Health inspection·August 18, 2022

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A skin observation evaluation was completed for Resident #26 at 9:02 p.m. on 8/8/22, which indicated there was no new skin conditions. The evaluation identified an open wound to the outer right ankle. On 8/17/22 at 11:42 a.m., the facility's Wound Care Nurse (WCN) stated she was aware of the dressing that was observed on Resident #26's right ankle. She stated the facility's protocol was to date the dressing (as to when it was put on) and the weekly skin assessments were to be accurate. The WCN stated she had interviewed the nurse that completed the skin evaluation on 8/8/22 and the nurse reported she did not visualize the right ankle wound as there was a dressing on it. The WCN reported the protocol for a new skin issue was to determine the type of wound, notify the physician, and obtain appropriate (wound care) orders. She stated she followed up on the skin issue the next time she was on duty. The WCN nurse reported she had interviewed the nurses and all had denied putting the dressing on Resident #26. The WCN confirmed the dressing observed on 8/15/22 could have been placed prior to the 8/8/22 as no other nurse had claimed to have put the dressing on. She stated the wound was 100% granulation, approximate nickel-sized, with light serosanguinous drainage and slightly macerated edges. On 8/17/22 at 2:34 p.m., the DON stated her expectation was when a skin concern was identified, the doctor was notified, treatment orders were obtained, families were notified, and documentation was completed. The DON reported, on 8/17/22 at 2:59 p.m., she reviewed the note completed on 8/8/22 and had contacted the nurse. The DON stated the nurse (who had completed the skin evaluation) had informed her she had not looked at Resident #26's (ankle) wound. The DON stated the nurse could not work until she had completed a competency with the DON. The policy - Skin & Wound Care, created 1/1/2007 and reviewed on 8/22/2017 and 3/2021, identified that The facility will promote dignity and enhance the resident's quality of life and quality of care by maintaining or restoring resident's skin integrity to the extent possible. The facility will evaluate risk and implement preventative measures that meet the standards of care and in accordance with state and federal regulations, trough initial and ongoing evaluation of resident's risk for skin breakdown and development of pressure injuries. The procedure portion of the policy identified the following: - Nurses will complete weekly - Use the PointClickCare (PCC) weekly Skin Observation UDA. - Provide treatments to existing wounds and newly identified wounds that follow the current standards of practice for wound care and will: -- Wound/Treatment Nurse/designee will conduct wound rounds weekly and monitor wound healing in accordance with state and federal regulations. -- The staff nurse will describe and measure the wound, notify physician, obtain orders, and notify resident and resident representative when a skin alteration is identified. The Wound Nurse/designee will evaluate all new wounds and for those evaluated to be pressure injuries will measure, stage, and update treatment orders if necessary. -- Keep resident and resident representative updated on the condition of the wound. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105658 If continuation sheet Page 2 of 11 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 08/18/2022 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 0684 Level of Harm - Minimal harm or potential for actual harm The Clinical Practice Guidelines for Skin Health/Wound Management, dated 2/19/21, identified that a nurse would complete a Skin Observation Evaluation on admission/re-admission, and weekly thereafter. The wound management portion of the guidelines indicated Upon identification of a wound on admission or during the resident's stay the following evaluations would be completed and included the following: Residents Affected - Few -- PCC Pain Evaluation -- PCC Skin Observation Evaluation -- PCC E-Interact Change of Condition form -- PCC Braden Scale on admission, weekly x 4, with new skin condition -- PCC Nursing to Therapy Communication Form to request restorative/positioning review The guidelines indicated that the WCN/designee would complete PCC Skin and Wound Analysis from upon identification and weekly until resolved. Instructions indicated staff were to utilize the Wound Care Order Set when notifying the physician and request orders for treatment of the area, an order to monitor skin integrity every shift and specify areas/dressings to observe, evaluate pain prior to dressing changes, and enter all products, if the treatment included a medication, in the instructions and ensure it flows to the TAR. The nurse was to document notification to Resident /Resident Representative on condition of the identified area and the treatment, and the staff nurse assigned to the resident was responsible in ensuring that dressing changes were completed as ordered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105658 If continuation sheet Page 3 of 11 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 08/18/2022 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to obtain physician's orders for, assess the use of, and develop care plans for padded side rails which were attached to the beds of four (Residents #8, #31, #76, and #81) of 36 sampled residents . Findings included: 1. Resident #8 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's Disease, muscle weakness, and unspecified psychosis. On 08/15/2022 at 11:15 a.m., Resident #8 was observed lying in her bed, which was low to the floor, with the head of the bed up at approximately a 45 degree angle, with padded bilateral side rails alongside the elevated head of the bed. An arm chair had been placed tight against the side of the bed, on the resident's right side and bilateral floor mats were observed on either side of the bed. During that observation, Resident #8 was continuously yelling out, with an occasional understandable word such as No, No, No. The resident had her eyes closed and the resident's aide, Staff I, commented the resident's vision was not good and she usually kept her eyes closed. Staff I confirmed the resident often yelled out. At times she was taken out of bed and placed into a high backed chair, but she did better when she remained in bed. The aide confirmed the padded side rails were for the resident to hold on to and confirmed the resident was able to move around in the bed on her own. Upon admission, a Side Rails Grab Bar Analysis was conducted, dated 02/16/2022. The resident was described as ambulatory, without the ability to transfer independently, without a history of falls in the prior three months, without the use of side rails/grab bars in the prior three months, and no history of attempting to climb over the rails/bars. The resident was described as having no involuntary movements, but having expressed the desire to have the side rails/grab bars raised when in bed. The resident's reason for agreeing to the side rails/grab bars was for bed mobility, turning, positioning and support. The analysis concluded that based on the evaluation the side rails/grab bars were indicated for the purpose of bed mobility, turning, positioning and support. The decision was made to use two quarter rails as they would most benefit the resident. The Analysis described the benefit to the resident by utilizing the side rails as enabling bed mobility, turning, positioning and support. The analysis confirmed that all risks associated with the use of side rails were present for this resident. The Rationale for the use of the side rails repeated bed mobility, turning, positioning and support. Question #14 asked what other less restrictive alternatives had been attempted and what was the resident's response. The answer was n/a. The answer was no to the question whether the side rails would prevent the resident from any activity she would be able to perform without the rails. There was no reference to the padding on the side rails. The Minimum Data Set (MDS) Assessment conducted upon admission dated 02/22/2022, and the most recent quarterly MDS dated [DATE], did not show either improvement or decline in the resident's Activities of Daily Living. The resident required extensive to total assistance by two staff for bed mobility and transfer, and in both assessments the use of side rails was not identified. The resident's Brief Interview for Mental Status (BIMS) score was a 5 at admission and a 3 on the quarterly, both indicating severe cognitive impairment. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105658 If continuation sheet Page 4 of 11 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 08/18/2022 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Care plans were reviewed for Resident #8 and noted to not include a care plan for the use of padded side rails, used for mobility or to assist in the prevention of falls. It was also noted that there was not a Physician's order for the use of side rails or grab bars. An interview was conducted with the Unit Manager on 08/18/2022 beginning at 10:30 a.m. She confirmed the Side Rail/Grab Bar assessment had been completed upon admission on [DATE] for Resident # 8 but the resident had not been reassessed for the use of side rails. She confirmed there was no physician's order nor care plan for the use of the side rails/grab bars but there should have been both an order from the physician and a care plan developed. At 1:00 p.m. on 08/18/2022 the Unit Manager reported upon further review and discussion with other facility staff, the side rails/grab bars for Resident #8 were attached to the bed in error and they had been removed. She reported that it was a mistake to have the bars on the resident's bed as she would not have benefited from their use. 2. Resident #31 was re-admitted to the facility on [DATE] with diagnoses that included unspecified mood disorder, unspecified dementia with behavioral disturbances, unspecified psychosis and having difficulty walking. Observation of the resident on 08/15/2022 at 11:00 a.m., revealed an elderly male sitting back against a raised head of the bed, almost upright, dozing. Padded side rails were observed along side the raised head of the bed. The side rail pad to the left of the resident was observed to be ripped along the top seam and was scratchy to the touch. A private sitter was in a chair next to the bed and she reported that she noticed the padding on the side rail and how it was ripped and was a potential skin tear hazard. She reported that staff had never commented on it to her. She reported that the resident did not reach out to the side rails and she wasn't sure why they were attached to the bed. Upon readmission, on 03/09/2022, a Side Rails Grab Bar Analysis was conducted for Resident #31. It documented the resident was not ambulatory, not able to transfer independently, had no history of falls in the past three months, but the resident had attempted to climb over or around the rails. The Analysis indicated the resident was able to use the side rail/grab bars for bed mobility, positioning, turning or support, and specifically for bed mobility. The Analysis indicated the resident had not expressed a desire to have the side rails/grab bars raised while in bed. The evaluation indicated the use of two quarter side rails/grab bars for this resident, for the purpose of turning and repositioning. The risks associated with the use of the side rails/grab bars included skin tears, bruises, and /or lacerations. The benefit of the use of the side rails/grab bars to the resident was for turning and repositioning. Question #14 asked what other less restrictive alternatives were attempted. The answer was n/a. The side rails/grab bars were identified as not preventing the resident from any activity he would be able to perform without the rails. The Minimum Data Set (MDS) Assessment completed on 03/16/2022, for his readmission on [DATE], identified the resident's Brief Interview for Mental Status (BIMS) as 8, indicating moderately impaired cognition. The resident's bed mobility and transfer ability were identified as requiring extensive to total assist by two staff. The MDS did not include side rails were in use. A quarterly MDS was completed on 06/09/2022 which identified the resident's BIMS as 2, indicating severely impaired cognition. His bed mobility and transfer abilities were assessed as the same as in March and the assessment did not include the use of side rails. The resident's care plans were reviewed and noted for not including a care plan for side rails or grab bars. A relevant care plan was reviewed which identified the resident at risk for pressure (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105658 If continuation sheet Page 5 of 11 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 08/18/2022 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few injury related to his decreased mobility, incontinence and diabetes mellitus. Interventions did not include the use of side rails to assist with his bed mobility. A review of the physician's orders revealed an order for side rails which was dated 08/10/2022. In the interview on 08/18/2022 beginning at 10:50 a.m. with the unit manager, she was confirmed an additional side rail analysis had not been completed for Resident # 31 and the side rails remained in place on the resident's bed. She confirmed that there was no care plan for the rails, but a physician's order had been written on 08/10/2022, five months after the assessment. 3. On 8/17/22 at 10:16 a.m., Resident #76 was observed lying in a low bed with bilateral floor mats and raised padded side rails. On 8/18/22 at 1:24 p.m., the resident was observed, lying in bed with bilateral raised padded side rails. Resident #76 was admitted on [DATE]. The admission Record included diagnoses not limited to Hemiplegia and hemiparesis following cerebral infarction affecting right non-dominant side, right hand contracture, history of falling, and dementia in other disease classified elsewhere without behavioral disturbance. The review of Resident #76's Order Summary Report, active as of 8/18/22, did not include a physician order for the observed padded side rails. Resident #76's care plan identified that an intervention was initiated and revised on 8/17/22 for bilateral padded side rails. 4. On 8/15/22 at 12:27 p.m., Resident #81 was observed lying in bed with bilateral raised padded side rails. On 8/18/22 at 1:09 p.m., the resident's bed was observed in the low position, with floor mats, and side rails in the up position. On 8/16/22 at 12:51 p.m., a review of Resident #81's care plan did not reveal the use of padded side rails. Resident #81 was admitted on [DATE]. The resident's admission Record included diagnoses not limited to vascular dementia without behavioral disturbance and unspecified anxiety disorder. The review of Resident #81's Order Summary Report, active as of 8/18/22, indicated a physician order dated 6/8/22 for the use of padded side rails. A review of Resident #81's care plan on 8/18/22 at 1:09 p.m., did not indicate an intervention related to the resident's use of padded side rails. 5. A review of the facility policy entitled, Siderails was conducted. The Policy statement read: The use of siderails shall be determined by the safety level of care. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105658 If continuation sheet Page 6 of 11 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 08/18/2022 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 0700 Under Procedure/Guidelines, the steps included: Level of Harm - Minimal harm or potential for actual harm Verify the need for siderails up as determined by the safety level of care . Residents Affected - Few Explain to the patient why siderails are up, answer questions as needed, stressing the purpose and importance of this safety device. Check patient frequently. Lower siderails when giving treatment/procedure then return to up position. Document siderails up. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105658 If continuation sheet Page 7 of 11 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 08/18/2022 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, interviews, and record review, the facility failed to ensure the medication error rate was less than 5.00%. Twenty-five medication administration opportunities were observed, and two errors were identified for two (Residents #32 and #26) of six residents observed. These errors constituted a 8.00% medication error rate. Residents Affected - Few Findings included: On 8/16/22 at 4:18 p.m., an observation of medication administration with Staff E, Licensed Practical Nurse (LPN), was conducted with Resident #32. The Staff E was observed dispensing the following medications: - Eliquis 2.5 milligram (mg) tablet - Gabapentin 400 mg capsule - Hydralazine 25 mg tablet - Gabapentin 400 mg capsule Staff E dispensed the medications by keeping the blister packaging in the drawer of the medication cart, popping the medication into her gloved hand then placing it into the medication cup. Staff E stated she had seen others take the packaging out of the cart (demonstrated) but it did not feel right to her. Staff E confirmed 4 tablets/capsules had been dispensed. Staff E entered the resident room and handed Resident #32 the medication cup. The resident asked if it contained Potassium and Staff E stated that it did. When the resident questioned it again, Staff E left the room and reviewed the medications (left on the med cart) and confirmed the medication cup contained two capsules of Gabapentin and not Potassium. Staff E returned to the room and asked the resident for the medication, the resident informed the nurse the medications had been taken. Staff E returned to the medication cart and dispensed one 10 milliequivalent tablet of Potassium ER which was then administered to the resident. A review of the August Medication Administration Record (MAR) for Resident #32 indicated that the following order: - Gabapentin capsule 400 mg - Give 1 capsule by mouth three times a day related to other intervertebral disc degeneration lumbar region. Start Date 10/6/21 and discontinued 8/17/22 at 10:38 a.m. This medication was scheduled for 9 a.m., 1 p.m., and 5 p.m. 2. On 8/16/22 at 4:58 p.m., an observation of medication administration with Staff F, Registered Nurse (RN), was conducted with Resident #26. The Staff F was observed dispensing the following medications: - Divalproex Delayed Release (DR) 250 mg tablet - Eliquis 2.5 mg tablet (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105658 If continuation sheet Page 8 of 11 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 08/18/2022 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 - Metoprolol Tartrate 25 mg tablet Level of Harm - Minimal harm or potential for actual harm - Novolog FlexPen - dialed 6 units for blood glucose of 309. The RN confirmed the dispensing of 3 tablets/capsules. Residents Affected - Few Staff F left the nursing station and approached Resident #26 in the common area. Staff F was asked to check the Divalproex order. She returned to the nursing station and verified the order for Divalproex indicated the resident was to receive 1.5 tablets of 250 mg Divalproex. Staff F searched the medication cart and verified there were no 1/2 tablets of Divalproex. She dispensed another 250 mg DR capsule of Divalproex and verified the tablet was not scored. The Wound Care Nurse (WCN) instructed Staff F to hold the medication, contact the physician for further orders and the pharmacy. The WCN assisted Staff F take the resident to the room. Resident #26 refused the two remaining (after Divalproex was removed from the medication cup) medications and Staff F was able to administer the Novolog. A review of Resident #26's August Medication Administration Record (MAR) indicated Staff F documented the resident had refused the 5:00 p.m. dose of 1.5 tablets of 250 mg Divalproex DR on 8/16/22. An interview with the Director of Nursing, on 8/18/22 at 1:00 p.m., was conducted as she called Staff F and placed her on speaker. Staff F reported she had dispensed the medication, left the nursing station and after being asked by this writer to check the Divalproex order, she saw the order was for 1.5 tablets of Divalproex, she took the medication (Divalproex) out of the cup, and attempted to administer the other medications to Resident #26, which were refused. The DON informed Staff F she could not document Divalproex (Depakote) was refused if she had taken the medication out of the med cup and it was not offered. Staff F stated she probably signed it out with the other medications. The DON ended the telephone call and left the interview. The policy - General Dose Preparation and Medication Administration, effective 12/01/07 and revised 5/1/10 and 1/1/13, indicated Facility staff should: 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, as set forth in Appendix 17: Facility Medication Administration Times Schedule. The policy identified that the facility should ensure that after medication administration staff Document necessary medication administration/treatment information (e.g., when medications are opened, when medications are given, injection site of a medication, if medications are refused, as needed (prn) medications, application sight) on appropriate forms. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105658 If continuation sheet Page 9 of 11 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 08/18/2022 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 0885 Report COVID19 data to residents and families. 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 policy review, the facility failed to ensure residents, resident representatives, and visitors were notified of the COVID-19 status. Residents Affected - Some Findings included: On 8/15/22 at approximately 9:00 a.m., the Nursing Home Administrator identified that there was COVID-19 positive residents in the building. A review of the facilities website on 8/18/22 at 9:35 a.m. (https://www.adventhealth.com/skilled-nursing/adventhealth-care-center-zephyrhills-south) instructed residents/representatives and potential visitors of the following for Important COVID-19 Updates: Extra Safety Measures for Your Protection Your health and safety have always been our top priority and we have expanded our policies, procedures and products to protect you and our caregivers. These safety measures include enhanced cleaning and sanitation, universal mask use, temperature checks, social distancing, visitor restrictions and keeping COVID-19 symptomatic patients separated from other patients. Details here, indicating to press the details here. The website continued: For continuous updates on the status of our facility and the residents in our care, please call our coronavirus information hotline at [PHONE NUMBER]. A 37-second telephone call was made at 9:34 a.m. to the facility's coronavirus hotline at [PHONE NUMBER]. The recording indicated that as of 8/7 (2022) the facility had one resident and two staff members who had tested positive in the last 24 hours. Additional confirmation telephone calls were made to the facility's hotline, on 8/18/22 at 9:35 a.m. and 9:36 a.m., the recorded message identified the same information - last recorded on 8/7 with one resident and two staff members. The facility provided the latest telephone recording script, dated 7/16/22 which indicated that the facility had no new confirmed cases of COVID-19 amongst our residents and 1 new confirmed cases of COVID-19 amongst our staff in the past week. The Respiratory Surveillance Line List identified that three staff members had tested positive, two on 8/10/22 and one on 8/15/22 since the hotlines recording and two residents - one on 8/8/22 and one on 8/12/22. On 8/18/22 at 1:42 p.m. and 1:43 p.m. a telephone call was made to the coronavirus hotline with the Infection Preventionist/Assistant Director of Nursing (IP/ADON). The IP confirmed the recording was last recorded on 8/7/22 and indicated one new resident and 2 new staff members. During an interview, on 8/18/22 at 2:25 p.m., with the IP, she stated that if a resident tests positive the Unit Manager and Social Worker calls residents and resident representatives. She stated the hotline was available and was supposed to be updated daily if we have a positive case, and the hotline should have been updated Monday night (8/15/22). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105658 If continuation sheet Page 10 of 11 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 08/18/2022 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 0885 Level of Harm - Minimal harm or potential for actual harm The Facility COVID-19 Pandemic Plan, effective 11/15/21 and last reviewed 6/15/22, indicated that Residents and families are provided a call-in number to hear a weekly update (or as required) on the facility status. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105658 If continuation sheet Page 11 of 11