Health inspection·April 6, 2023

F 0641 Level of Harm - Minimal harm or potential for actual harm 2. Resident #101 was admitted to the facility after hospitalization for a cerebral hemorrhage. Resident #101's past medical history was significant for hypertension, prostate cancer, and traumatic brain injury after fall at home. Resident #101 was discharged to an Assisted Living Facility (ALF) on 3/9/23. Review of Resident #101's medical record revealed: Residents Affected - Some A Social Services' discharge summary written on 3/9/23 at 10:33 a.m., read as follows, Resident discharged home to [name of facility] ALF on 3/9/23 with all meds. [name of company] home health to follow with recommended Physical Therapy, Occupational Therapy. Resident informed of discharge process. Resident has been informed of pickup time between 11-1 pm, pickup arrangements scheduled and confirmed with residents accepting facility. Review of Resident #101's Minimum Data Set (MDS) Section A showed resident was discharged on Wednesday March 22, 2023 at 11:14:28 a.m. to an acute care hospital. An interview was conducted with Staff A, Registered Nurse and Staff B, Licensed Practical Nurse from the facility MDS office. Staff A and B reviewed Section A of the MDS and the resident's discharge summary. Staff A and B said discharge to hospital was a typo and they would correct it. 3. A review of the admission Record indicated Resident #24 was admitted on [DATE] with diagnoses which included but not limited to right hand contracture, left hand contracture, abnormal weight loss, and unspecified protein-calorie malnutrition. An observation on 4/4/23 at 9:59 a.m., identified Resident #24 lying in bed with eyes closed and bilateral hands in an curled position held above the blankets. The observation did not reveal a splint, brace or soft device on either hand. The review of the recent comprehensive assessment, Significant Change in Status which was dated 2/9/23, included active diagnoses of arthritis and right hand contracture. A review of section G indicated the resident had no Functional Limitation in Range of Motion impairment of the upper extremity which included shoulder, elbow, wrist, and/or hand. A continued review of the skin condition portion of the comprehensive assessment indicated the determination of pressure ulcer/injury risk was done by clinical assessment and did not identify that the resident had a pressure ulcer/injury, a scar over bony prominence, or a non-removable dressing/device. The determination instructed assessors to Check all that apply. The skin assessment indicated the resident had one unstageable pressure ulcer due to coverage of wound bed by slough and/or eschar. The care plan for Resident #24 identified the resident had limited physical mobility related to (r/t) Alzheimer's, contractures, (and) weakness. The interventions indicated staff were to monitor/document/report as needed any signs/symptoms of immobility, contractures forming or worsening, thrombus formation, skin breakdown, (and) fall related injury that was initiated on 6/18/21. On 4/5/23 at 12:38 p.m., the Assistant Director of Nursing (ADON) reported to overseeing the restorative program. The ADON stated that Resident #24 had refused splints (to bilateral hands) and also rolled washcloths. The staff member indicated that the resident's family was more for quality of life versus quantity. An interview was conducted on 4/5/23 at 1:12 p.m., with Staff A and Staff B regarding Resident #24. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105986 If continuation sheet Page 2 of 23 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 04/06/2023 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 0641 Level of Harm - Minimal harm or potential for actual harm Staff B stated she did not know whether the resident had contractures and would have to look at the clinical record. Staff B reviewed the diagnoses list of the resident and confirmed the resident had right and left hand contractures. Staff B reviewed the Significant Change in Status assessment, dated 2/9/23, and confirmed the assessment did not identify that the resident had an upper extremity impairment. Staff B stated, was a mistake and thank you for bringing to our attention. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105986 If continuation sheet Page 3 of 23 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 04/06/2023 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to confirm the accuracy of a Pre-admission Screening and Resident Review (PASRR) and to correct the document for one (Resident #17) of one resident sampled when mental illness or suspected mental illness diagnoses were identified and added to the resident's medical diagnoses . Findings included: The admission Record for Resident #17 identified the resident was originally admitted on [DATE] and readmitted on [DATE]. The record included diagnoses not limited to generalized anxiety disorder, unspecified mood (affective) disorder, delusional disorders, dementia in other diseases classified elsewhere mild with other behavioral disturbance, and moderate recurrent major depressive disorder. The admission record indicated the resident's diagnosis of dementia was present on admission with an onset date of 10/1/22 and the diagnoses of anxiety disorder, mood disorder, delusional disorders and major depressive disorder was present on admission with the onset date of 1/25/22. On 4/3/23 at 2:28 p.m., Resident #17 was interviewed while lying in bed. The resident related that an aide at the facility had been rough during care. The resident reported informing the facility however did not know who was told or when it was reported. During an interview on 8:56 a.m. on 4/6/23, Resident #17 reported of not remembering speaking with this writer. I won't remember a hour from now. The PASRR for Resident #17, dated 9/28/18, identified the form was completed by a case manager at an acute care facility and no diagnosis or suspicion of Serious Mental Illness (SEMI) or Intellectual Disability (ID) indicated. Level II PASRR evaluation not required. The PASRR section IA: did not identify that the resident was diagnosed with any mental illness (MI) or suspected MI that included: anxiety disorder, bipolar disorder, depressive disorder, dissociate disorder, panic disorder, personality disorder, psychotic disorder, schizoaffective disorder, schizophrenia, somatic symptom disorder, substance abuse or other condition. Resident #17's care plan identified that the resident had depression which was initiated on 1/12/21, had a diagnosis of delusional disorder with statements that the pictures of family on dresser were not actually family which was initiated on 11/10/22, was at risk for further behavior problems related to diagnoses of depression and altered mental health which was initiated on 1/12/21, and used psychotropic medications related to diagnoses of depression, insomnia, anxiety, mood disorder, and delusional disorder which was initiated on 1/12/21. The Psychiatric Diagnostic Evaluation, dated 1/11/22, indicated Resident #17 was being seen for intermittent anxiety, admitted to feeling anxious at sometimes, and reported doing much better with the last medication change. The evaluation identified the resident's limitations included cognitive impairment, physically frail, and was dependent with activities of daily living. The Psychiatric Diagnostic Evaluation, date of service 1/25/22, indicated Resident #17 remained having anxiety symptoms and sometimes struggles with mood. The evaluation identified that the resident received 150 milligram (mg) of the antidepressant Trazodone every bedtime and the 450 mg of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105986 If continuation sheet Page 4 of 23 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 04/06/2023 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few antidepressant Bupropion daily and did not want changes to the medications at that time. The note indicated that the resident was previously seen by psychiatry. The Psychiatric Diagnostic Evaluation, date of service 2/22/22, indicated that Resident #17 described continuing having anxiety symptoms and struggling with (resident) mood. The note identified that the resident had fought depression and had some low points. The Quarterly Minimum Data Set, dated [DATE], identified a Brief Interview of Mental Status (BIMS) score of 7 out of 15, which indicated severe cognitive impairment. The resident's mood interview identified that the resident felt little interest or pleasure in doing things and had trouble falling or staying asleep or sleeping too much nearly every day, felt feeling down, depressed or hopeless for 7-11 days, and felt bad about self or felt like a failure or having let family down for several day (2-6 days). The assessment indicated that the resident did not exhibit any behaviors or potential indicator of psychosis such as hallucinations and/or delusions. The Nursing Home Administrator stated, on 4/4/23 at 4:18 p.m., that the facility did not have a policy regarding PASRR's. On 4/6/23 at 10:24 a.m., the Social Service Director (SSD) said she was responsible for PASARR's and revised them if a diagnosis was missing or there was mental health issue or intellectual disability. The SSD reviewed Resident #17's diagnoses and confirmed that the resident had diagnoses that included anxiety, unspecified mood disorder, and major depressive disorder. The SSD confirmed that the PASRR from 8/23/19 did not have the diagnoses. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105986 If continuation sheet Page 5 of 23 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 04/06/2023 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to develop a Care Plan related to pain for one (Resident #46) of one residents reviewed for Hospice services. Findings included: A review of Resident #46's record revealed the resident was admitted to the facility on [DATE] and had diagnoses that included Severe Protein Calorie Malnutrition, Hydrocephalus, Altered Mental Status, and Chronic Obstructive Pulmonary Disease. A review of the resident's current physician orders revealed Resident is a member of the Bronze A team Hospice, Dx E43.0 unspecified protein-calorie malnutrition . with an order date of 3/10/23 A continued review of the resident's current physician orders revealed the resident had a current order for Morphine Sulfate (Concentrate) Oral Solution 100 MG/5 ML, Give 0.25 ml by mouth every 4 hours as needed for pain or dyspnea *Non acute pain*, dated 3/28/23. A review of the resident's Medication Administration Record (MAR) revealed Resident #46 had a pain level of 5 on 4/3/23 at 1654 (4:54 p.m.) and 4/5/23 1104 (11:04 a.m.), and received Morphine 0.25 ml. A review of the resident's record revealed there was no care plan in place to address the resident's pain. In an interview on 4/04/23 at 2:55 p.m., the Minimum Data Set (MDS) Director, Licensed Practical Nurse, (LPN) and the MDS Coordinator, Registered Nurse (RN) revealed they worked together to complete MDS assessments and ensured appropriate care plans were developed and maintained for each resident. The MDS Director and the MDS Coordinator reviewed Resident #46's record and was unable to locate a current care plan to address pain. The MDS Director reported, I can't say why there is no care plan for pain. She reported she did not know why there was no hospice care plan. Further review of the record revealed the MDS Coordinator had developed a care plan for Resident #46 to address pain on 3/7/23 and resolved the care plan on the same day. The MDS Director reported there was no process in place to review and/or monitor the resident's care plan for accuracy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105986 If continuation sheet Page 6 of 23 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 04/06/2023 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to ensure that one (Resident #74) of nine, facility-reported urinary catheters, were stored in a sanitary manner related to the resident's urinary drainage bag being observed on the floor on multiple occasions. Findings included: A review of the admission Record for Resident #74 indicated the resident was admitted on [DATE] and 10/14/22. The record included diagnoses not limited to unspecified retention of urine, presence of urogenital implants, unspecified obstructive and reflux Uropathy, and benign prostatic hyperplasia without lower urinary tract symptoms. An observation was made on 4/4/23 at 9:41 a.m. of Resident #74 lying in bed with a urinary catheter bag on the floor next to the bed. The resident stated the bag fell on the floor as it was not the normal bag. On 4/5/23 at 10:28 a.m., Resident #74 was observed with his eyes closed lying in bed with the urinary drainage bag lying on the floor next to the bed. During the observation of medication administration with Staff J, agency Licensed Practical Nurse (LPN), Resident #74 was observed lying in bed, alert and oriented, with a urinary drainage bag on the floor. Staff J administered medications to the resident as the bag lay on the floor under the over-the-bed table. Staff J did not address its placement or attempt to educate the resident on the proper management of the bag. On 4/5/23 at 10:29 a.m., Staff R, Certified Nursing Assistant (CNA) observed the urinary drainage bag on the floor. Staff R stated Resident #74 was independent and staff helped the resident with showers and served the meal. Staff R confirmed the drainage bag should be hung up and said it was what the resident did and the resident did not hang it up after using the bathroom. Photographic evidence was obtained. A review of Resident #74's quarterly Minimum Data Set (MDS), dated [DATE], identified a Brief Interview of Mental Status (BIMS) score of 14 out of 15, which indicated intact cognitive. The data set revealed the residents' urinary status was not rated due to the resident had a catheter, urinary ostomy or no urine output for the entire 7 days (of the assessment period). The assessment identified that the resident required limited assistance from one-person with toileting. The review of Resident #74's care plan identified the following problems associated with the residents indwelling urinary catheter: - Had an indwelling catheter related to (r/t) obstructive Uropathy. The interventions included: resident had an indwelling catheter, position catheter bag and tubing below the level of the bladder, ensure tubing is anchored above knee, and ensure tubing and bag are not touching the floor. - Resident displays behaviors. Carries indwelling catheter bag above level of bladder. Refuses to use leg bag for catheter. The interventions included to discourage resident from carrying Foley bag above level of bladder, explain risks of continued behavior, and praise all efforts at compliance. Encourage use of privacy bag. - Risk for infection r/t indwelling catheter. The interventions included Manage indwelling (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105986 If continuation sheet Page 7 of 23 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 04/06/2023 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 0690 catheters to minimize risk of infection. Level of Harm - Minimal harm or potential for actual harm - Resident has an Activities of Daily Living (ADL) self-care performance deficit r/t deconditioning, weakness, and impaired mobility status post (s/p) hospital (hosp.) stay diagnosis (dx) metabolic encephalopathy, acute kidney infection (AKI), and urinary tract infection (UTI). 12/29/22 readmit dx congestive heart failure (CHF) exacerbation, pneumonia, and UTI. The interventions identified that the resident required extensive assistance from one staff member for toileting. Residents Affected - Few - Resident had a self-care deficit related to toileting. The intervention identified that the resident used the bathroom for toileting. - Knowledge Deficit. The interventions did not include amongst other listed resident/representative educations that staff were to educate on the placement of the urinary drainage bag. A review of the Resident #74's care plan with interventions identified that the resident chose to leave the indwelling catheter drainage bag on the floor. On 4/6/23 at 9:27 a.m., the Director of Nursing (DON) stated that a catheter drainage bag should be kept below the waist and not touching the ground. The DON reported that Resident #74 was unique. On 4/6/23 at 10:51 a.m., the Infection Preventionist stated education was ongoing with Resident #74 regarding keeping urine drainage bag off of floor. The review of facility policy - Urinary Indwelling Catheter, number 250.3590, identified that Interventions should be implemented to minimize the risks associated with indwelling catheter use may include: Avoid drainage bag/tubing from coming in contact with floor. (if contact made with floor cleanse with disinfecting wipes). The nursing assistant education, provided by the facility, identified that Catheters create a high risk for Urinary Tract Infections (UTIs). A catheter associated urinary tract infection (CAUTI) occurs when microbes enter the urinary tract through the catheter and cause an infection. Microbes travel up the catheter into the bladder and kidneys. CAUTIs can cause severe illness and death. Proper catheter care can reduce the risk of a CAUTI. The education instructed nursing assistants to Do not let the drainage bag touch or rest of the floor. This can contaminate the system. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105986 If continuation sheet Page 8 of 23 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 04/06/2023 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 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm Based on record review, interviews, and policy review, the facility failed to ensure pain management services were provided per physician orders for one (Resident #35) of three residents reviewed for pain. Residents Affected - Few Findings included: During an interview on 04/03/23 at 12:52 p.m., Resident #35 stated she had frequent pain even with pain medication. A review of Resident #35's medical record showed a physician order dated 02/22/23, for Acetaminophen Tablet 325 mg- Give 2 tablet by mouth every 6 hours as needed for Pain - Mild (1-4) A second physician order dated 02/22/23 stated, Hydrocodone Acetaminophen Oral 10-325 mg- Give 1 tablet by mouth every 6 hours as needed for Pain-Moderate (5-7). The comprehensive care plan showed a focus for acute/chronic pain, a goal for Resident #35 to satisfyingly report pain control, and an intervention of a pain management treatment plan, dated 02/22/2023. A review of Resident #35's medical record showed the Medication Administration Record (MAR) for March 2023. The March 2023 MAR showed the following discrepancies between Resident #35's disclosed pain level and the pain medication to be administered per physician's order: The physician order of Hydrocodone Acetaminophen Oral 10-325 mg- Give 1 tablet by mouth every six (6) hours as needed for Pain-Moderate (5-7) was given outside the physician ordered parameters on the following dates: -03/01/23- pain level of 3 -02/03/23- pain level of 4 -03/05/23- pain level of 4 -03/09/23- pain level of 3 -03/14/23- pain level of 2 -03/15/23- pain level of 3 -03/20/23- pain level of 3 -03/28/23- pain level of 3 -03/30/34- pain level of 4 The physician order of Acetaminophen Tablet 325 mg- Give 2 tablet by mouth every 6 hours as needed for Pain - Mild (1-4) was given outside the physician ordered parameters on the following date: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105986 If continuation sheet Page 9 of 23 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 04/06/2023 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 0697 - 03/20/23- pain level 6 Level of Harm - Minimal harm or potential for actual harm During an interview on 04/05/23 at 3:39 p.m., the Director of Nursing (DON) confirmed the pain medications were not given per physician order and outside the parameters. Residents Affected - Few A review of the facility's policy titled, Pain Management Program reviewed date 10/24/22, stated, Medication will be administered based on evaluated level of pain and by MD order. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105986 If continuation sheet Page 10 of 23 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 04/06/2023 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure medications were administered appropriately and within the parameters ordered by the physician for two (Residents #2 and #57) of five residents sampled for medication regimen review. Residents Affected - Few Findings included: 1. The admission Record for Resident #2 indicated the resident was admitted on [DATE] and 10/25/22. The record included diagnoses not limited to metabolic encephalopathy, essential (primary) hypertension, and Type 2 Diabetes mellitus without complications. The March 2023 Medication Administration Record (MAR) identified an order for Midodrine 5 milligram (mg) - Give 1 tablet by mouth three times a day for blood pressure support. Give for systolic blood pressure (sbp) less than 100. The March MAR indicated staff administered Midodrine twenty-one times when Resident #2's systolic blood pressure was greater than 100 and twice for a systolic blood pressure that was not documented out of 90 opportunities. The April MAR indicated staff had administered Midodrine three times when Resident #2's systolic blood pressure was greater than 100 and once for an undocumented blood pressure out of 16 opportunities. The care plan indicated Resident #2 had an ineffective peripheral tissue perfusion and a risk for decreased cardiac output which instructed staff to evaluate blood pressure. On 4/6/23 at 12:41 p.m., the Director of Nursing reviewed the March MAR and confirmed that Midodrine had been given out of parameters. The Regional Director of Nursing stated the order was written backwards and it (the medication) should be as needed. 2. The admission Record for Resident #57 identified the resident was admitted on [DATE], with diagnoses which included but not limited to lumbar region radiculopathy, unspecified low back pain, thoracic region spinal stenosis, lumbar region fusion of spine, and cervical region fusion of spine. The Order Summary Report for Resident #57 included physician orders for: - Acetaminophen tablet 325 milligram (mg) - Give 2 tablet by mouth every 6 hours as needed for pain - mild (1-4). - Norco tablet 5-325 mg (Hydrocodone-Acetaminophen) - Give 1 tablet by mouth every 12 hours as needed for pain - moderate (5-7). A review of the March Medication Administration Record (MAR) identified that Resident #57 was not administered Acetaminophen for mild pain of 1-4 rating. The MAR indicated that the resident had been administered Norco twice for a pain level of 3 and twice for a pain level of 2 out of 10 administrations of the medication. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105986 If continuation sheet Page 11 of 23 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 04/06/2023 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 0757 Level of Harm - Minimal harm or potential for actual harm The review of the April Mar for Resident #57 identified that the resident had not received any pain medication as of 4/6/23. During an interview on 4/5/23 at 3:45 p.m. the Director of Nursing reviewed Resident #57's record and confirmed that the resident was administered Norco outside of parameters. Residents Affected - Few The policy - General Dose Preparation and Medication Administration, effective 12/1/07 and revised on 5/1/10, 1/1/13, and 1/1/22, indicated This policy 6.0 sets forth the procedures relating to general dose preparation and medication administration. 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 procedure indicated that Facility staff should 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, as set forth in the facility's medication administration schedule. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105986 If continuation sheet Page 12 of 23 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 04/06/2023 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview the facility failed to ensure that the medication error rate was less than 5.00%. Thirty-two medication administration opportunities were observed, and two errors were identified for two (Residents #86 and #74) of four residents observed. These errors constituted a 6.25% medication error rate. Residents Affected - Few Findings included: 1. An observation of medication administration was conducted on 4/5/23 at 8:09 a.m. for Resident #86 with Staff I, Licensed Practical Nurse (LPN). The staff member dispensed the following medications: - Vitamin C 500 milligram (mg) tablet - Fluticasone propionate nasal spray 50 microgram (mcg) - Multivitamin tablet - Oxybutynin Extended Release 5 mg tablet - Formoterol 20 mcg/2 milliliter (mL) vial - Gabapentin 100 mg - 3 capsules = 300 mg (removed from Emergency Drug Kit (EDK)) - Aspirin Enteric-coated 81 mg tablet Staff I confirmed 7 tablets had been dispensed prior to entering the resident room. The resident refused an ordered Lidocaine patch and the staff member returned to the medication cart and dispensed: - Tramadol Extended Release 100 mg tablet Staff I notified the Nurse Practitioner that Resident #86's Fenofibrate and Midodrine was not available. Staff I called pharmacy regarding the delivery of the medications and reported Gabapentin and Midodrine were being delivered today, 4/5/23, and the Fenofibrate order had to be discontinued and reordered due to insurance purposes. On 4/5/23 at 8:52 a.m., Staff I returned to Resident #86's room with the medications and the resident refused Gabapentin. The staff member placed 3 capsules of Gabapentin into a drug dissolving liquid located in the medication cart, returned to the resident room, and administered the medications. A review of Resident #86's admission Record identified that the resident was originally admitted on [DATE] and readmitted on [DATE]. The record included diagnoses not limited to subsequent encounter for fracture with routine healing - other fracture of T11-T12 vertebra, acute and chronic respiratory failure with hypoxia, and Type 2 diabetes mellitus without complications. The review of Resident #86's April Medication Administration Record (MAR) identified a physician order for the following medication: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105986 If continuation sheet Page 13 of 23 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 04/06/2023 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 - Oxybutynin Chloride ER oral tablet Extended Release 24 hour 5 mg (Oxybutynin Chloride) - Give 10 mg by mouth one time a day for bladder spasms. The observation of Resident #86's medication administration identified that one 5 mg tablet of Oxybutynin was dispensed and administered. Residents Affected - Few 2. An observation of medication administration was conducted at 4:19 p.m. on 4/5/23 with Staff J, LPN for Resident #74. Staff J dispensed the following medications: - Docusate 100 mg softgel capsule - Carvedilol 12.5 mg tablet - Warfarin 10 mg tablet Staff J obtained the residents' glucometer from a clear plastic bag, a glucometer test strip, and a alcohol pad then entered the resident's room. Resident #74 poked own finger with lancet and the Staff J announced a blood glucose level of 193. The resident reported oh 2 units. Staff J returned to the medication cart, dispensed Resident #74's requested Hydrocodone/Acetaminophen 5/325 mg tablet and placed a needle on the Insulin Lispro insulin pen. The staff member confirmed dispensing 4 tablets. After returning to the resident room, Staff J dialed the insulin pen to 1 unit, identifying the process of priming the insulin pen, then dialed the dose selector to 5 units and injected the 5 units into the resident's upper left arm. Staff J administered the oral medication and obtained a pain level of 7 from the resident. A review of Resident #74's April MAR on 4/6/23 at approximately 8:45 a.m., indicated the following physician order: - Humalog Kwikpen solution Pen-injector 100 unit/milliliter (mL) (Insulin Lispro). Inject as per sliding scale: If 150-199 = 1 unit. Call MD if <70, after glucose gel and recheck in 15 minutes; 200-249 = 3 units; 250-299 = 5 units; 300-349 = 7 units; 350-399 = 9 units; 400-449 = 10 units; 450+ = 10 units and notify MD. Subcutaneously before meals and at bedtime for Diabetes Mellitus (DM). Prime pen with 2 units air shot prior to insulin administration. On 4/6/23 at 9:00 a.m., a review was completed with Staff S, LPN of Resident #74's recent glucometer readings. The glucometer identified a blood glucose reading of 193 on 4/5/23. The staff member confirmed the resident did not have a level of 293 as Staff J had documented. Staff S confirmed recent readings of 153 and 101 completed after the reading of 193. A review of the April MAR indicated Resident #74 had a blood glucose level of 101 at 6:30 a.m. on 4/6/23 and had a blood glucose level of 153 at 9:00 p.m. on 4/5/23. On 4/6/23 at 9:21 a.m., the Director of Nursing and Regional Director of Nursing were notified of the medication error rate. The policy - General Dose Preparation and Medication Administration, effective 12/1/07 and revised on 5/1/10, 1/1/13, and 1/1/22, indicated This policy 6.0 sets forth the procedures relating to general dose preparation and medication administration. Facility staff should also refer to Facility (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105986 If continuation sheet Page 14 of 23 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 04/06/2023 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 policy regarding medication administration and should comply with Applicable Law and the State Operations Manual when administering medications. The procedure indicated that Facility staff should 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, as set forth in the facility's medication administration schedule. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105986 If continuation sheet Page 15 of 23 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 04/06/2023 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, interview and record review, the facility failed to maintain the kitchen in a clean and sanitary manner and ensure that kitchen equipment was functioning appropriately related to a broken walk-in/reach-in refrigerator and soiled steamer oven. Findings included: On 4/04/23 at 10:54 a.m. a comprehensive tour of the kitchen was conducted. The tour, with the Certified Dietary Manager (CDM) present, revealed the Walk-in/reach-in refrigerator had condensation around the door, which was also noted to be sealed with silver tape. An interview with the CDM at this time revealed this had been an on-going issue. Several vendors came in but were unable to seal and/or fix the door appropriately so the door was not used. She reported she did not know when the last time the vendor was in to fix the reach-in door to the refrigerator. (Photographic Evidence obtained) On 4/04/23 at 10:58 a.m., both sides of the steamer oven were noted to be soiled with dried up food and grease. An interview with the CDM at this time revealed she would get it cleaned. She reported the task was usually completed by the maintenance department, but at this time, the facility did not have a Maintenance Director. A interview on 4/04/23 at 11:24 a.m., with Staff H, Plant Service Director for a sister facility, revealed he called a vendor and they would come out to service the walk-in/reach-in refrigerator. He reported he was not aware of what had been done in the past to fix the doors of the walk-in/reach-in refrigerator. On 4/04/23 at 11:45 a.m., the CDM provided the cleaning checklist for the week of 4/1/23. The checklist did not allow for documentation that the sides of the equipment were checked and/or cleaned. The checklist did not reflect documentation of the the condensation and presence of silver tape on the walk-in/reach-in refrigerator. An interview on 4/04/23 at 2:20 p.m., with the Administrator (NHA) and Staff H revealed the vendor was in the building and working on walk-in/reach-in refrigerator. Staff H reported that this could be an infection control issue because the tape was not cleanable. A request was made of the facility to provide all vendor invoices related to the repair and or service to the walk-in/reach-in refrigerator, but none was provided. Review of the facility policy titled Dietary Sanitation with an effective date of 01/01/2007 and a review date of 11/20/2017 revealed the following: Sub-heading Cleaning and Maintenance: 1. Cleaning schedules for all equipment areas of the dietary department are posted with completion of cleaning recorded by the staff member assigned. /the cleaning schedules are monitored by the dietary manager to verify they are being followed by staff. 5. The Dietary manager provides supervision and monitors proper procedures are being followed by department staff, in accordance with requirements. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105986 If continuation sheet Page 16 of 23 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 04/06/2023 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 FORM CMS-2567 (02/99) Previous Versions Obsolete Review of the facility policy titled Environment Maintenance with an effective date of 01/01/2007 and a review date of 12/19/2013 revealed the following: It is the policy of this facility to provide a safe, clean, well maintained facility and grounds. The facility will be maintained and equipped to provide a sanitary, orderly, and comfortable environment that protects the health and safety of residents, personnel and public. Event ID: Facility ID: 105986 If continuation sheet Page 17 of 23 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 04/06/2023 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 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure coordination of services by ensuring Hospice provided the facility with a Hospice plan of care and the Hospice plan of care was maintained in the facility for one (Resident #46) of one resident reviewed for Hospice services. Findings included: Review of Resident #46's record revealed the resident was admitted to the facility on [DATE] and had diagnoses that included Severe Protein Calorie Malnutrition, Hydrocephalus, Altered Mental Status, and Chronic Obstructive Pulmonary Disease. Review of the residents current physician orders revealed Resident is a member of the Bronze A team Hospice, Dx E43.0 unspecified protein-calorie malnutrition . with an order date of 3/10/23 Continued review of the resident's record revealed no presence of a care plan that should have been provided by Hospice. An interview on 4/04/23 at 2:55 p.m. with the Minimum Data Set (MDS) Director, Licensed Practical Nurse (LPN) and the MDS Coordinator, Registered Nurse (RN) revealed they worked together to complete MDS assessments and ensured appropriate care plans were developed and maintained for each resident. The MDS Director reported she did not know why there was no Hospice care plan. A phone interview on 4/04/23 at 3:13 p.m., with the Hospice LPN and the Critical Care Management Assistant (CCMA) revealed they had a Hospice plan of care and journal notes on file which were reprinted on 3/31/23 and should be in the facility. An interview on 4/04/23 at 3:32 p.m., with Staff D, LPN revealed she was an agency nurse and was familiar with the resident. She said she was not sure where the Hospice plan of care would be. She said it might be in the computer, but was unable to locate it. She said the Unit Manager would know where it was and left the area to find the Unit Manager. An interview on 4/04/23 at 3:39 p.m. with Staff E, LPN, Unit Manager, while she searched the nurses station, revealed she could not find the Hospice plan of care. She reported, they should have one here. She reported she would call hospice and obtain a Hospice plan of care. During an interview on 4/05/23 at 12:14 p.m. with Staff F, RN, Hospice Case Manager, and Staff G, RN Hospice Clinical Care Manager, Staff G reported the Hospice care plan was typically kept in the residents medical records, and one was also kept in a folder for the family. He reported the Hospice care plan should have been in the folder left by the Hospice admission department, per their hospice process. Staff F reported she was assigned to resident #46 and saw the resident a couple of times a week. She reported she did not check for presence of the Hospice care plan. Staff G reported the Hospice nurse should be checking for the presence of the Hospice care plan on the first of every month. Review of the Inpatient Services Agreement between the facility and the hospice vendor entered into on 2/12/2018 revealed the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105986 If continuation sheet Page 18 of 23 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 04/06/2023 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 0849 Under the heading 3. Responsibilities of Hospice sub-section (ii) Plan of Care Level of Harm - Minimal harm or potential for actual harm (b) Provision of Plan of Care to Facility. Upon a Hospice Patient's admission to Facility, Hospice shall furnish a copy of the current Plan Care. Hospice shall specify the Inpatient Services to be furnished by Facility to such Hospice Patient. Residents Affected - Few Review of the facility policy titled Hospice Program with an effective date of 12/22/21 revealed the following: 8. Coordinated care plans for residents receiving hospice services will include the most recent hospice plan of care as well as the care and services provided by our facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105986 If continuation sheet Page 19 of 23 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 04/06/2023 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to implement an effective Infection Control program related to staff knowledge of the facility's expectation in the cleansing of personal protective eye equipment and knowledge of the contact time necessary to kill microbes on reusable equipment on two of two units, and to adhere to posted precautions while administering an aerosol treatment for one (Resident #86) of one resident observed. Residents Affected - Some Findings included: 1. On 4/3/23 at 9:00 a.m., Staff L, Receptionist, said she was unsure of the COVID-19 status of the facility and the expected personal protective equipment to be worn was a surgical mask. Staff C, Infection Preventionist (IP), stated on 4/3/23 at 10:26 a.m., the county COVID-19 transmission rate was high so the Center of Disease Control and Prevention (CDC) recommendation was to wear a surgical mask and eye protection while in patient care areas. The interview was conducted next to the Dining Room for the [NAME], [NAME], and [NAME] units. A sign posted with education and screening forms in the facility lobby indicated that the county positivity rate requires all health care workers to wear a mask. The sign did not identify that eye protection was necessary. On 4/3/23 at 12:03 p.m., Staff T, Certified Nursing Assistant (CNA), reported washing goggles with soap and water. Staff T reported having a spray to clean goggles. Staff T stated the spray was in the soiled utility or the shower room. An observation of the soiled utility room for the [NAME]/[NAME]/[NAME] units did not contain a spray bottle. An observation was conducted with Staff T of a spray bottle in the shower room at the end of [NAME] hall. The bottle was labeled Peroxide Multi Surface Cleaner and Disinfectant and contained a bright yellow liquid. Staff T took the spray bottle to the soiled utility room, sprayed writers goggles with the liquid and stated it was to be wet for 3-5 seconds then rinsed off the goggles and wiped them with a paper towel. Staff T then washed personal goggles and eyeglasses with soap and water. A review of Peroxide Multi Surface Cleaner and Disinfectant on 4/6/23 at 6:22 a.m., identified that the cleaner disinfects in 3-5 minutes, killed SARS-CoV 2 in 30 seconds when diluted and used according to directions, and killed Norovirus in 45 seconds. An interview was conducted on 4/3/23 at 12:24 p.m. with Staff U, Licensed Practical Nurse (LPN). Staff U said the Peroxide cleaner was in the clean utility room and after using it the staff store their goggles in a paper bag. When informed of cleaning the goggles in the soiled utility room, Staff U stated oh no we don't go in there unless necessary due to it being smelly. An observation was conducted with Staff U of the clean utility room with a hanging shoe caddy that contained brown paper bags. Staff U the Peroxide liquid was to be wet for 5 minutes and cleaned goggles after shift before giving report, report took longer than 5 minutes but has to be on for at least 5 minutes. The facility provided two policies regarding the process of protective eye wear: - Facility Practice Guidelines: Utilization and Reprocessing of eye protection, revised on 3/31/20, 1/8/21, and 4/30/21, indicated that To define utilization of protective eye wear, and to minimize (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105986 If continuation sheet Page 20 of 23 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 04/06/2023 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the potential for transmission of organisms by reprocessing eye protection per CDC guidelines. This policy identified that for residents without transmission-based precautions and community positivity rates are medium to high: The employee may use the eye protection (i.e. goggles) between residents without disinfecting from resident to resident for those without transmission-based precautions. The policy identified for reprocessing eye protection staff should spray the eye wear with Peroxide Multi Surface Cleaner and Disinfectant until wet, allow to sit for 30 seconds per manufacturer guidelines to kill SARS CoV 2 and after 30 seconds wipe dry with clean paper towel. - Facility (Skilled Nursing Facility-SNF) COVID-19 Pandemic Plan, created 7/13/21, effective 11/15/21, and most recently reviewed 10/5/22, identified that Team members will use eye protection for all resident encounters while facility is an area of substantial to high community transmission. Reusable eye protection should be cleaned and disinfected after each patient encounter. During the meal service on 4/3/23 at 12:26 p.m., Staff N and O, CNAs, were observed taking meal trays into rooms without cleaning and/or disinfecting the face shield or goggles worn. Staff Member O stated the staff were supposed to clean glasses in between each resident but was nervous and forgot. On 4/3/23 at 1:41 p.m. Staff N, demonstrated going into the clean utility room, she sprayed the face shield (with Peroxide cleaner) and said leave the spray on for a couple seconds then wipe it down. Staff N admitted not cleaning the face shield in between each resident. Staff P, LPN stated on 4/3/23 at 1:51 p.m. that it did not make sense to clean the goggles in the clean utility room, next to an open container of spoons. The staff member reported to only cleaning goggles when patient was doing a breathing treatment or on precautions. On 4/4/23 at 12:55 p.m., Staff Q, CNA, was observed sitting in the dining room on [NAME]/[NAME]/[NAME] hall with protective eye goggles sitting atop of head above forehead while at a table with a resident. Staff Q was observed at 1:02 p.m. on 4/4/23, entering the employee education room then coming to the nursing station wearing goggles atop of head, in the common area near eight residents. On 4/5/23 at 8:36 a.m., an observation was made of an unknown staff member wearing an olive green scrub top with a white [NAME] printed kerchief over hair walking from [NAME] hall to [NAME] hall. The staff member was not wearing eye protection. Staff U, Registered Nurse (RN), was observed, on 4/6/23 at 8:06 a.m., standing at the medication cart outside of [NAME] 3 and 5 with eye protection (goggles) on forehead. On 4/6/23 at 8:10 a.m., Staff L, Receptionist, stated that the Peroxide Multi Cleaner (spray bottle observed on desk) was to clean the counters. The staff member stated the cleaner should be left on for 4-3 minutes. Staff M, CNA, was observed, on 4/6/23 at 8:13 a.m., on [NAME] hall, placing a meal tray inside the metal cart. Staff M's goggles were hanging from the collar of scrub top. Staff M reported picking up trays from breakfast. On 4/6/23 at 8:14 a.m., the Director of Nursing (DON) was walking through the common area outside of the nursing station on [NAME]/[NAME]/[NAME] halls with goggles on forehead, which was moved to be placed appropriately. During an interview on 4/6/23 at 9:27 a.m., the DON reported the patient care areas were where (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105986 If continuation sheet Page 21 of 23 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 04/06/2023 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 0880 Level of Harm - Minimal harm or potential for actual harm patients were located, if a patient was in the lobby it would be considered a patient care area. The Regional DON stated the corporate office pulled transmission rate information from the Department of Health website and as of Friday it was high, one of the only counties staying that way. The DON stated staff should be consistent with answers regarding the use and cleaning of goggles. The DON stated the Peroxide cleaner contact time was 5 minutes, 30 seconds for eyewear and everywhere else was 5 minutes. Residents Affected - Some An observation was conducted on 4/5/23 at 8:52 a.m., of medication administration with Staff I, LPN for Resident #86. The staff member retrieved Formoterol 20 microgram (mcg)/2 milliliter (mL) from the refrigerator. The door to the resident room identified that all persons entering the room should adhere to Aerosolizing precautions for both occupants of the room. During the observation Resident #86 was coughing without covering mouth, the cough was moist and non-productive. Staff I placed the medication into the nebulizer cup, turned on the machine, and applied the aerosol mask on resident. Aerosol was observed emitting from the mask. Staff I stated she would be back in 10 minutes and left the room. Staff I stated they wear masks and goggles while in the residents' room and identified the mask worn was a regular surgical mask, indicating the one worn. Staff I was not sure when to clean goggles but cleaned them after they got foggy, about ten times in a 12 hours shift. Staff I admitted to not cleaning the goggles after each resident. 2. The sign posted on Resident #86's door identified that all visitors must see nurse prior to visiting. The sign instructed that visitors to the room: - Perform hand hygiene before entering the room and before leaving the room. - Wear N-95, gown, gloves, facemask, and eye protection when entering room while treatment is in progress and 1 hour after. Do not remove mask inside room. Dietary personnel are not permitted to enter prior to checking with nurse. - Keep door to room closed during treatment and 1 hour after completion of treatment. On 4/5/23 at 9:08 a.m., photos were taken of Resident #86's door, which was open. The log attached to the personal protective equipment caddy hanging on the door indicated that No person shall enter the room without documenting the entry on this log. For the safety of our residents and staff, and those in the community, refusal to comply will not be accepted. The log identified that one staff member had documented entry on the 4/4/23 11 p.m.-7 a.m. shift, the same staff member documented entry twice during the 11-7 shift on 4/5/23. The log did not indicate any other names of staff members who had entered the room on 4/4 or during the day shift on 4/5/23. During an interview on 4/6/23 at 9:27 a.m., the DON stated the log was to be signed and staff should have dressed in a N95 mask, gown, and gloves when the nebulizer was started as the aerosol comes out immediately. Staff C, Infection Preventionist, stated on 4/6/23 at 10:51 a.m. that PPE should have been donned when the nebulizer was administered. The staff member stated the receptionist should know the COVID status of the facility. Staff C stated on 4/6/23 at 10:41 a.m., staff were instructed it was not necessary to clean goggles in between residents. The policy - Managing Aerosol Generating Procedures (AGP) during COVID-19, revised on 10/21/22, identified that the purpose was to provide updated guidelines on resident management involving AGP (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105986 If continuation sheet Page 22 of 23 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 04/06/2023 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some during the COVID-19 Pandemic. The process identified that the door to the room should remain closed while AGP was in use and for one hour after. An interview was conducted with Staff C on 04/06/23 at 10:04 a.m. Staff C said the county Covid-19 transmission rate was high so everyone was required to wear disposable surgical masks. During the interview, Staff C said the staff wear eye protection in all resident care areas because we worry about Covid-19 transmission from mucus membranes, wearing eye protection was an additional measure to protect staff. Staff C stated her expectation was Staff will wear goggles anytime there is potential contact with residents. Staff C explained the facility infection control policies were inconsistent pertaining to wearing, cleaning of eye protection and she instructed staff to follow Facility Practice Guidelines: Utilization and Reprocessing of Eye Protection Last revision date 4/30/21. Staff C said they followed the Center for Disease Control guidelines on enhanced barrier precautions and implemented aerosolized precautions for respiratory treatments. Review of facility policies revealed: Facility (SNF) COVID-19 Pandemic Plan reviewed 10/5/22 Eye Protection: in areas of substantial to high community transmission healthcare personnel are using eye protection in all resident care areas. Eye Protection: Disposable eye protection should be removed and discarded after each use. Reusable eye Protection should be cleaned and disinfected after each patient encounter. Facility Practice Guidelines: Utilization and Reprocessing of Eye Protection Last revision date 4/30/21 -the employee may use eye protection (i.e. goggles) between residents without disinfection from resident to resident for those without transmission-based precautions. -anytime eye protection (i.e. goggles) is removed from the face during the shift, follow the cleaning instructions noted below prior to re-application. This would include when visible soiled, before breaks, or before navigating from a transmission precautions room to a regular room. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105986 If continuation sheet Page 23 of 23