometers, and the dish machine was observed with the final rinse dial stuck below the required range while trays, cups, and dishes were being processed.
Dish machine final rinse temperature was not working properly, with the wash dial at 150 degrees F and the final rinse dial at 162 degrees F during observation, below the manufacturer’s required 180-195 degrees F range. Staff and the Dietary Supervisor noted repeated cycles did not correct the reading, and the service company later found the final rinse thermostat was burned out and inaccurate.
A resident with severe cognitive impairment and need for eating assistance was not served a lunch tray at the same time as the other residents seated at the same dining table. Staff began passing trays to the table, served the other residents, then moved on to another table before serving the resident several minutes later. The facility policy states residents are to be treated with respect and dignity, and staff stated that residents at one table should be served together.
Failure to provide needed ADL care occurred when a resident with spastic hemiplegia and seizures was observed with long fingernails digging into the palm of a contracted hand. The resident said staff had not trimmed the nails, while interviews showed nail care was assigned to CNAs or other designated staff, with CNAs still responsible if the designated person was unavailable. The resident’s care plan and MDS showed he needed assistance with multiple ADLs, including personal hygiene.
Medication Error Rate Exceeded 5%: The facility had a 10.23% medication error rate, with nine errors in 88 opportunities. During med pass, an RN left a resident’s meds unattended, then crushed multiple ordered meds together and mixed them with applesauce before administration; the resident’s ordered Zunveyl DR tablet was not available. An LPN gave a multivitamin tablet from stock instead of the ordered liquid form to another resident, and an RN found ordered losartan unavailable for a third resident.
The facility failed to show an effective QAPI plan was implemented to identify and address repeated deficient practices related to F761, Label/Store Drugs & Biologicals. The deficiency had been cited on a prior survey, and the Administrator stated the QAPI team met monthly with management to review department concerns and analyze data, but the report still found the repeated deficiency unresolved.
The facility failed to maintain an effective pest control program, leading to a fly infestation in areas such as the kitchen and conference room. Despite having a pest control contract, flies were not included in the treatment plan, resulting in persistent issues confirmed by staff and photographic evidence.
The facility failed to protect residents' healthcare information as electronic health record screens on three medication carts were left open and unattended, displaying residents' information. Staff, including an LPN and an RN, did not follow the procedure to lock screens when away from the carts, despite being trained. The Director of Nursing acknowledged the requirement to close screens to protect personal information, as outlined in the facility's HIPAA policy.
A facility failed to coordinate with the State authority to ensure an accurate Level I PASRR for a resident with a major mental disorder. The PASRR omitted diagnoses of Schizophrenia, Bipolar disorder, and Anxiety, despite these being present in the resident's records. The Social Services Director was notified of the new diagnoses months later, leading to a delay in updating the PASRR.
The facility failed to accurately reconcile two controlled medications on a medication cart. An LPN administered medication but did not sign it out due to being busy with other tasks. The DON confirmed that the procedure requires signing out medications once removed from the bingo card. The facility's policy mandates recording both narcotic disposition and patient administration.
The facility failed to properly store and label medications, with a vial of Lorazepam injection found without an open date and crushed medication left unattended on a cart. An RN acknowledged the oversight, and the DON confirmed the policy requirement for labeling open vials. These incidents highlight deficiencies in medication storage and labeling practices.
An LPN failed to follow infection prevention protocols by not wearing a gown while providing wound care to a resident under enhanced barrier precautions. The resident had a Stage 4 pressure ulcer and an indwelling catheter, requiring gowns and gloves during care. The facility's policy mandates these precautions for residents at risk of multidrug-resistant organisms.
The facility did not maintain clean lint screens for two out of three dryers, as observed during a laundry tour. The Housekeeping Director could not immediately provide the lint log, which later revealed unsigned entries for specific times, contrary to the facility's policy requiring lint removal every three hours. This indicates a lapse in following the established laundry procedures.
Inadequate Supervision Allowed Resident to Ignite Room Fire
Penalty
Summary
The facility did not maintain adequate supervision to ensure a safe environment free from accident hazards for one resident who was identified as a dependent smoker and required supervision. The resident had diagnoses including cerebral infarction, adjustment disorder, bipolar disorder, anxiety disorder, schizophrenia, mood disorder, and cocaine abuse. Her records also documented repeated behavioral escalation, verbal aggression, physical aggression, and destructive behavior toward staff and property in the days leading up to the incident. On the evening of the incident, the resident became upset after being told she needed a physician order for an over-the-counter antacid. She cursed at staff, lit a cigarette in the hallway, and staff confiscated the cigarette and lighter before she returned to her room unsupervised. Shortly afterward, she exited her room and told staff that she had set her room on fire and that they needed to remove her roommate. Staff then observed smoke and fire in the room, removed the roommate, closed the door, called 911, and evacuated residents from the affected units. The record also showed that the resident had obtained cigarettes and lighters during a supervised shopping trip several days earlier, and those items were brought into the facility without detection. Facility documentation and staff interviews described that the resident was a smoker who required supervision, that smoking materials were supposed to be controlled by staff, and that smoking was prohibited outside the designated area. Despite this, the resident was able to possess and use a lighter inside the building, and she used it to ignite a fire in her room.
Unsecured housekeeping carts, bed left high, and sanitizer dispenser placed above light switch
Penalty
Summary
The facility failed to keep housekeeping carts secured and unattended carts were observed on multiple hallways with keys left in the locks. On 1/12/2026, a housekeeping cart was observed unattended on the fourth-floor East hallway, and staff stated the key should be kept in a pocket when away from the cart. The surveyor was able to have the top section opened without a key, and disinfectant bottles were visible inside. Similar observations were made on the fourth-floor [NAME] hallway, the third-floor East hallway, and the second-floor [NAME] side hallway, where housekeeping staff opened the top section of the carts without a key while the carts were unattended and disinfecting chemicals were present inside. The Housekeeping Director stated there were seven housekeeping carts and staff are to keep them locked at all times when unattended to prevent residents from encountering the chemicals kept in the cart. The facility also failed to keep Resident #77’s bed in the lowest position when staff left the room. Resident #77 was observed in bed with the bed in a high position while no staff were present. A CNA entered the room and stated the bed had been left high because the CNA went to get the lifter and was supposed to leave the bed down. Resident #77 was admitted and readmitted with a diagnosis including seizures, had a BIMS score of 9 indicating moderate cognitive impairment, and was dependent for all ADLs. The resident’s care plan identified fall risk related to seizure disorder, impaired mobility, anemia, impaired vision, psychotropic drug use, aggressive behaviors at times, unaware of safety measures, history of falling, and potential side effects of medications, with an intervention to keep the bed in the lowest position. The facility also had a fully operational hand sanitizer dispenser mounted directly above a light switch in the conference room, and maintenance staff stated the placement was missed after a company change; the inspector noted the three-foot requirement and the potential hazard that sanitizer could enter an outlet and cause the breaker to malfunction.
Inaccurate narcotic counts and improper wasting of controlled medications
Penalty
Summary
The facility failed to maintain accurate narcotic accounting records and failed to follow narcotic disposal/wasting protocols for the 4th Floor East medication cart. During a narcotic count review, the Medication Monitoring Control Record Log did not match the corresponding bingo card counts for multiple controlled medications, including tramadol 50 mg for Resident #76, lacosamide 100 mg for Resident #77, lorazepam 0.5 mg for Resident #103, oxycodone/APAP 10-325 mg for Resident #34, lorazepam 1 mg for Resident #11, alprazolam 1 mg for Resident #17, and lorazepam 0.5 mg for Resident #63. The discrepancies showed the log counts were consistently one higher than the bingo card counts for several medications, and one medication count was two lower than the log. Staff Q, RN stated she had given Resident #76’s tramadol at 6:00 PM but had not signed for it when removing the medication. She reported the tablet was dropped on the floor, flushed, and replaced with another tablet, but no witness was present for the waste. Staff Q stated she should have had a witness to waste the narcotic. Staff R, RN supervisor confirmed that wasted medication requires a witness signature before flushing and that narcotics should be signed off in the book as soon as they are removed. A second narcotic count was completed with Staff R, RN, and the discrepancies were acknowledged.
Food Storage and Dish Machine Temperature Monitoring Deficiencies
Penalty
Summary
The facility failed to store food under sanitary conditions by not ensuring that two of the three reach-in refrigerators in the kitchen had thermometers on the inside. During the initial kitchen tour, Reach-in Refrigerator #2 was observed at 37 degrees F outside and contained shredded cheese for the tray line, but no inside thermometer was present. Reach-in Refrigerator #3 was observed at 38 degrees F outside and contained mayonnaise, tuna salad, chicken salad, butters, and creamers, but also had no inside thermometer. The Dietary Supervisor confirmed that the inside thermometers were missing and stated that the thermometer should be in there. The facility’s food storage policy stated that refrigerated foods would be stored at proper temperatures and that a thermometer showing the proper temperature being maintained would be used. The facility also failed to ensure proper washing of dishes and utensils because the high temperature dish machine did not have an operable final rinse temperature gauge. Observation of the dish machine showed the wash dial at 150 degrees F and the final rinse dial at 162 degrees F, while staff stated the final rinse temperature should be 180 degrees F. Several additional cycles were run, and the final rinse dial remained at 162 degrees F. The Dietary Supervisor stated the wash temperature should be 180 degrees F and stopped the machine after the issue was identified. The dish machine temperature log policy required monitoring and documenting wash and final rinse temperatures at every meal service, and the manufacturer temperatures listed the final rinse at 180 to 195 degrees F.
Dish Machine Final Rinse Temperature Failure
Penalty
Summary
The facility failed to ensure the high temperature dish machine final rinse cycle was working properly. Record review showed the facility’s Dish Machine Temperature Log policy required staff to monitor and document wash and final rinse temperatures at each meal service, and the manufacturer’s operating temperatures listed the final rinse at 180-195 degrees F. During observation, the wash dial was at 150 degrees F and the final rinse dial was at 162 degrees F, which was below the required final rinse temperature. Staff A and the Dietary Supervisor observed that repeated cycles did not change the final rinse reading, and the Dietary Supervisor stopped the machine and called the service company. The Dietary Supervisor stated the technician came out and found the thermostat was burned out and needed replacement. The dish machine temperature log for January documented wash temperatures of 161 degrees F and final rinse temperatures of 180 degrees F for breakfast, lunch, and supper, despite the observed malfunction. The repair invoice documented that the final rinse temperature was not accurate, the thermostat for the final rinse was broken and burned, and the thermostat was replaced and tested to 180 degrees F.
Resident not served meal tray at same time as tablemates
Penalty
Summary
Facility failed to ensure a dignified dining experience for one resident when the resident’s lunch tray was not served at the same time as the other residents seated at the same dining table. On 01/12/2026 at 12:31 PM, lunch trays arrived in the third-floor dining room. Staff began passing meal trays to residents at the first dining table at 12:32 PM, and by 12:35 PM all residents at that table had been served except Resident #40. Staff then began serving residents at the second dining table at 12:36 PM, while Resident #40 remained without a tray. Resident #40 was served at 12:44 PM, after the other residents at the first table had already received their meals. Record review showed the resident was admitted and readmitted with diagnoses including muscle wasting and atrophy, multiple sites. The quarterly MDS dated 12/30/2025 showed a BIMS score of 3, indicating severe cognitive impairment, and that the resident needed supervision or touching assistance when eating. The care plan identified the resident as at risk for nutritional and/or hydration deficits and included interventions to encourage and assist with eating as needed. Staff and the Restorative Nurse stated that all residents seated at one table should be served together or at the same time, and the facility policy stated that residents are to be treated with respect and dignity.
Failure to Provide Needed Nail Care
Penalty
Summary
Adequate ADL care was not provided for one resident who was unable to perform all needed self-care. On 01/12/2026, the resident was observed seated in bed and stated concerns about not having his nails trimmed by staff. The resident’s left hand was contracted, and his fingernails were long and digging into the palm of his hand; photographic evidence was taken. The resident was admitted as a re-entry on 6/30/2025 with diagnoses including spastic hemiplegia affecting the left dominant side and epileptic seizures. The quarterly MDS indicated the resident was cognitively intact and required varying levels of assistance with eating, oral hygiene, dressing, personal hygiene, toileting hygiene, bathing, and footwear. The care plan identified a self-care deficit related to encephalopathy, spastic hemiplegia, and epileptic seizures, with interventions including allowing the resident to perform tasks at his own pace, providing assistance only in areas of difficulty, setting up hygiene items within reach, and showering as scheduled and as needed. Staff interviews showed that nail care was generally assigned to CNAs, though nurses or a designated staff member might also perform it, and that if the designated person was unavailable, CNAs were still responsible for providing the care. The facility policy stated that residents unable to carry out ADLs would receive necessary services to maintain grooming and personal and oral hygiene.
Medication Error Rate Exceeded 5%
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, with nine medication errors out of 88 opportunities for an error rate of 10.23%. During observation of medication administration for Resident #85, who had diagnoses including Parkinsonism, heart failure, Alzheimer disease, dysphagia, and schizoaffective disorder, Staff N, RN prepared multiple medications at once, left them unattended on the resident’s overbed table, and then crushed all of the medications together in a pill crusher pouch before mixing them with applesauce and administering them. The resident’s ordered Zunveyl delayed-release tablet was not available on the cart at the time of administration. Additional medication errors were observed for other residents. For Resident #27, who had Alzheimer disease, Staff S, LPN administered a multivitamin with mineral tablet from facility stock even though the order was for multivitamin and mineral liquid 15 mL by mouth daily. For Resident #117, who had hypertensive heart disease without heart failure, Staff P, RN observed that ordered Losartan Potassium 25 mg tablets were not available in the medication cart, and the medication was not readily available after checking the supervisor, emergency kit, and automated dispensing machine. The facility policy reviewed required verification of the right drug, dose, route, rate, time, and customer, and that the MAR reflect the most recent medication order.
QAPI Program Failed to Address Repeated Drug Storage Deficiency
Penalty
Summary
The facility failed to demonstrate that an effective plan of action was implemented to correctly identify quality deficiencies in the problem area related to repeated deficient practices for F761, Label/Store Drugs & Biologicals. The report states that this deficiency had been cited previously during a recertification survey exit on 07/18/2024. Record review of the facility’s QAPI Plan, issued 6/10/2021, showed the facility’s policy to maintain an effective, comprehensive, data-driven QAPI program focused on indicators of care outcomes and quality of life. During interview, the Administrator stated that the QAPI team included the Medical Director, Administrator, and all management team members, and that meetings were held monthly to discuss concerns for each department, develop the next plan for improvement, and analyze data to determine which interventions were working or not.
Facility Fails to Control Fly Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in a significant presence of flies throughout various areas, including the kitchen, conference room, and multiple floors where residents reside. Observations revealed swarms of flies in the conference room and kitchen, with flies noted around the steam table and tray line. Staff, including the Dietary Supervisor and Registered Dietitian, confirmed the presence of flies during interviews. Photographic evidence was submitted to support these observations. The facility's pest control policy, issued in March 2020, outlines the need for a comprehensive pest control program and a contract with an outside pest service. However, the pest control contract, effective from May 2024, did not include flies as part of the interior pest control treatment. Despite regular visits from the pest control company, as confirmed by the Director of Maintenance and the Administrator, the issue of flies persisted, indicating a gap in the pest control measures specifically addressing flies.
Failure to Protect Residents' Healthcare Information
Penalty
Summary
The facility failed to protect residents' healthcare information on three out of seven medication carts reviewed. During observations on the third floor, electronic health record computer screens were found open and unattended, displaying residents' information. On one occasion, a Licensed Practical Nurse (LPN) left the screen open on the medication cart, explaining that the computer had issues and might have turned back on when plugged in. Another incident involved a Registered Nurse (RN) who left the screen open while checking on a resident, despite being trained to close the screen when away from the cart. A third observation noted an LPN leaving the screen open during a medication administration. The Director of Nursing confirmed that the electronic medication administration screen should be closed when staff is away from the cart to protect residents' personal information. The facility's HIPAA Security Measure policy, dated May 2024, mandates reasonable and appropriate measures to protect residents' identifiable information in electronic format, including automatic logoff after a predetermined time of inactivity. Despite this policy, the facility did not ensure compliance, resulting in the exposure of residents' private information.
Failure to Timely Update PASRR for Resident with Major Mental Disorder
Penalty
Summary
The 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 a resident with a major mental disorder. The Level I PASRR dated 2/19/24 omitted diagnoses of Schizophrenia, Bipolar disorder, and Anxiety, despite the resident having these conditions. The resident's demographic sheet and electronic health records indicated diagnoses of Major Depressive Disorder, Psychosis, Bipolar, Anxiety, and Schizophrenia, but the PASRR did not reflect these, leading to the conclusion that a Level II PASRR evaluation was not required. The facility's policy requires notification of the state mental health authority after a significant change in a resident's mental condition. However, the Social Services Director was only notified of the resident's new diagnoses by the previous case worker via email last week, months after the initial PASRR was completed. This delay in communication and failure to update the PASRR in a timely manner resulted in the deficiency. The facility's process for completing PASRRs involves evaluating all diagnoses upon admission and reviewing current Level I PASRRs to determine the need for Level II evaluations, which was not adequately followed in this case.
Controlled Medication Reconciliation Failure
Penalty
Summary
The facility failed to accurately reconcile two controlled medications on one of the seven medication carts reviewed during the survey. This deficiency was identified on the 4th floor medication cart, where a controlled medication count was conducted with a Licensed Practical Nurse (LPN), referred to as Staff E. The Medication Monitoring/Control Records were found to be inaccurate when compared to the corresponding bingo card. Staff E admitted to administering the medication to a resident but failing to sign it out at the time of administration due to being occupied with other nursing tasks. The Director of Nursing (DON) confirmed that the correct procedure requires nurses to sign out controlled medications once they are removed from the bingo card. The facility's policy on Controlled Substance Administration and Accountability, implemented in June 2021, mandates that the Controlled Drug Record serves the dual purpose of recording both narcotic disposition and patient administration, with safeguards in place to prevent loss, diversion, or accidental exposure.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to properly store and label medications in one medication room and one medication cart. During an observation on the second floor, a vial labeled Lorazepam injection was found without an open date. A Registered Nurse (RN) acknowledged that the vial should have been labeled with an open date, indicating a lapse in following the facility's policy for labeling medications. This oversight was confirmed by the Director of Nursing, who stated that all open vials should be labeled with an open and expiration date. Additionally, an observation was made of crushed medication left unattended in a transparent medicine cup on top of a medication cart. A Registered Nurse admitted to leaving the medication unattended while going to call another nurse to open the fridge. This action was against the facility's policy, which states that no medication should be left unattended. These incidents highlight deficiencies in the facility's medication storage and labeling practices, as outlined in their policy dated 11/28/2019.
Infection Control Breach During Wound Care
Penalty
Summary
The facility failed to adhere to infection prevention protocols for a resident under enhanced barrier precautions. During a wound care observation, the LPN responsible for wound care did not wear a gown while attending to a resident with a Stage 4 pressure ulcer and an indwelling catheter. The resident was under enhanced barrier precautions due to the presence of wounds and a catheter, which necessitates the use of gowns and gloves during high-contact care activities. The facility's policy on Enhanced Barrier Precautions, revised in April 2024, mandates the use of gowns and gloves for residents at increased risk of acquiring multidrug-resistant organisms, such as those with wounds or indwelling medical devices. The LPN acknowledged the mistake of not wearing a gown during the procedure, which was a deviation from the established protocol. This oversight was identified during a survey when the facility had 172 residents.
Failure to Maintain Clean Lint Screens in Laundry
Penalty
Summary
The facility failed to ensure that lint screens were cleaned for two out of three dryers, as observed during a laundry tour. The surveyor noted that two dryers had lint screens filled with lint, despite the facility's policy requiring lint removal every three hours while in use. The Housekeeping Director was unable to provide the lint log immediately, stating it was located upstairs. Upon later review, the lint log for July 18 was found to be unsigned for the 1:00 AM, 3:00 AM, and 5:00 AM checks. The Housekeeping Director mentioned that staff would sign for these times on the following overnight shift, indicating a lapse in adherence to the facility's laundry policy.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Miami
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Gardens Nursing And Rehab Center | 0.3 mi | ★★★★★ | 26 | 0 |
| Hampton Court Nursing And Rehabilitation Center | 2.3 mi | ★★★★★ | 0 | 0 |
| Aventura Rehab And Nursing Center | 2.4 mi | ★★★★★ | 8 | 0 |
| Regents Park At Aventura | 2.9 mi | ★★★★★ | 6 | 0 |
| North Beach Healthcare And Rehabilitation Center | 3 mi | ★★★★★ | 11 | 0 |
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