Solaris Healthcare Lake Zephyr
SOLARIS HEALTHCARE LAKE ZEPHYR in ZEPHYRHILLS, FL — inspection on November 24, 2025.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During an interview at 3:16 p.m. on 11/24/2025, the Nursing Home Administrator (NHA) stated when residents complain of disturbances from roommates, the expectation was for the staff to attempt to resolve the situation.
The NHA stated grievances are for more detailed concerns like missing items.
The NHA was not aware of Resident #5's complaint of roommate disturbance keeping Resident #5 awake.
The NHA stated the expectations of the CNA, was to notify the nurse and if unresolved to continue the chain of command to social services.
A policy titled: Filling Grievances and Complaints, with a review date of 01/2024, revealed: Policy Statement Our facility will help residents, their representatives, other interested family members, or resident advocates file grievances or complaints when such requests are made.
Policy Interpretation and Implementation
- Any resident, representative, family member, or appointed advocate may file a grievance or complaint
concerning treatment, medical care, behavior of other residents, staff members, theft of property, etc., without fear of threat or reprisal in any form. 2.
Upon admission, residents are provided with written information on how to file a grievance or complaint. A copy of our grievance/complaint procedures is posted on the center bulletin board. 3.
Grievances and/or complaints may be submitted orally or in writing. 4.
The Administrator has delegated the responsibility of grievance and/or complaint investigation to the Grievance Officer. 5.
Upon receipt of a grievance and/or complaint, the Grievance Officer will investigate the allegations and submit a written report of such findings to the Administrator within five (5) working days of receiving the grievance and/or complaint. 6.
The Administrator will review the findings with the person investigating the complaint to determine what corrective actions, if any, need to be taken. 7.
The resident, or person filing the grievance and/or complaint on behalf of the resident, will be informed of the findings of the investigation and the actions that will be taken to correct any identified problems. A written summary of the investigation will also be provided to the resident, and a copy will be maintained in the grievance log. 8.
Should the resident not be satisfied with the result of the investigation, or the recommended actions, he or she may file a written complaint to the office of the local ombudsman or to the state survey and certification agency. (Note: Address and telephone numbers of these agencies are posted on the center bulletin board.)
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/24/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Solaris Healthcare Lake Zephyr
38250 A Ave Zephyrhills, FL 33542
SUMMARY STATEMENT OF DEFICIENCIES
order diagnostic and lab testing based on diagnostic and monitoring needs.2.
The staff will process test requisitions and arrange for test.3.
The laboratory, diagnostic radiology provider, or other testing source will report test results to the facility.The Review by Nursing Staff showed:2.
The person who has to communicate results to a physician will review and be prepared to discuss the following (to the extent that such information is available): a.
The individual's current condition in any recent changes in status, including vital signs and mental status. b.
Major diagnosis, allergies, pertinent current medications, other recent pertinent lab work, actions already taken to address results and treat the resident, impertinent aspects of advanced directives (for example, limitations on testing and treatment); e.
Any concerns or issues the physician will expected to address upon receiving the results.
Review of the section, Determining the Reason for Testing revealed:1. If the results do not mute their proceeding criteria for immediate notification, then the nursing staff will review why the test was obtained, as well as the residents current clinical status including the presence of any signs and symptoms. a. If the resident has signs and symptoms of acute illness or condition change and he/ she is not stable or improving, or there are no previous results for comparison, then the nurse will notify the physician promptly to discuss the situation, including a description of relevant clinical findings as well as the test results. b. If the individual is stable or improving in the results do not warrant immediate notification, then the nursing staff may notify the physician routinely (for example, a stable individual with slightly abnormal follow up test results, or low or therapeutic drug blood levels),Review of Test Results showed The resident's attending physician will be notified of the results of diagnostic test.Review of policy - Skin and Wound Management, policy and procedure review12/10/2024, revealed staff would examine the skin of a new admission for ulcerations or alterations in skin.
The policy was specific towards Pressure/Injury(s)/Skin breakdown and not towards surgical wounds as discussed with the DON. A policy related to management of surgical wounds was not provided.
Facility ID: