Health inspection·April 2, 2021

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 4/2/21 at 12:24 PM with Resident #72 revealed that she was in pain all the time. She reported that she had a stroke which affected her right side and that she gets pain in her right leg and that pain is all the time and that she gets a shooting pain in her right leg all night long which keeps her awake. she said her pain is bad and right now at a 7. She reported that she gets medications when she asks for it and that she always has to ask because of the pain, but that it is not effective. She reported that nothing else is done for the pain other than the medication. Interview on 4/02/21 at 12:49 PM with the MDS Assistant, Licensed Practical Nurse (LPN) revealed that Resident #72 should have had a care plan in place to address her pain and that it got overlooked. She reported that she was responsible for creating the care plan and does not have an answer as to why one was not done for this resident's pain. Interview on 4/2/21 at 1:07 PM with Staff F LPN, revealed that she was assigned to work with Resident #72 on this day and is very familiar with the resident. She reported that the resident has constant pain in her right leg and gets pain medication to address the pain. She reported that the resident's pain is worse when she is repositioned. Review of the facility policy titled Care Plan with the most recent revised date of 10/31/19 revealed that A person-centered comprehensive care plan will be developed by the interdisciplinary team with respect to the residents' choice of participants which encompasses resident choice and assessed needs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105658 If continuation sheet Page 2 of 8 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 105658 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/02/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare Lake Zephyr 38250 A Ave Zephyrhills, FL 33542 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one Resident #184 was receiving oxygen according to professional standards of practice of three residents sampled. Residents Affected - Few Findings Included: Observation of Resident #184 on 3/30/21 at 4:00 p.m. the resident was lying in bed on the Covid-19 positive unit with oxygen set at 3 liters via nasal cannula. Staff member B, LPN confirmed the oxygen was set at 3 liters. An interview with Staff member E, LPN on 3/30/21 at 4:02 p.m. confirmed the resident was on continuous oxygen. Observation of Resident #184 on 4/1/21 at 5:45 p.m. sitting up in bed on the Covid-19 positive unit with oxygen set at 2.5 liters via nasal cannula. Staff member B, LPN confirmed the oxygen was set at 3 liters via nasal cannula and stated the resident should have an order for the oxygen. Resident #184 admitted on [DATE] and diagnosed with Covid-19 on 3/25/21 where he was moved to the Covid-19 positive unit. Review of physician orders revealed an order for oxygen 2 liters via nasal cannula for shortness of breath dated 4/1/21. Review of physician orders revealed to change the humidification for oxygen as needed dated 4/2/21. Review of physician orders revealed to change oxygen tubing every night shift every Saturday dated 4/2/21. Review of the care plan revealed a problem area of altered Cardiovascular status. An intervention included oxygen as ordered dated 3/30/21. A problem area of Congestive Heart failure with respiratory distress potential to include Covid 19 positive was initiated on 3/30/21. An intervention to give oxygen as ordered initiated on 3/30/21. During an interview with the Director of Nursing on 4/02/21 at 3:29 p.m. she stated a resident on oxygen should have an order for oxygen. Review of the policy for Physician/prescriber authorization and communication of orders to pharmacy revised on 10/31/16, four pages, revealed: 1) Facility should not administer medications or biologicals except upon the order of a Physician/Prescriber lawfully authorized to prescribe for and treat human illnesses. Review of the policy for Oxygen dated 4/13 one page revealed: It is the policy of this facility that oxygen be used in a manner that promotes the safety and well being of residents and reduces the risk of fire associated with use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105658 If continuation sheet Page 3 of 8 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 105658 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/02/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare Lake Zephyr 38250 A Ave Zephyrhills, FL 33542 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to notify the physician of pharmacy recommendations for 1 of 5 (#48) residents reviewed for unnecessary medications Findings included: Review of Resident #48's record revealed that this resident was admitted to the facility on [DATE] with a readmission date of 2/16/21. Review of Resident #48's physician orders revealed that she has current orders for Clonazepam 0.5 milligrams (mg) and Oxycodone HCI 5 mg for pain. Review of the resident record revealed that the consultant pharmacist completed the monthly drug regimen reviews with the following recommendations: -Recommendation date: 2/2/21Comment: The resident receives a long-acting Benzodiazepines, Clonazepam 0.5 mg GIVE 1 TABLET BY MOUTH AT BEDTIME DX:SLEEP/INSOMNIA for anxiety which is a high risk medication in the elderly due to the increased risk of drowsiness, depression, confusion, addiction, and falls. There is no documentation of failure/contraindication to first-line therapies (e.g., SSRI, SNRI documented in the medical record. Recommendation: Please reduce Clonazepam tapering as indicated (e.g., decreasing the dose by no more than 25%, or 10-12% in high risk residents, every 2 weeks) while concurrently monitoring for reemergence of target behaviors and/or withdrawal symptoms. if an alternate is clinically indicated , please initiate buspirone 5 mg twice daily increasing as tolerated 5 mg/day every 3 days. in divided doses until the desired maintenance dose is achieved . Closer review of the form revealed a undated and unsigned written note indicating Resident seen by provider 2/1/21 No changes to medication. There was no documentation in the resident record that would indicate that the physician had seen the recommendation and no indication that the use of the Clonazepam had been addressed by the physician after the recommendation had been made. -Recommendation date: 3/2/21 Comment: Resident receives Oxycodone Hydrochloride and a CYP3A4 inhibitor, Fluconazole. , Recommendation: Please reevaluate the current opiod regimen and consider discontinuing Oxycodone Hydrochloride and consider alternate therapy with Acetaminophen 650 mg PO Q6H. Ongoing assessment of pain to evaluate the effectiveness of treatment is recommended.: Closer review of the form revealed that there was a x marking the spot for except recommendation (s) above, please implement as written. Additionally there was an undated and unsigned hand written note indicating that It was dc' d on 2/25/21. Closer review of the physician orders revealed that the course of the Fluconazole was completed on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105658 If continuation sheet Page 4 of 8 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 105658 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/02/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare Lake Zephyr 38250 A Ave Zephyrhills, FL 33542 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2/25/21. There was no documentation in the resident record that would indicate that the physician had seen the recommendation and no indication that the use of the Oxycodone Hydrochloride had been addressed. Interview with the Director of Nursing (DON) on 4/02/21 at 8:54 AM revealed that she receives the recommendations from the Consultant Pharmacist and then disperses them to the unit managers who then follow through with the recommendations. She reported that If the physician does not want any changes then that is documented. She reported that the unit manger will document on the form what was done and physician orders would reflect the changes. She confirmed that it was not clear if the recommendations related to the Clonazepam and the Oxycodone were followed, and that it was not clear if the physician saw the recommendation. She confirmed that each recommendation has a signature spot directly on the recommendation for the physician to sign. She confirmed that on both recommendation forms the signature areas were both blank. She reported that she will see if there was any additional information documented anywhere else and will see if the physician was aware of the recommendation. During a phone interview on 4/02/21 at 9:14 AM Staff M, APRN (Advanced Practice Registered Nurse) revealed that with her patients who reside downstairs, the unit manager hands her the pharmacy reviews, but that is the only person that she gets them from and that she does not routinely get the recommendations. Staff M reported that if she does not sign them then she did not see them. Continued interview with Staff M at this time revealed that even if she has seen the patient the day before the recommendation she expects to get and review the pharmacy recommendations as they come in. During a phone interview on 4/2/21 at 5:00 PM with the Consultant Pharmacist revealed that she typically gets a response regarding the pharmacy recommendations and is not sure what happened to the recommendations in question. She reported that her expectation is that the physician review the recommendations and that the physician follow-up accordingly with the recommendations and document the changes or rational if there are no changes. A request was made of the facility for a policy related to following consultant pharmacy recommendations, but none was provided. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105658 If continuation sheet Page 5 of 8 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 105658 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/02/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare Lake Zephyr 38250 A Ave Zephyrhills, FL 33542 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observations, record reviews, and interviews the facility failed to ensure that the medication error rate was less than 5.00%. Thirty-one medication administration opportunities were observed and two errors were identified for one Resident (#55) of ten residents observed. These errors constituted a 6.45% medication error rate. Residents Affected - Few Findings Included: Observation of medication administration on 4/1/21 at 11:02 a.m. with Staff member D, LPN and Resident #55. Staff member D, checked the blood sugar for Resident #55 with a result of 154. Review of physician orders for the sliding scale of Novolog solution 100 unit/ml included 151 - 200 equals giving 2 units of insulin. Prime pen with 2 units air shot prior to insulin administration. Staff member D, verified the Novolog flex pen for resident #55 and placed a new needle on the pen. At 11:10 a.m. Staff member D, gave 2 units of Novolog without priming the pen of 2 units prior to use. During an interview with Staff member D, LPN she confirmed she would prime the Novolog flex pen with 2 units of insulin and remove the air prior to setting the pen for 2 units to give, which she did not do this time. Observation of medication administration with Staff member E, LPN on 4/1/21 at 3:58 p.m. for Resident #55 included obtaining a blood sugar for sliding scale insulin administration. Staff member E, obtained the blood sugar reading of 179 for Resident #55 and stated she would get 2 units of insulin according to the sliding scale of 151 to 200 is 2 units. Review of physician orders for the sliding scale of Novolog solution 100 unit/ml included 151 - 200 equals giving 2 units of insulin. Prime pen with 2 units air shot prior to insulin administration. Staff member E, verified the Novolog flex pen, added a needle and set the flex pen at 2 units and went to Resident #55, explained the process and gave the resident 2 units of insulin. During an interview with Staff member E, LPN on 4/1/21 at 4:12 p.m. she stated she has never been given instructions on how to prime the insulin pen prior to use and has not done that. During an interview with Staff member B, LPN on 4/1/21 at 6:00 p.m. she confirmed the flex pens use 2 units to prime the pen prior to use. Staff member B, LPN confirmed the pens have been out for a while and will need to retrain the nurses on the use of the flex pens. During a phone interview with the Consultant pharmacist on 4/2/21 at 5:09 p.m. she confirmed the Novolog flex pen should be primed prior to use but did not consider this to be a significant error. Review of the Novolog flexpen, page 9, no date: Giving the airshot before each injection: Before each injection small amounts of air may collect in the cartridge during normal use. To avoid injecting air and to ensure proper dosing. E) Turn the dose selector to select 2 units. F) Hold your Novolog flex pen with the needle pointing up. Tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge. G) Keep the needle pointing upwards press the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105658 If continuation sheet Page 6 of 8 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 105658 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/02/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare Lake Zephyr 38250 A Ave Zephyrhills, FL 33542 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete push-button all the way in. The dose selector returns to 0. A drop of insulin should appear at the needle tip. If not, change the needle and repeat the procedure not more than 6 times. Review of policy for General dose preparation and medication administration, revised on 1/1/13, three pages, revealed: 4.1.1 Verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident. Event ID: Facility ID: 105658 If continuation sheet Page 7 of 8 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 105658 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/02/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare Lake Zephyr 38250 A Ave Zephyrhills, FL 33542 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 0800 Level of Harm - Minimal harm or potential for actual harm Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. Based on observation, record reviews, and interviews, the facility failed to ensure that hot foods were held at 135 degrees Fahrenheit or higher on the steam table in one of one kitchen. Residents Affected - Some Findings included: On 04/01/21 at 11:16 a.m., the main cook took the temperatures of the foods being served for lunch. The tuna melt was at 119 degrees Fahrenheit. The main cook reported to the Certified Dietary Manager (CDM) that the temperature of the tuna melt was at 119 degrees Fahrenheit. The CDM stated that the temperature was ok and that the recipe stated to grill cheese until melted and she continued making more tuna melts on the stove. At 11:25 a.m., the Registered Dietitian (RD) stated the holding temperature should be at least 135 degrees Fahrenheit for the tuna melts and they should be cooked as they go. The RD stated the recipe was tricky. She then stated a temperature of 119 degrees Fahrenheit was ok for the tuna melts because the tuna was probably made last night and the toast had to be heated. Staff continued placing sandwiches on trays for lunch for residents. The facility provided their Production Recipe for the tuna melt sandwich which revealed the following: Ingredients Canned Tuna Mayonnaise Sweet Pickle Relish Sliced American Cheese White Bread Margarine Cook to a minimum internal temperature of 145 degrees Fahrenheit for 15 seconds. Hold or serve hot food at or above 140 degree Fahrenheit. The policy Dietary Sanitation provided by the facility revised 11/20/17 revealed the following: 1. Food service staff follow procedures that reduce potential for food borne pathogens, in storing, preparing, and serving food. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105658 If continuation sheet Page 8 of 8