Solaris Healthcare Zephyrhills

In the surveyor’s words

From the most serious findings on record at Solaris Healthcare Zephyrhills, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF641Apr 6, 2023

  Based on observations, interviews, record reviews, the facility failed to ensure the comprehensive Minimum data Set (MDS) assessments were accurately coded for three (Residents #95, #101 and #24) of twenty-one sampled residents Findings included: 1. During an interview on 04/03/23 at 10:50 a.m., Resident #95 stated he had not been on a ventilator and stated he only used a continuous positive airway pressure (CPAP) machine at night. An observation on 04/03/23 at 10:50 a.m., showed Resident #95 was not on a ventilator and was sitting in wheelchair. Resident #95 was observed as he proceeded to wheel himself out of his room and down the hallway. A review of Resident #95's medical record showed no current or discontinued physician orders for a ventilator. […]

• No harm, potential for more than minimal, patternF812Apr 6, 2023

  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. […]

• No harm, potential for more than minimal, patternF880Apr 6, 2023

  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. 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. […]

• No harm, potential for more than minimal, patternF812Jun 17, 2021

  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. […]

• No harm, potential for more than minimal, isolatedF684May 15, 2025

  Based on observation, interview, and record review, the facility failed to provide central venous catheter dressing changes as ordered in accordance with professional standards of practice for one (Resident #20) of three residents reviewed with a midline catheter. Findings included: During an observation on 5/12/2025 at 12:55 PM, Resident #20 was sitting at their bedside with a left upper arm single lumen midline catheter. The transparent dressing was lifting up at the edges and there was gauze under the transparent dressing occluding the view of the insertion site. The dressing was dated 5/6/2025. During an interview on 5/12/2025 at 12:55 PM Resident #20 stated, They have not changed [the dressing] yet. It was put in a week ago and no one has changed it since it was put in. […]