Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Solaris Healthcare Lake Zephyr during CMS and state inspections, most recent first.
The facility failed to implement care plan interventions for oxygen administration for four residents. Observations revealed discrepancies between the prescribed oxygen levels and those administered, with residents receiving incorrect oxygen settings. Staff interviews confirmed expectations for regular checks, but these were not consistently followed, leading to non-compliance with care plans.
The facility failed to adhere to infection control standards for PPE and hand hygiene. Two residents on enhanced barrier precautions were assisted by CNAs who wore gloves but no gowns, despite the requirement for both. Additionally, an LPN was observed not performing hand hygiene during multiple medication administrations. These actions were contrary to the facility's infection control policies.
A facility failed to provide proper catheter care for a resident, leading to a full catheter bag on the floor and urine backflow, risking infection. Another resident's catheter was reinserted without documented consent, despite the facility's policy requiring it. Staff interviews revealed inconsistencies in documentation and infection control practices.
A resident with a complex medical history was found to have bruising and a recent fracture, but CNAs failed to report these observations to a nurse as required. The facility's policy mandates immediate reporting of such injuries, which was not followed, resulting in a delay in addressing the resident's condition.
A resident with multiple health conditions, including dementia, was found with a recent hip fracture and bruising, which staff failed to report promptly. Despite several staff members observing the bruising over a few days, it was not reported until later, leading to a delay in treatment. The facility's policies on reporting changes in condition and preventing neglect were not followed.
Failure to Implement Oxygen Administration Care Plans
Penalty
Summary
The facility failed to implement care plan interventions related to oxygen administration for four residents. Resident #42 was observed with an oxygen concentrator running at 1.5 liters per minute, despite a physician's order and care plan indicating it should be set at 2 liters per minute. The resident expressed uncertainty about the correct oxygen setting, and a Licensed Practical Nurse (LPN) confirmed that nurses are expected to check oxygen levels each shift. Resident #56 was observed with oxygen levels set at 3.5 liters and 2.5 liters during different observations, contrary to the physician's order of 2 liters per minute. The care plan for this resident included administering oxygen as ordered, but this was not followed. Similarly, Resident #60 was observed with oxygen levels at 5 liters and 4.5 liters, while the care plan specified 4 liters per minute. The oxygen concentrator was placed out of the resident's reach, which could hinder self-adjustment or monitoring. Resident #71 was observed with oxygen set at 5 liters per minute, although the physician's order and care plan specified 4 liters. An LPN acknowledged the discrepancy and emphasized the importance of following doctor's orders and care plans. The Director of Nursing (DON) stated that nurses should verify oxygen levels at least once per shift. The facility's policy on care plans highlighted the need for individualized plans with measurable objectives, but these were not effectively implemented for the residents in question.
Infection Control Deficiencies in PPE Use and Hand Hygiene
Penalty
Summary
The facility failed to adhere to infection control practice standards for personal protective equipment (PPE) while providing direct care for two residents on enhanced barrier precautions (EBP). Resident #98, who had multiple diagnoses including a pressure ulcer and an indwelling catheter, was observed being assisted by two certified nursing assistants (CNAs) who wore gloves but no gowns, despite the presence of an EBP sign on the door indicating the need for both gloves and gowns during high-contact activities. Both CNAs acknowledged in interviews that they should have worn gowns while handling the resident's catheter. Similarly, Resident #319, who had an indwelling catheter and was under EBP, was assisted by a CNA who also wore gloves but no gown while changing the resident's clothing. The CNA admitted to forgetting to wear a gown and not noticing the EBP sign on the door. The Director of Nursing confirmed that staff should follow the policy for EBP, which includes wearing gowns and gloves for high-contact activities involving urinary catheters. Additionally, the facility failed to perform hand hygiene during medication administration. An LPN was observed multiple times not performing hand hygiene between medication administrations, after removing gloves, and after touching her face and hair. The Infection Prevention Officer stated that hand hygiene should be performed before and after each medication pour, indicating a lapse in adherence to infection control protocols during medication administration.
Deficiencies in Catheter Care and Consent Documentation
Penalty
Summary
The facility failed to provide necessary care and services for urinary catheter care for Resident #319, who was readmitted with multiple diagnoses including neuromuscular dysfunction of the bladder and Alzheimer's Disease. Observations revealed that the resident's urinary catheter bag was full and laying on the floor, causing a backflow of urine towards the bladder. This situation was acknowledged by staff as a risk for infection, yet it was not addressed in a timely manner, indicating a lapse in maintaining unobstructed urine flow and infection control as per the facility's policy. Additionally, the facility failed to document consent for the insertion of a catheter for Resident #458, who had a history of postlaminectomy syndrome and functional urinary incontinence. The resident initially came with a catheter, which was reinserted due to refusals of care and to minimize infection risk to a surgical incision. However, there was no written documentation of consent, and the facility relied on verbal consent, which was not properly recorded in the progress notes, contrary to the facility's policy on documentation. Interviews with the Director of Nursing and staff revealed inconsistencies in the documentation process and a lack of adherence to the facility's policy on catheter care and consent documentation. The absence of proper documentation and failure to follow infection control protocols contributed to the deficiencies identified during the survey.
Failure to Report Injury of Unknown Source
Penalty
Summary
The facility failed to report an injury of unknown source within the required two-hour timeframe for a resident. On two separate occasions, Certified Nursing Assistants (CNAs) observed bruising on the resident but did not report these observations to a nurse. The first observation was made by a CNA who noticed a yellowish bruise near the resident's vaginal area, and the second observation was made by another CNA who saw a bruise on the resident's left lateral thigh. These observations were not reported to a nurse, which is a violation of the facility's policy on reporting changes in a resident's condition. The resident involved had a complex medical history, including metabolic encephalopathy, mood disorder, dementia, and Alzheimer's disease, among other conditions. The resident was dependent on staff for most activities of daily living. A subsequent skin evaluation revealed bruising in the groin area and left hip, accompanied by swelling, and an X-ray confirmed a recent comminuted intertrochanteric fracture of the left hip. The facility's policies require immediate reporting of such injuries, but the CNAs failed to fulfill this responsibility, leading to a delay in addressing the resident's condition.
Failure to Prevent and Report Injury of Unknown Origin
Penalty
Summary
The facility failed to prevent an injury of unknown origin for a resident, identified as Resident #41, who was found to have a comminuted intertrochanteric fracture of the left hip. The resident, who was dependent on staff for most activities of daily living due to multiple diagnoses including dementia and Alzheimer's disease, was observed with bruising in the groin area and left hip, accompanied by swelling. An X-ray confirmed the fracture, which was deemed recent and led to the resident being transferred to the hospital for further assessment. Interviews and record reviews revealed that several staff members observed bruising on Resident #41 over a period of days but failed to report it immediately. On 7/10/2024, a CNA noticed a yellowish bruise on the resident's left vaginal area but assumed it had already been addressed. Another CNA observed a bruise on the left lateral thigh on 7/11/2024 but also did not report it, assuming it was old. It wasn't until 7/12/2024 that the bruising was reported to a nurse, who then ordered an X-ray and initiated an internal investigation. The facility's policies on reporting changes in a resident's condition and preventing abuse, neglect, and exploitation were not followed, as staff failed to promptly report the bruising and potential injury. The facility's orientation and training materials emphasize the importance of reporting such incidents, yet the staff did not adhere to these guidelines, resulting in a delay in addressing the resident's injury.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Zephyrhills
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hillside Health And Rehabilitation Center | 1.3 mi | — | 0 | 0 |
| Solaris Healthcare Zephyrhills | 2.4 mi | — | 0 | 0 |
| Adventhealth Dade City | 8.2 mi | — | 0 | 0 |
| Royal Oak Nursing Center | 8.6 mi | — | 1 | 0 |
| Dade City Health And Rehabilitation Center | 9 mi | — | 4 | 4 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.