Health inspection·May 15, 2025

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Policy: Midline catheter dressings will be changed at specified intervals, or when needed, to prevent catheter-related infections associated with contaminated, loosened or soiled catheter-site dressings. General Guidelines: 1. Change midline catheter dressing 24 hours after catheter insertion, every 5-7 days, or if it is wet, dirty, not intact, or compromised in any way. 4. Use a sterile, transparent, semi permeable membrane (TSM) or gauze dressing. If gauze dressing is used, cover the gauze with a TSM dressing and change the dressing every 48 hours. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105986 If continuation sheet Page 2 of 6 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 05/15/2025 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm 3. Residents Affected - Few Review of Resident #48's admission Record showed diagnoses of chronic obstructive pulmonary disease with acute exacerbation, hypoxemia, and dependence on oxygen. Review of Resident #48's physician orders dated 12/22/2022 showed, Oxygen 2L via NC [nasal cannula] continuous every shift. During an observation on 5/13/25 at 7:33 AM, Resident #48 was sitting in a wheelchair at their bedside with oxygen running at 3.5 liters via nasal cannula on an oxygen concentrator. The oxygen concentrator was behind the residents wheelchair out of the residents reach. During an interview on 5/14/25 at 11:25 AM, Staff D, RN stated, [Resident #48] would not be able to change her oxygen. I think it gets bumped by staff during care, she goes on a tank when she is going in the wheelchair and back on the concentrator when she is in the room. All oxygen should be at the rate it's ordered. During an interview on 5/14/25 at 2:10 PM, the DON stated, All physician orders for oxygen should be followed. Nurses should check daily what flow rates a resident is on. Review of the facility policy titled Oxygen Administration, with a review date of 12/10/24, revealed the following: Purpose: The purpose of this procedure is to provide guidance for safe oxygen administration. Preparation: 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. 2. Review the resident's care plan to assess any special needs of the resident. Based on observations, interviews, and record review, the facility failed to ensure respiratory care and services were provided consistent with professional standards of practice for oxygen administration for three (Resident #40, Resident #258, and Resident #48) of five residents reviewed for oxygen administration. Findings included: 1. Review of Resident #40's admission Record documented diagnoses of chronic obstructive pulmonary disease (COPD) and unspecified asthma. Review of Resident #40's physician orders dated 5/5/25 showed, Oxygen 2 Liters continuously via nasal canula. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105986 If continuation sheet Page 3 of 6 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 05/15/2025 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the resident centered comprehensive plan of care for Resident #40 showed a Focus dated 2/11/25, The resident has Asthma/COPD. Interventions included: Monitor for difficulty breathing (Dyspnea) on exertion and oxygen as indicated. During an observation on 5/12/25 at 9:09 AM, Resident #40 was lying in bed with oxygen infusing via nasal cannula at 3L/min (3 Liters per minute). During an interview on 5/13/25 at 8:02 AM, Staff B, Registered Nurse (RN) confirmed Resident #40's oxygen was infusing at 3L/min and stated, I think it is supposed to be on 2 but I will check it. Staff B, RN proceeded to check the electronic medical record (EMR) and confirmed the physicians order for Resident #40 for oxygen at 2 Liters continuously via nasal canula. During an interview on 5/13/25 at 10:30 AM, Resident #40's husband stated, she doesn't get out of bed on her own, so she couldn't change it referring to the resident's oxygen administration. During an observation on 5/13/25 at 10:45 AM, Resident #40 was sitting in her wheelchair with oxygen infusing via nasal cannula at 3L/min. 2. Review of Resident #258's admission Record showed diagnoses of acute respiratory failure with hypoxia, acute respiratory failure with hypercapnia, chronic obstructive pulmonary disease with (acute) exacerbation, unspecified asthma, and emphysema. Review of Resident #258's physician order dated 5/6/25 revealed, Oxygen 3 LPM [Liters per minute] via nasal cannula every shift. Review of the resident centered comprehensive plan of care for Resident #258 showed a Focus dated 5/5/25, The resident has Emphysema/COPD r/t (related to) smoking with respiratory failure, hypoxic/hypocarbia. Interventions included oxygen as ordered. During an observation on 5/12/25 at 11:04 AM, Resident #258 was lying in bed with oxygen infusing via nasal cannula at 2L/min. During an observation on 5/13/25 7:29 AM resident #258 was sitting on the side of his bed eating breakfast. Oxygen was infusing via nasal cannula at 2L/min. During an interview on 5/13/25 Resident #258 stated, I only take my oxygen off when I go out of my room, and then they place me on that tank. Resident #258 stated he does not know how to change the flow of his oxygen. During an interview on 5/13/25 at 8:04 AM Staff A, Certified Nursing Assistant (CNA) confirmed resident #258's oxygen was infusing 2L/min. Staff B, RN checked the orders in the EMR and stated, Yes, it was running at the wrong rate. During an interview on 5/15/25 at 8:30 AM, the facility's Director of Nursing stated, Oxygen should be running at the physician ordered rate. Nurses should check the levels when giving meds [medications]. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105986 If continuation sheet Page 4 of 6 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 05/15/2025 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 Based on observations, interviews, and policy and procedure review, the facility failed to maintain an effective infection prevention and control program designed to help prevent the transmission of communicable diseases and infection, by failing to perform hand hygiene during medication administration for three resident (#20, #60, and #47) of eight residents observed for medication administration. Residents Affected - Few Findings included: During an observation of medication administration on 5/14/2025 at 8:00 AM, Staff C, Registered Nurse (RN), removed medication cart keys from their pocket, unlocked the medication cart, activated the computer and typed on the computer. Staff C, RN prepared medications, went to Resident #20's room, entered the room, and donned gloves without performing hand hygiene. Staff C, RN cleaned the needleless connector of Resident #20's left upper arm midline catheter with an alcohol pad and administered a normal saline flush. Staff C, RN opened the IV (intravenous) tubing and connected the IV tubing to a medication bag. Staff C, RN attached the IV tubing to the midline catheter needleless connector and began to administer the medication. Staff C, RN doffed gloves and exited the room without performing hand hygiene and returned to the medication cart. During an observation of medication administration on 5/14/2025 at 8:15 AM, Staff C, RN returned to the medication cart from a residents room, removed medication cart keys from their pocket, unlocked the medication cart, activated and typed on the computer, removed medication cards, and began to prepare medications for Resident #60 without performing hand hygiene. Staff C, RN entered Resident #60's room, donned a gown and gloves, and administered medications to the resident through a gastrostomy tube. Staff C, RN removed the gown and gloves and exited the room without performing hand hygiene and returned to the medication cart. During an observation of medication administration on 5/14/2025 at 8:35 AM , Staff C, RN returned to the medication cart, removed medication cart keys from their pocket, unlocked the medication cart, activated and typed on the computer, removed medication cards, and began to prepare medications for Resident #47 without performing hand hygiene. Staff C, RN entered Resident #47's room and administered oral medications. Staff C, RN donned gloves without performing hand hygiene and administered eye drops to the resident. Staff C, RN doffed the gloves and exited the room without performing hand hygiene and returned to the medication cart and began to prepare medications for another resident. During an interview on 5/14/2025 at 12:25 PM, Staff C, RN stated, I didn't realize that I did not wash my hands or use hand sanitizer. I should have done that. We should use hand sanitizer before and after we put on gloves. During an interview on 5/14/2025 at 2:30 PM, the facility's Director of Nursing (DON) stated, I would expect all staff to follow our infection control standards for handwashing. Review of the facility policy and procedure titled Handwashing/Hand Hygiene, last approval date of 1/2025, showed the following: Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of infections. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105986 If continuation sheet Page 5 of 6 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 05/15/2025 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 Policy Interpretation and Implementation: . Level of Harm - Minimal harm or potential for actual harm 2. All personnel shall follow the handwashing/hand hygiene procedures to prevent the spread of infections to other personnel, residents, and visitors. Residents Affected - Few 7. Use alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap and water for the following situations: . b. before and after direct contact with residents; c. before preparing or handling medications; . e. Before and after handling an invasive device ( e.g, urinary catheters, IV access sites), . m. After removing gloves. 8. Hand hygiene is the final step after removing and disposing of personal protective equipment. 9. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105986 If continuation sheet Page 6 of 6