Sierra Lakes Nursing & Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Sierra Lakes Nursing & Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689May 1, 2026

  Based on observations, records reviewed and interviews, it was determined that the facility did not maintain adequate supervision to ensure a safe environment that is free from accident and hazards for 1 out of 5 residents sampled for accident hazards and supervision. On 04/28/2026, at approximately 6:20 PM, Resident #1 became dissatisfied with staff after being denied [brand] over-the-counter antacid medication that was not ordered by the physician. The resident #1 proceeded to light a cigarette in the hallway. Facility staff confiscated the cigarette and lighter and Resident #1 returned to her room unsupervised. Shortly thereafter, Resident #1 exited her room and informed staff that she had set her room on fire, and they needed to remove her roommate. […]

• No harm, potential for more than minimal, widespreadF925Jul 18, 2024

  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. 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… […]

• No harm, potential for more than minimal, widespreadF812Feb 23, 2023

  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. […]

• No harm, potential for more than minimal, patternF689Jan 15, 2026

  Based on observations, record reviews and interviews, the facility failed to prevent accidents and hazards as evidenced by unsecured housekeeping carts on the Fourth Floor East and [NAME] Hallways. 2) Resident #77 was observed unattended in high positioned bed. 3) A hand sanitizer dispenser observed located directly above a light switch in the facility's conference room of the facility. There were 160 residents residing in the facility at the time of survey.The findings include. On 1/12/2026 at 9:51 AM an observation was made of an unattended housekeeping cart with key in the lock on the fourth-floor East hallway (photo evidence). Staff E, Housekeeping was immediately notified about identified concern and interviewed about facility's protocol for keeping the housekeeping cart secure. […]

• No harm, potential for more than minimal, patternF761Jan 15, 2026

  Based on observations record review and interviews, the facility failed to maintain accurate narcotic accounting records, failed to record and implement narcotic disposal/wasting protocols in accordance with professional standards of practice for one (4th Floor East Cart) of four medication carts reviewed. As evidenced by Medication Monitoring Control Records for the 4th Floor East Cart were inaccurate when compared to the corresponding bingo cards and staff failed to have a witness before disposing narcotic. There were 160 residents residing in the facility at the time of the survey. The findings include:On 01/12/2026 at 5:51 PM, Staff Q, RN, revealed she was assigned to the 4th Floor East Cart and had completed giving all the 6:00 PM medications. […]