Inspection visit

Health inspectionJune 17, 2021

SOLARIS HEALTHCARE ZEPHYRHILLSCMS #1059864 citations on this visit

4 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 4 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews the facility failed to ensure splints and/or orthotic devices were applied for three (#50, #75, and #13) out of four residents sampled for limited range of motion. Findings included: 1. On 6/14/21 at 1:24 p.m., a lunch tray was observed on the overbed table of Resident #50. Resident #50 was observed with contractures to bilateral upper extremities and not wearing any orthotic device. On 6/16/21 at 3:50 p.m., an observation was conducted, with Staff F, Certified Nursing Assistant (CNA), of Resident #50 and the staff member confirmed that the resident was not wearing a splint. She stated, [Resident #50] used to have one that therapy put on and the aides took it off in the afternoon but doesn't have it anymore. The staff member looked in Resident #50's dresser drawers and was unable to locate the resident's splint. Staff J, CNA, confirmed, on 6/17/21 at 9:44 a.m., that Resident #50 was not wearing a splint and was unable to locate a splint in the residents' closet or in the wheelchair stored next to the residents' bed. She stated she would have to ask someone else where they had put it. On 6/17/21 at 11:13 a.m., Staff I, Licensed Practical Nurse (LPN), stated that she had documented that Resident #50 had refused bilateral hand splints. She stated that Staff D, Restorative LPN, had taken the splints and that they (splints) may be in the residents' closet. During the observation of Resident #50, who was not wearing splints on either hand, Staff I asked the resident, who was non-verbal, if she wanted to wear the splints. Staff I looked in the residents' closet and stated, again, that Staff D must have them. After looking in the closet herself, Staff I reported that the splints had previously been in the closet prior to Staff D taking them. The admission Record indicated that Resident #50 was admitted on [DATE] and 9/18/19. The record included diagnoses not limited to right wrist contracture, right hand contracture, trigger finger of left middle finger, and aphasia following unspecified cerebrovascular disease. The quarterly Minimum Data Set (MDS), dated [DATE], did not identify a Brief Interview of Mental Status (BIMS) score for Resident #50 as the resident was rarely/never understood. The MDS indicated that the resident had no speech - absence of spoken words, was usually understood - difficulty communicating some words or finishing thoughts but is able if prompted or given time, and usually understands - misses some part/intent of message but comprehends most conversation. The Functional Limitation (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 12 Event ID: 105986 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 105986 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/17/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare Zephyrhills 7350 Dairy Rd Zephyrhills, FL 33540 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few of Range in Motion portion of section G indicated that the resident had an impairment on both sides of the upper and lower extremity. A review of the Order Summary Report, active as of 6/17/21, identified an order, dated 1/8/20, for: - Splint (Right hand splint to be worn about 4 to 6 hours on during daytime. Cleanse and inspect skin prior to applying the splinting device. Apply and insure proper positioning of hand splinting device to right hand. Monitor for any red areas that do not dissipate within 15 minutes, increase pain, changes in sensation, or swelling) every day shift. The electronic Task tab indicated that the CNAs were to Apply splinting devices(s) per order, Right hand splint to be worn 4 to 6 hours during the daytime as resident allows. The 30-day look-back period, from 5/19 to 6/17/21, identified the following: - Applied splinting device on 5/31 at 9:03 a.m., 6/2 at 2:59 p.m., and 6/3/21 at 8:03 a.m. - Resident had refused splint on 5/25 at 11:35 a.m., 5/27 at 1:31 p.m., and 6/17/21 at 8:50 a.m. - Removed splinting device on 5/22 at 11:39 a.m., 6/10 at 7:32 a.m., and 6/12/21 at 8:03 a.m. - Not applicable on 5/19, 5/20, 5/21, 5/23, 5/24, 5/28, 5/29, 5/20, 6/4, 6/5, 6/6/, 6/7, 6/8, 6/9, 6/11, 6/13, and 6/14/21. The May 2021 and June 2021 Treatment Administration Record (TAR) indicated that Resident #50 had refused the right hand splint on 5/1, 5/2, 5/6, 5/13-5/15, 5/20, 5/22, 5/28, 5/30, and 6/12/21. The TAR indicated that users should 9 (9=other/see progress notes). The progress notes on 5/8 and 6/9/21 identified that the resident refused to wear the splint, no other progress notes mentioned Resident #50's splint. The CNA tasks did not include any documentation that splints were applied, removed, refused, or were not applicable on 5/26, 6/1, 6/15 and/or 6/16/21. The June 2021 CNA [NAME] indicated that aides were to Apply splinting device(s), per order Right Hand splint to be worn 4 to 6 hours during the daytime as resident allows. The [NAME] indicated that assistants applied the right hand splinting device on 6/2 - 6/14/21 but did not identify when the splint was removed or that the resident had refused care. The record identified that staff had not applied the splinting device on 6/15 or 6/16/21. On 6/17/21 at 1:49 p.m., the Interim Director of Nursing (DON) reviewed the [NAME] and the CNA tasks related to Resident #50's right hand splint and other tasks. She stated that the [NAME] and Tasks did not match, and it looked like the charting of the [NAME] was when they opened up the Plan of Care and that it did not specify whether the splint was on or off. The [NAME] for Resident #50's splinting indicated that the application did not occur at any specific time, did not identify how long the resident tolerated the splint, or that the splint was removed. On 6/17/21 at 10:00 a.m. the Quality Management Specialist (QMS) and Staff D, Restorative LPN confirmed that if a resident refused to wear the ordered splints it should be documented as a refusal. Staff D reviewed the CNA task and confirmed that the aides were not documenting the application and removal of Resident #50's splints. Staff D stated, on 6/17/21 at 11:41 a.m., she had taken the residents' splint away because it was a left hand splint and the order was for a right hand splint. She reported she was unable to locate the right hand splint and had asked central supply to order another (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105986 If continuation sheet Page 2 of 12 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 105986 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/17/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare Zephyrhills 7350 Dairy Rd Zephyrhills, FL 33540 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 0688 Level of Harm - Minimal harm or potential for actual harm one. Staff D reviewed the Therapy to Nursing Communications document and indicated that on 10/14/20 occupational therapy communicated that Resident #50 would tolerate a left hand splint 4-6 hours on without increased pain to decrease risk of contractures and to notify nurse of any skin issues, redness, or increased pain. She stated she was not sure what happened to the resident's right hand splint or when it went missing. Residents Affected - Few The Restorative Nursing Program Goals, start date 9/21/20, indicated Resident #50 would tolerate a right hand splint for 4-6 hours without increased pain to decrease risk of further contracture. The program description instructed restorative staff to perform right hand hygiene and skin inspection prior to application of the right hand splint. The goals identified a right hand [brand name] hand/wrist/finger orthotic. The Restorative Nursing Program Goals, start date 10/20/20, indicated Resident #50 would tolerate a left hand splint 4-6 hours on without increase pain to decrease risk of further contracture. The goals identified a left hand [brand name] splint. A review of Resident #50's May 2021 and June 2021 Treatment Administration Record (TAR) did not include an order for a left hand splint. The Order Summary Report did not include an order for a left hand splint prior to 6/17/21. 2. On 6/14/21 at 10:57 a.m., Resident #75 was observed wearing a modified yellow non-slip sock to the right elbow while holding her right arm at a 90 degree angle across her upper abdomen. On 6/17/21 at 9:47 a.m., Resident #75 was observed not wearing a splint to either upper extremity. The admission Record indicated that Resident #75 was admitted on [DATE] and 5/3/21. The record included diagnoses not limited to left hand contracture and hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting unspecified side. The annual MDS, dated [DATE], identified a Brief Interview of Mental Status (BIMS) score of 15 out of 15, indicative of an intact cognition. The MDS indicated that the resident exhibited no behaviors, such as rejection of care, and had a functional limitation in range of motion to one upper and lower extremity. A Therapy to Nursing Communication document, dated 7/1/20, indicated that occupational therapy communicated that staff were to provide patient (pt) with Left (L) hand splint daily, patient (pt) demonstrates (demo's) tolerance of 4-6 hours. Skin check and hand hygiene prior and post application. The Certified Nursing Assistant (CNA) [NAME] for June 2021 instructed Nursing Rehab/Restorative: Splint/Brace Program #1: Apply left hand splint daily 4-6 hrs. as tolerated. Inspect skin prior to applying splint, apply and ensure proper positioning to Left hand splint, any redness that don't dissipate within 15 minutes, increase pain, changes in sensation, or swelling, report to nursing supervisor/charge nurse immediately. The [NAME] did not identify that staff had applied the left hand splint as tolerated on 6/1 6/17/21. The Care Plan identified a Problem that Resident benefits from splints/braces to left hand splint due to hemiparesis of unspecified side, initiated on 9/10/20. The intervention, initiated on 6/17/21, was for staff to apply left hand splint 4-6 hours daily for contracture management/comfort as tolerated. Resident #75 was identified as having an Activities of Daily Living (ADL) self-care performance deficit related to (r/t) hemiplegia, limited mobility, limited Range of Motion (ROM), and stroke, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105986 If continuation sheet Page 3 of 12 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 105986 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/17/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare Zephyrhills 7350 Dairy Rd Zephyrhills, FL 33540 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 0688 initiated 9/9/19 and revised 9/18/19. The interventions included: Level of Harm - Minimal harm or potential for actual harm - Left hand orthotic on as ordered, initiated 9/18/19. Residents Affected - Few - Provide patient (pt) with left hand splint daily, pt demo's tolerance of 4-6 hours. Skin check and hand hygiene prior and post application, initiated 7/9/20. The Order Summary Report, active as of 6/17/21, did not include an order for Resident #75's left hand splint. A review of the June 2021 Medication Administration and Treatment Administration Records did not include documentation that a left hand splint was applied by staff. Staff I, Licensed Practical Nurse (LPN), stated, on 6/17/21 at 9:53 a.m., that Resident #75's splint was not on as she had not had time to put it on her yet. On 6/17/21 at 9:57 a.m., the Quality Management Specialist (QMS) stated the facility had reviewed 50 residents who received Restorative Services and identified 19 that needed to continue with the Restorative program. She reported that the facility had added two (2) aides and a weekly meeting which was used to identify if a resident had splints. She stated that the floor CNAs were responsible for donning splints and Restorative aides rounded on residents to make sure that the splints were applied. If the splints were not applied, the Restorative aides were to notify the Restorative nurse. She stated most splinting orders were for 4-6 hours as tolerated and that at some time during the day the splint should be observed on the resident. The Restorative LPN stated, on 6/17/21 at 10:13 a.m., that Restorative should be applying the splint as needed on Resident #75. She stated she was transitioning the Restorative program so that the floor nurses or CNAs would be putting on splints. She reported that the task of applying splints populated under the CNA tasks because it was under their Plan of Care. The Restorative LPN reviewed the task history for Resident #75 and confirmed that the CNAs were not documenting that the splint was applied or removed. On 06/17/21 at 5:17 p.m., the QMS stated they (the facility) needed an outside person to come in and tweak the process. She said they had an issue with a restorative aide, so they let them go and hired 2 other persons as restorative aides. She stated, Its been a challenge. 3. Review of Resident #13's record revealed that this resident was admitted to the facility on [DATE] with diagnoses that included: sprain of unspecified ligament of left ankle; history of falling; pain in left ankle and joints of left foot; localized swelling, mass and lump, left lower limb; hemiplegia, unspecified affecting left non-dominant side. On 6/14/21 at 12:27 p.m., Resident #13 was observed lying in her recliner. Her left hand was noted with a contracture with no splint in place. On 6/15/21 at 4:00 p.m., Resident #13 was observed sitting up in her reclining chair. The resident was noted to not have a splint in place on her left hand. During an interview with the resident at this time, she reported that she had a splint for her left leg, by verbalizing and pointing to her leg. It was noted that the leg splint was not in place at this time. On 6/16/21 at 9:10 a.m., Resident #13 was observed sitting up in her wheelchair with her morning meal tray on the over-bed table and a staff member present at her bedside, The staff member was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105986 If continuation sheet Page 4 of 12 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 105986 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/17/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare Zephyrhills 7350 Dairy Rd Zephyrhills, FL 33540 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few observed to encourage the resident to eat her morning meal. There was no hand splint or leg splint/brace noted on the resident's person or noticeable in the resident's room. Observations of Resident #13 on 6/16/21 at 1:17 p.m., revealed the resident sitting up in her wheelchair eating her midday meal. The resident was noted to not be wearing splints on any of her upper or lower extremities. In an interview with the resident at this time, the resident reported that there is a splint for my leg over there, as she pointed towards her dresser. An inspection of the resident's dresser revealed a leg brace found in the bottom drawer. The resident reported that she did not wear the brace. Observations of the resident on 6/17/21 at 9:35 a.m., revealed the resident lying in bed. She was noted to have no splints in place. Inspection of the resident's room revealed that the leg brace was still present in the bottom dresser drawer. Review of the physician orders dated 2/17/21, revealed that the resident was to Wear leg brace on LLE (left lower extremity) every shift. May remove for ADL care and skin check Review of the physician order dated 2/17/21, revealed that the resident was WBAT (weight bearing as tolerated) to left leg. Review of the treatment administration record for the month of June 2021 revealed that for three days of the survey 6/14/21 to 6/16/21, staff documented the code 9, which indicated that a progress note was entered. This was documented twice on 6/14/21, once on 6/15/21 and once on 6/16/21. On the night of 6/15/21 and the day of 6/16/21 staff documented a check mark, which indicated that the treatment was provided. Review of Resident #13's progress notes dated, 6/14/21 14:43 (2:43 p.m.), 6/14/21 20:12 (8:12 p.m.), and 6/15/21 19:53 (7:53 p.m.) read as follows, Wear leg brace on LLE (left lower extremity) every shift. May remove for ADL care and skin check. Review of the Therapy to Nursing Communication dated 3/10/21 indicated that occupational therapy was communicating that the Pt uses a L [Brand name] Grip Hand Orthosis for 4-6 hours to reduce Pt's risk of further hand contracture. Review of the OT (occupational therapy) Discharge Summary dated 3/10/21 revealed that equipment recommended upon discharge included L [Brand name] grip hand Orthosis. Review of the Restorative Nursing Program Goals dated 3/9/21 from PT (physical therapy) revealed the following: 1. RE seated thera ex 2 X 15 reps each in all planes 2. Bed (-) w/c transfer with minimum assistance transferring to R side with L leg brace donned 3. Sit to stand pulling up on rail with minimum assistance L brace donned x 3 reps. The document indicated RNP (Restorative Nursing Program) to start 3/15 Review of the undated Restorative Nursing Program Goals from OT (occupational therapy) revealed the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105986 If continuation sheet Page 5 of 12 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 105986 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/17/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare Zephyrhills 7350 Dairy Rd Zephyrhills, FL 33540 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 0688 following: Level of Harm - Minimal harm or potential for actual harm -Pt will tolerate LUE (left upper extremity) PROM (passive range of motion) exercise to decrease risk of worsening contractures. Residents Affected - Few -Pt will wear L hand splint for 4-6 hours to decrease risk of worsening contractures. The document indicated Start Date: 03/15/2021 Review of the care plan dated 6/3/21 with a revision date of 6/7/21 revealed, Transfer Nursing Restorative Program r/t (related to) muscle weakness with interventions that included Transfer from bed to w/c with 2 asst. as tolerated (transferring to right side with left leg brace donned); STS (sit to stand) using rail in hallway 2 sets x 3 reps as tolerated with 2 asst, with left leg brace on 3x/wk. Review of the care plan dated 6/3/21 with a revision date of 6/7/21 revealed, Active Range of Motion Nursing Restorative Program r/t muscle weakness. with interventions that included RLE (right lower extremity) seated thera exercises all planes/joints 2 sets x 15 reps daily. Review of the care plan dated 6/3/21 with revision on 6/12/21 revealed, Splint/Brace Nursing Restorative Program r/t (decrease risk of contracture) with interventions that included Apply left hand splint daily for 4-6 hrs. as tolerated, monitor skin integrity before/after for swelling, discoloration, any concerns report to nurse immediately. Review of the care plan dated 2/13/21 revealed, The resident has an ADL self-care performance deficit r/t left ankle sprain r/t fall at home, left hemi, left arm contracture with interventions that included Pt uses a L [Brand name] Grip Hand Orthosis for 4-6 hours to reduce Pt's risk of further hand contracture.; Set-up call light, bed table with meals and needed items to my right as I have left arm contracture. There was no documentation in the record that would indicate that Resident #13's restorative program was ever implemented. The record did not indicate that Resident #13's left hand splint and left leg brace were consistently applied. An interview on 6/17/21 at 10:47 a.m. with the Director of Therapy Services revealed that the last OT screen was completed on 5/19/21 where a recommendation was made per the resident's daughter request for a 3 in 1 commode. She reported that the last assessment with service range 2/12/21-3/10/21 indicated that the resident refused therapy. She reported that there was a left [Brand name] grip to the residents left hand in place at the time of the resident's discharge from therapy with a recommendation for its use. She reported that the OT discharge date was 3/10/21. The Director of Therapy Services reported that she was not sure if anything other device was in place at this time. She reported that once a client was discharged from therapy they were discharged to restorative care and then nursing was responsible for splint use unless a re-evaluation was requested. She reported that at the time of the PT evaluation dated 2/14/21, a left knee and ankle brace was in place. An interview on 6/17/21 at 11:23 a.m. with Staff H, RN Unit manager revealed that the resident did have a brace to her leg. She reported that the resident refused the brace and if the resident refused to wear the brace this would be documented in the progress notes. Staff H completed a review of the resident's progress notes and confirmed that the only progress notes present in the record (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105986 If continuation sheet Page 6 of 12 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 105986 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/17/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare Zephyrhills 7350 Dairy Rd Zephyrhills, FL 33540 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 0688 indicating that the resident had refused the use of her leg brace was on 6/17/21, 6/9/21, 6/8/21 and 6/2/21. Level of Harm - Minimal harm or potential for actual harm An interview was conducted with the Director of Nursing (DON) and Staff C, LPN MDS Coordinator on 6/17/21 at 12:02 p.m. Staff C reported that the resident refused the use of the leg brace, but staff put it on her and remove it if the resident requests. She reported that the resident would ask for it to be removed sometimes right away after application. She reported that this information was documented in the resident's record by nursing. Residents Affected - Few In an interview on 6/17/21 at 4:23 p.m., Staff C, LPN MDS Coordinator revealed that the team care planned Resident #13 for the use of the palm guard and confirmed that there was a recommendation for the use of the palm guard. She reported that it would appear that this recommendation was missed. Interview on 6/17/21 at 4:46 p.m. with the Director of Therapy Services revealed that the day after discharge from therapy the resident was presented at the morning meeting with the recommendations to use the palm grip and a restorative plan was set up for her. Interview on 6/17/21 at 5:09 p.m. with the Restorative Manger with the Registered Nurse Quality Management Specialist present revealed that some restorative services were missed in the month of March. She reported that the previous DON was responsible to direct residents to nursing restorative care for follow-through by the restorative team. She reported that she was not sure if Resident #13 was ever placed on the restorative case load. The Registered Nurse Quality Management Specialist reported that if a resident was discharged from therapy and recommended for restorative services, then those services would start a week later. A policy related to restorative care was requested of the facility, but was not provided. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105986 If continuation sheet Page 7 of 12 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 105986 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/17/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare Zephyrhills 7350 Dairy Rd Zephyrhills, FL 33540 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 0694 Provide for the safe, appropriate administration of IV fluids 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 observations, record reviews, and interviews the facility failed to maintain professional standards of practice related to a vascular catheter for one (#6) of one resident reviewed. Residents Affected - Few Findings included: The admission Record indicated Resident #6 was admitted on [DATE] and 5/22/20. The record included diagnoses not limited to acute diastolic (congestive) heart failure and acute respiratory failure unspecified whether with hypoxia or hypercapnia. An observation was conducted on 6/16/21 at 8:38 a.m., of Resident #6 as Staff E, Licensed Practical Nurse (LPN) performed wound care for a sacral pressure ulcer. The observation revealed an upper left extremity midline catheter with an intact dressing. At 9:05 a.m., Staff E confirmed that the midline dressing was dated 6/7/21, nine days prior to the observation. At 9:08 a.m., Staff E reported that the midline dressing should be changed every 7 days by the floor nurse. The staff member stated the floor nurses were responsible for midline dressing changes. A review of the Order Summary Report, active as of 6/16/21, did not include maintenance orders (flushes or dressing changes) related to the midline catheter. The June 2021 Medication Administration Record (MAR) indicated that Resident #6 was administered Ceftriaxone Sodium Solution Reconstituted 1 gram (gm) - Use 1 gm intravenously every 24 hours for wound infection for 14 days, started 6/1/20. A review of the June 2021 Treatment Administration Record (TAR) indicated it did not include an order for a midline dressing change. A nursing note, dated 6/1/21, indicated that Resident #6 had a midline placed in his upper left arm. A nursing note, dated 6/7/21 and written by Staff K, Licensed Practical Nurse (LPN), indicated that the Intravenous (IV) dressing was changed today without complications. Resident #6's care plan identified that he had a diagnosis of wound infection and was receiving IV antibiotic which put the resident at risk for complications. The interventions did not include the maintenance of a midline catheter. The policy, Midline Catheter Dressing Change, dated 1/15/04 and revised 10/1/05, 3/19/07, 8/15/08, and 7/1/12, indicated that the nurse was responsible and accountable for obtaining and maintaining competence with infusion therapy within his or her scope of practice. The guidance instructed that a sterile dressing change using transparent dressings is performed: - 24 hours post-insertion or upon admission; - at least weekly; - if the integrity of the dressing has been compromised (wet, loose, or soiled). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105986 If continuation sheet Page 8 of 12 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 105986 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/17/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare Zephyrhills 7350 Dairy Rd Zephyrhills, FL 33540 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 that the medication error rate was less than 5.00%. Twenty-six medication administration opportunities were observed and six (6) errors were identified for five (#33, #87, #56, #57, and #75) of six residents observed. These errors constituted at 23.08% medication error rate. Residents Affected - Few Findings included: 1. On 6/14/21 at 11:56 a.m., an observation of medication administration with Staff L, Licensed Practical Nurse (LPN) was conducted with Resident #33. Staff A was observed administering the following medications: - Ondansetron disintegrating 4 milligram (mg) tab orally - Oxycodone 5 mg Immediate Release (IR) tab orally - Diazepam 5 mg tab orally - Lutein (2) 20 mg softgels orally A review of the Medication Administration Record (MAR) for Resident #33 revealed the following physician order which had been administered in error: - Lutein 20 mg capsule - Give one (1) capsule by mouth one time a day related to unspecified Vitamin Deficiency. 2. On 6/15/21 at 9:52 a.m., an observation of medication administration with Staff M, Registered Nurse (RN) was conducted with Resident #87. Staff M was observed administering the following medications: - Aspirin Enteric Coated 81 mg tab orally - Senna (2) 8.6 mg tabs orally - Cyproheptadine 4 mg tab orally - Losartan-Hydrochlorothiazide 50-12.5 mg tab orally - Clopidogrel 75 mg tab orally - Carvedilol 3.125 mg tab orally A review of the Medication Administration Record (MAR) for Resident #87 revealed the following medications were not administered per the physician order: - Senna-Tabs (Sennosides) - Give one (1) tablet by mouth two times a day for constipation. - Debrox Solution 6.5% - Instill 10 drops in both ears for Cerument impaction for 4 days. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105986 If continuation sheet Page 9 of 12 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 105986 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/17/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare Zephyrhills 7350 Dairy Rd Zephyrhills, FL 33540 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 During the dispensing to the medication Staff M confirmed that she had dispensed two (2) tablets of Senna and immediately following the administration, Staff M signed that the Debrox ear drops were unavailable. She stated that the ear drops were a new order but thought the facility stocked them. 3. On 6/15/21 at 10:18 a.m., an observation of medication administration with Staff M, RN, was conducted with Resident #56. Staff M stated, at 9:50 a.m., that she had previously dispensed Resident #56's medication and that the resident had told her to come back. The staff member removed a medication (med) cup and Xiidra eye drops from the med cart and entered the residents room then retrieved the inhalers from atop the dresser. The following medications were observed being administered: - Xiidra 5% - instilled 2 drops in each eye. - Breo Ellipta inhalation - one inhale. - Combivent inhalation - one inhale. - Spiriva inhalation - one inhale. A review of the Medication Administration Record (MAR) for Resident #56 revealed the following medication was not administered per the physician order: - Spiriva Respimat Aerosol Solution 2.5 microgram/act (mcg/act)- 2 puffs inhale one time day for Chronic Obstructive Pulmonary Disease/Shortness of Breath (COPD/SOB). 4. On 6/16/21 at 8:02 a.m., an observation of medication administration with Staff K, LPN, was conducted with Resident #57. Staff K was observed administering the following medications: - Sodium Cl 1 gram (gm) tab orally - Multivitamin tab orally - Buspirone 15 mg tab orally - Albuterol Sulfate 2 mg tab orally - Divalproex Sodium Delayed Release 125 mg tab orally - Amlodipine 5 mg tab orally - Famotidine 20 mg tab orally - GlycoLax Powder 17 gm orally A review of the Medication Administration Record (MAR) for Resident #87 revealed the following medications were not administered per the physician order: - Multivitamin with minerals - Give one (1) tablet by mouth one time a day for wound healing. 5. On 6/16/21 at 11:32 a.m., an observation of medication administration with Staff K, LPN, was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105986 If continuation sheet Page 10 of 12 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 105986 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/17/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare Zephyrhills 7350 Dairy Rd Zephyrhills, FL 33540 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 conducted with Resident #75. Staff K was observed obtaining a blood glucose level of 391 from the resident. The staff member returned to the medication cart and extracted the following: - Novolog 100 unit/milliliter Flexpen. Staff K took a couple of alcohol pads, an Insulin pen needle, and the pen to Resident #75's bedside. She cleaned the residents abdomen with a alcohol pad, placed the needle on the Flexpen, dialed the pen to 10 units (per sliding scale) and injected the insulin into Resident #75. After returning to the medication cart, Staff K confirmed she had not primed the Novolog Flexpen with two units, she stated she must have been nervous. According to the manufacturer users should give an airshot before each injection. The medication insert indicated that before each injection small amounts of air may collect in the cartridge during normal use. To avoid injecting air and to ensure proper dosing. The information instructed users to turn the dose selector to select 2 units, hold the Novolog Flexpen with the needle pointing up, tap the cartridge gently a few times to make any air bubbles collect at the top, and push the push-button all the was to the selector reads 0. This information can be found at https://www.novo-pi.com/novolog.pdf. The Interim Director of Nursing stated, on 6/17/21 at 1:51 p.m., that she expected staff to administer medications per physician orders. An interview was conducted, on 6/17/21 at 3:54 p.m., with the Consulting Pharmacist. The Consultant stated there would be no adverse reactions from not priming the insulin pens. After the discussion of findings she stated the pharmacy does have a nurse that goes into facility's to educate on Medication Administration and indicated that it sounded like that may be something that should happen. The policy, General Dose Preparation and Medication Administration, effective 12/1/07 and revised 5/1/10 and 1/1/13, indicated that Facility staff should also refer to facility policy regarding medication administration and should comply with applicable law and the State Operations Manual when administering medications. The policy identified that the 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. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105986 If continuation sheet Page 11 of 12 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 105986 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/17/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare Zephyrhills 7350 Dairy Rd Zephyrhills, FL 33540 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation and interview, the facility failed to maintain the dish machine at the required water temperature for rinsing (180 degrees Fahrenheit) per the manufacturer's recommendations in one of one kitchen. Findings included: On 06/14/21 at 9:45 a.m., an initial tour of the kitchen was conducted with the Certified Dietary Manager (CDM). The metal plate attached to the dish machine indicated that the minimum wash temperature was 150 degrees Fahrenheit, and the minimum rinse temperature was 180 degrees Fahrenheit. Two staff members were observed in the dish machine area using the machine at this time. The digital temperature on the dish machine reflected 147 degrees Fahrenheit for wash and 169 degrees Fahrenheit for rinse after the first cycle. The digital temperature on the dish machine reflected 148 degrees Fahrenheit for wash and 172 degrees Fahrenheit for rinse on the second cycle. The digital temperature on the dish machine reflected 152 degrees Fahrenheit for wash and 175 degrees for rinse on the third cycle. The digital temperature on the dish machine reflected 154 degrees Fahrenheit for wash and 169 degrees Fahrenheit for rinse after the fourth cycle. The CDM stated that she would contact maintenance to look at the machine. On 06/15/21 at 9:05 a.m., the CDM reported that the dish machine was fixed. She reported that the booster on the machine needed to be adjusted. The CDM reported that the temperature should be at least 150 degrees Fahrenheit for wash and 180 degrees Fahrenheit for rinse. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105986 If continuation sheet Page 12 of 12

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Citations

4 citations recorded^*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

0694GeneralS&S Dpotential for harm
F694 - Parenteral Fluids
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
0759GeneralS&S Dpotential for harm
F759 - Medication Errors
Ensure medication error rates are not 5 percent or greater.
0812GeneralS&S Epotential for harm
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
0688GeneralS&S Dpotential for harm
F688 - Mobility
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

FAQ · About this visit

Common questions about this visit

What happened during the June 17, 2021 survey of SOLARIS HEALTHCARE ZEPHYRHILLS?

This was a inspection survey of SOLARIS HEALTHCARE ZEPHYRHILLS on June 17, 2021. The surveyor cited 4 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at SOLARIS HEALTHCARE ZEPHYRHILLS on June 17, 2021?

Yes, 4 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide for the safe, appropriate administration of IV fluids for a resident when needed."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

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Data from CMS Care Compare public records. Dataset last refreshed June 22, 2026. If you believe any information is inaccurate, report it here.

Health inspection·June 17, 2021