Health inspection·February 22, 2024

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure appropriate care and services related to a soiled Percutaneous Endoscopic Gastrostomy (PEG) tube and connector for one (Resident #4) of five total sampled residents. Findings included: An observations of Resident #4's PEG tube and connector on 2/22/24 at 10:32 a.m. revealed the residents PEG tube and connector closest to his body was noted to have black bio-growth on the tubing for the full length of the connector. (Photographic Evidence obtained) An interview with Staff A, Licensed Practical Nurse (LPN) at this time confirmed the PEG tube and connector was covered with black bio-growth. She said the PEG tube should not be in this condition. She said today, 2/22/24, was the first time she had worked with Resident #4, and the first time she had seen the resident's PEG tube. She said she did not know how long the PEG tube connector had been this condition. A review of Resident #4's record showed the resident was re-admitted to the facility on [DATE] with diagnoses that included Encounter for Attention to Gastrostomy. A review of the quarterly Minimum Data Set (MDS) dated [DATE] and a Brief Interview for Mental Status (BIMS) showed a score of 15, which indicated intact cognition. A review of the Resident #4's nurses notes showed the following: -2/17/24 16:11:00 (4:11 p.m.) -Peg tube noted to have black looking residual stuck to inside of tubing. Will follow up with MD for tube replacement. -2/18/24 15:21:00 (3:21 p.m.) -Peg tube noted to have black looking residual stuck to inside of tubing. Will follow up with MD for tube replacement. Closer review of both nurses notes revealed that both notes were documented by the same LPN and were identical. Additionally, there was no documentation that would indicate the staff member had actually notified the physician. A review of current physician orders dated 8/17/22 related to the PEG Tube site care showed, Cleanse peg tube site with NS, pat dry, then apply a drain sponge every night shift and as needed for soiled or dislodged. (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 2 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 02/22/2024 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)