Solaris Healthcare Lake Zephyr
38250 A Ave, Zephyrhills, FL 33542 · For profit - Limited Liability company · 120 certified beds · (813) 782-5508 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- a high number of inspection citations overall (16) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- about 21% of its spending goes to commonly-owned related companies
- its last standard health inspection was over 2 years ago — the star rating may not reflect current conditions
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 3 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 4 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 5.9% | 8.7% | 15.4% | better |
| Long-stay residents who lose too much weight | 3.1% | 5.5% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.3% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 1.4% | 0.7% | 2.0% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 1.2% | 4.6% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 1.6% | 2.5% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 7.0% | 9.5% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 3.1% | 14.4% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 99.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.1% | 4.5% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 5.9% | 10.5% | 21.2% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 1.2% | 8.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.4% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 95.5% | 94.7% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 23.1% | 26.1% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 5.8% | 9.1% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 2.41 | 2.13 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 0.77 | 1.15 | 1.80 | better |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
45.9% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 168 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 48.8% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 172 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.46 therapist hours per resident per day in 2026Q1 — more than 77% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 43% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 45.9%CMS range 39.4–51.7 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 12.2%CMS range 9.4–15.5 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 48.8% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 47.1% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 30.8% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 95.4% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 94.3% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 98.9% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 4.6% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 5.9%CMS range 3.6–9.4 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.05 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 120 beds and averages 109.5 residents a day — about 91% occupied, or roughly 10 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.67 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.68 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.15 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.39 hrs/resident/day on weekends vs 3.78 on weekdays — 10% thinner on weekends. RN hours go from 0.75 to 0.52 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 44% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
This trend is not current. The most recent of these two inspections was over 2 years ago; the arrow describes what inspectors found then, not what the home is like now.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
16 citations, most serious first. The 10 most serious are shown; the remaining 6 are one tap away and print in full.
- Potential for harm · D2025-11-24 · tag F0585 — failed to handle grievances — isolatedHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review the facility failed to ensure a grievance process was followed for one resident (#5) of three residents sampled for grievances.Findings Included: Review of Resident #5's medical record revealed the resident was re-admitted to the facility on [DATE]. The medical diagnosis of the resident included: concussion with loss of consciousness status unknown, subsequent encounter trauma fall with laceration 3 centimeters with hematoma, major depressive disorder, recurrent, moderate, and adjustment disorder with anxiety. Review of Resident #5's Minimum Data Set (MDS), revealed the resident had a Brief Interview Mental Status (BIMS), score of 13 out of 15, indicating the resident's cognition was intact. During an interview at 9:54 a.m. on 11/24/2025 Staff C, Certified Nursing Assistant (CNA) stated once or twice a resident had complained of being kept awake by another resident's behavior. Staff C stated staff could file a grievance on behalf of residents. During an interview at 10:22…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-11-24 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews the facility failed to provide adequate and appropriate health care for one (#2) of three sampled residents as evidence by not obtaining a urinalysis with culture and sensitivity as ordered by the physician and not monitoring a surgical site for signs of infection, drainage, and/or a clean intact dressing.Findings included:Review of Resident #2s admission Record showed the resident was admitted on [DATE] from an acute care facility and discharged on 7/15/25. The record revealed a primary diagnosis of aftercare following joint replacement surgery and included diagnoses of presence of right artificial hip joint and presence of left artificial knee joint.Review of Resident #2s Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form (Agency for Healthcare Administration (AHCA) form 3008), dated 7/1/25 form revealed the resident was status post (s/p) anterior approach hip replacement, was receiving post-operative (op) antibiotic(s) prophylactically,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-07-30 · tag F0656 — failed to write and follow a full care plan — patternDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, and record review, the facility failed to implement care plan interventions related to oxygen administration for four residents (#42, #56, #60, and #71) out of 4 residents reviewed for oxygen administration. Findings include: 1. During an observation 07/15/24 at 09:38 AM, Resident #42 was lying in bed with a nasal cannula in place and the oxygen concentrator running at 1.5 liters per minute (LPM). During an observation on 7/15/24 at 1:30 PM Resident #42 was lying in bed with a nasal cannula in place and the oxygen concentrator running at 1.5 liters per minute. During an interview on 7/15/24 at 1:30 PM Resident #42 stated, I think my oxygen should be running on 3, but the nurse is the one who usually checks it. A record review of Resident #42's Physicians order reads, (ACC-OXYGEN) Oxygen 2 liter via NC [nasal cannula] every shift. A review of Resident #42's care plan, dated 6/13/24, reads, The resident has dx [diagnosis] of Heart Failure, OXYGEN SETTINGS: O2 via: nasal prongs @ 2 LPM (continuously). During an interview on 7/18/24 at 08:30 AM Staff…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-07-30 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review. the facility 1) failed to adhere to infection control practice standards for personal protective equipment (PPE) while providing direct care for two residents (#98 and #319) out of eight residents on enhanced barrier precautions (EBP), and 2) failed to perform hand hygiene during medication administration during 3 out of 9 observations of medication administration. Findings included: 1. Review of the medical record showed Resident #98 was admitted on [DATE] with diagnoses including pressure ulcer of sacral region (unstageable), Peripheral Vascular Disease, Paroxysmal Atrial Fibrillation, Acute Kidney Failure, Chronic Kidney Disease (Stage 3B), and Sepsis. Review of the physician's order, dated 06/03/2024, for Resident#98 read, (Incontinence Indwelling Catheter Urethral every shift related to Pressure Ulcer of Sacral Region, Unstageable .16Fr [French]/10 ml [milliliters]. Review of the physician's order, dated 07/02/2024, for Resident #98 read, Enhanced…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-07-30 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility 1) failed to provide the necessary care and services for urinary catheter care, maintaining urinary flow into the urinary catheter bag and ensuring appropriate infection control techniques during urinary catheter care for one resident (#319) out of three residents reviewed for incontinence care, and 2) failed to document consent related to insertion of a catheter for one resident (#458) out of three residents reviewed. Findings included: 1. Review of the medical record showed Resident #319 was readmitted on [DATE] with diagnoses including neuromuscular dysfunction of the bladder, infection and inflammatory reaction due to internal right hip prosthesis, pressure ulcer of sacral region, Stage 1, anxiety disorder, depression, cellulitis of right lower limb, pyuria, and Alzheimer's Disease. Review of the physician's order, dated 07/01/2024, for Resident #319 read, Indwelling Catheter Urethral every shift. Size 16. Dx (diagnosis) Neurogenic Bladder.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-07-30 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to report within two hours an injury of unknown source for one resident (# 41) of three sampled residents. Findings Included: On 7/10/2024 during the 7:00 a.m. to 3:00 p.m. shift, Staff O, Certified Nursing Assistant (CNA) observed a yellowish bruise near Resident's #41's vaginal area and did not report the observation to the nurse. On 7/11/2024 on 11:00 p.m. to 7:00 a.m. shift, Staff M, CNA said she observed a small bruise on Resident #41's left lateral thigh and did not report the observation to the nurse. Review of a Situation Background Assessment Recommendation (SBAR) form, dated 7/12/2024, showed Resident #41 had changes in skin color or condition and there were no medication changes in the past week. The blood pressure was 136/74, Pulse 82, Respiratory rate 18, Temperature 98.0 degrees and weight was 111.4 pounds. Resident #41's skin evaluation showed, Resident present bruising in the groin area and left hip, accompany by swelling of the left…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-07-30 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to prevent an injury of unknown origin for one resident (# 41) out of three sampled residents for injuries/accidents. Findings Included: Review of a Situation Background Assessment Recommendation (SBAR) form, dated 7/12/2024, showed Resident #41 had changes in skin color or condition and there were no medication changes in the past week. The blood pressure was 136/74, Pulse 82, Respiratory rate 18, Temperature 98.0 degrees and weight was 111.4 pounds. Resident #41's skin evaluation showed Resident present bruising in the groin area and left hip, accompany by swelling of the left labia left thigh, left hip. X-ray Stat was ordered. The documentation was signed by Staff F, Registered Nurse (RN). Review of admission records showed Resident #41 was originally admitted on [DATE], with diagnoses to include metabolic encephalopathy, mood disorder, dementia, muscle wasting and atrophy, cognitive communication deficit, Alzheimer's disease, aphasia, contracture of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-08-18 · tag F0885 — failed to notify residents/families about COVID-19 — patternReport COVID19 data to residents and families.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and policy review, the facility failed to ensure residents, resident representatives, and visitors were notified of the COVID-19 status. Findings included: On 8/15/22 at approximately 9:00 a.m., the Nursing Home Administrator identified that there was COVID-19 positive residents in the building. A review of the facilities website on 8/18/22 at 9:35 a.m. (https://www.adventhealth.com/skilled-nursing/adventhealth-care-center-zephyrhills-south) instructed residents/representatives and potential visitors of the following for Important COVID-19 Updates: Extra Safety Measures for Your Protection Your health and safety have always been our top priority and we have expanded our policies, procedures and products to protect you and our caregivers. These safety measures include enhanced cleaning and sanitation, universal mask use, temperature checks, social distancing, visitor restrictions and keeping COVID-19 symptomatic patients separated from other patients. Details here, indicating to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-08-18 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure that all skin conditions were appropriately addressed for two (Residents #25, #26) of 36 sampled residents. Findings included: 1. Observations of Resident #25 on 08/15/22 at 10:27 a.m. revealed the resident had an undated dressing to her right outer ankle. An interview with Resident #25 at this time, revealed she had issues with her ankle and the wound care nurse came one time per week and changed her dressing and forgot to date it as she did not have a pen handy. Review of the resident's record revealed she had a current order dated 3/29/22 for the following, (AC-Wound) Wound Care prevention Right outer ankle Skilled nursing to apply skin prep cover with 3 x 3 foam dressing change weekly and PRN soiling every day shift every 7 days for wound prevention An interview on 08/17/22 at 11:51 a.m. with Staff A, Wound Care, Registered Nurse (RN), revealed the resident's dressing order was preventative as the resident had an arterial wound on the right ankle that kept opening up, but was now closed. She…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-08-18 · tag F0700 — isolatedTry different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to obtain physician's orders for, assess the use of, and develop care plans for padded side rails which were attached to the beds of four (Residents #8, #31, #76, and #81) of 36 sampled residents . Findings included: 1. Resident #8 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's Disease, muscle weakness, and unspecified psychosis. On 08/15/2022 at 11:15 a.m., Resident #8 was observed lying in her bed, which was low to the floor, with the head of the bed up at approximately a 45 degree angle, with padded bilateral side rails alongside the elevated head of the bed. An arm chair had been placed tight against the side of the bed, on the resident's right side and bilateral floor mats were observed on either side of the bed. During that observation, Resident #8 was continuously yelling out, with an occasional understandable word such as No, No, No. The resident had her eyes closed and the resident's aide, Staff I,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 6 citations
- Potential for harm · Dcited before2022-08-18 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, and record review, the facility failed to ensure the medication error rate was less than 5.00%. Twenty-five medication administration opportunities were observed, and two errors were identified for two (Residents #32 and #26) of six residents observed. These errors constituted a 8.00% medication error rate. Findings included: On 8/16/22 at 4:18 p.m., an observation of medication administration with Staff E, Licensed Practical Nurse (LPN), was conducted with Resident #32. The Staff E was observed dispensing the following medications: - Eliquis 2.5 milligram (mg) tablet - Gabapentin 400 mg capsule - Hydralazine 25 mg tablet - Gabapentin 400 mg capsule Staff E dispensed the medications by keeping the blister packaging in the drawer of the medication cart, popping the medication into her gloved hand then placing it into the medication cup. Staff E stated she had seen others take the packaging out of the cart (demonstrated) but it did not feel right to her. Staff E confirmed 4 tablets/capsules had been dispensed. Staff E entered the resident room and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2021-04-02 · tag F0800 — patternProvide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record reviews, and interviews, the facility failed to ensure that hot foods were held at 135 degrees Fahrenheit or higher on the steam table in one of one kitchen. Findings included: On 04/01/21 at 11:16 a.m., the main cook took the temperatures of the foods being served for lunch. The tuna melt was at 119 degrees Fahrenheit. The main cook reported to the Certified Dietary Manager (CDM) that the temperature of the tuna melt was at 119 degrees Fahrenheit. The CDM stated that the temperature was ok and that the recipe stated to grill cheese until melted and she continued making more tuna melts on the stove. At 11:25 a.m., the Registered Dietitian (RD) stated the holding temperature should be at least 135 degrees Fahrenheit for the tuna melts and they should be cooked as they go. The RD stated the recipe was tricky. She then stated a temperature of 119 degrees Fahrenheit was ok for the tuna melts because the tuna was probably made last night and the toast had to be heated. Staff continued placing sandwiches on trays for lunch for residents. The facility provided…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2021-04-02 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to develop and implement a comprehensive careplan for 1 of 3 (#72) residents sampled for pain. Findings included: Review of Resident #72's record revealed that this resident was admitted to the facility on [DATE], had a Brief Interview For Mental Status (BIMS) score of 13 (Cognitively intact), with diagnoses that included Hemiplegia and Hemiparesis following cerebral infarction affecting right dominant side. Review of the resident's physician order summary revealed that this resident had current orders that included the following: -Hydrocodone-Acetaminophen 5-325 MG, Give 1 tablet by mouth every 8 hours as needed for pain - Severe (8-10) -Acetaminophen tablet 325 MG, Give 2 tablet by mouth every 4 hours as needed for general discomfort -Gabapentin Capsules, Give 300 mg by mouth at bedtime for pain related to TYPE 2 DIABETES MELLITUS WITH DIABETIC NEUROPATHY Review of the March 2021 and April 2021 Medication Administration Record (MAR) revealed that…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-04-02 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one Resident #184 was receiving oxygen according to professional standards of practice of three residents sampled. Findings Included: Observation of Resident #184 on 3/30/21 at 4:00 p.m. the resident was lying in bed on the Covid-19 positive unit with oxygen set at 3 liters via nasal cannula. Staff member B, LPN confirmed the oxygen was set at 3 liters. An interview with Staff member E, LPN on 3/30/21 at 4:02 p.m. confirmed the resident was on continuous oxygen. Observation of Resident #184 on 4/1/21 at 5:45 p.m. sitting up in bed on the Covid-19 positive unit with oxygen set at 2.5 liters via nasal cannula. Staff member B, LPN confirmed the oxygen was set at 3 liters via nasal cannula and stated the resident should have an order for the oxygen. Resident #184 admitted on [DATE] and diagnosed with Covid-19 on 3/25/21 where he was moved to the Covid-19 positive unit. Review of physician orders revealed an order for oxygen 2 liters via…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-04-02 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to notify the physician of pharmacy recommendations for 1 of 5 (#48) residents reviewed for unnecessary medications Findings included: Review of Resident #48's record revealed that this resident was admitted to the facility on [DATE] with a readmission date of 2/16/21. Review of Resident #48's physician orders revealed that she has current orders for Clonazepam 0.5 milligrams (mg) and Oxycodone HCI 5 mg for pain. Review of the resident record revealed that the consultant pharmacist completed the monthly drug regimen reviews with the following recommendations: -Recommendation date: 2/2/21- Comment: The resident receives a long-acting Benzodiazepines, Clonazepam 0.5 mg GIVE 1 TABLET BY MOUTH AT BEDTIME DX:SLEEP/INSOMNIA for anxiety which is a high risk medication in the elderly due to the increased risk of drowsiness, depression, confusion, addiction, and falls. There is no documentation of failure/contraindication to first-line therapies (e.g., SSRI, SNRI…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2021-04-02 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, record reviews, and interviews the facility failed to ensure that the medication error rate was less than 5.00%. Thirty-one medication administration opportunities were observed and two errors were identified for one Resident (#55) of ten residents observed. These errors constituted a 6.45% medication error rate. Findings Included: Observation of medication administration on 4/1/21 at 11:02 a.m. with Staff member D, LPN and Resident #55. Staff member D, checked the blood sugar for Resident #55 with a result of 154. Review of physician orders for the sliding scale of Novolog solution 100 unit/ml included 151 - 200 equals giving 2 units of insulin. Prime pen with 2 units air shot prior to insulin administration. Staff member D, verified the Novolog flex pen for resident #55 and placed a new needle on the pen. At 11:10 a.m. Staff member D, gave 2 units of Novolog without priming the pen of 2 units prior to use. During an interview with Staff member D, LPN she confirmed she would prime the Novolog flex pen with 2 units of insulin and remove the air prior to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to SOLARIS HEALTHCARE — 22 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 4.0 | -1.0 vs chain |
| Health inspection | 3 of 5 | 3.5 | -0.5 vs chain |
| Staffing | 4 of 5 | 3.8 | +0.2 vs chain |
| Quality measures | 4 of 5 | 4.5 | -0.5 vs chain |
The other 21 homes this chain runs (chain average 4.0★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| ZEPHYRHILLS SOUTH SNF OPERATIONS HOLDINGS LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 06/05/2023 |
| ACC SNF OPERATIONS HOLDINGS LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 06/05/2023 |
| CH ACC HOLDINGS LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 06/05/2023 |
| SEAM TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 06/05/2023 |
| SK HOLDINGS ACC HOLDINGS LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 06/05/2023 |
| KLEIN, SOLOMON | Individual | CORPORATE OFFICER | — | since 06/05/2023 |
| WILKINS, STACEY | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 06/05/2023 |
5 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 79% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $1.8M paid to related parties — landlords or management companies under common ownership — equal to about 21% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in FL
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Florida Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 105658. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-07-30, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.