Cycle 1
Health 2024-07-30 · Fire 2024-07-30
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Zephyrhills, FL
Solaris Healthcare Lake Zephyr
3-star overall rating with 3-star inspections with 5 recent health deficiencies
38250 A Ave, Zephyrhills, FL
(813) 782-5508
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
116
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Solaris Healthcare
Operator or chain grouping
Approved since
1989-06-28
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
22 facilities
Chain averages 4 overall / 3 health / 4 staffing / 5 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.66
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.77
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
2.10
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
3.53
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.43
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
3.20
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.48
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.68
CMS adjusted RN staffing hours
Adjusted total hours
3.63
CMS adjusted total nurse staffing hours
Case-mix index
1.33
Higher values indicate more complex resident acuity
RN turnover
37%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
48%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,627
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
35.51
Composite VBP score used to determine payment impact.
Payment multiplier
0.9891
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0.54
Baseline 20.15% · Performance 21.18% · Measure score 0.54 · Achievement 0.54 · Improvement 0
Healthcare-associated infections
6.59
Baseline 4.79% · Performance 5.87% · Measure score 6.59 · Achievement 6.59 · Improvement 0
Total nurse turnover
4.30
Baseline 49.27% · Performance 46.09% · Measure score 4.30 · Achievement 4.30 · Improvement 0.80
Adjusted total nurse staffing
2.77
Baseline 4.54 hours · Performance 3.87 hours · Measure score 2.77 · Achievement 2.77 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.18% |
10.72%
1.5 pts worse
|
No Different than the National Rate · Eligible stays 215 · Observed rate 13.95% · Lower 95% interval 9.41% |
| Discharge to community | 45.87% |
50.57%
4.7 pts worse
|
No Different than the National Rate · Eligible stays 168 · Observed rate 40.48% · Lower 95% interval 39.41% |
| Medicare spending per beneficiary | 1.05 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 95.93% |
95.27%
0.7 pts better
|
Numerator 259 · Denominator 270 |
| Falls with major injury | 0.37% |
0.77%
0.4 pts better
|
Numerator 1 · Denominator 270 |
| Discharge self-care score | 54.7% |
53.69%
1 pts better
|
Numerator 99 · Denominator 181 |
| Discharge mobility score | 27.62% |
50.94%
23.3 pts worse
|
Numerator 50 · Denominator 181 |
| Pressure ulcers or injuries, new or worsened | 3.33% |
2.29%
1 pts worse
|
Numerator 9 · Denominator 270 · Adjusted rate 2.95% |
| Healthcare-associated infections requiring hospitalization | 5.87% |
7.12%
1.2 pts better
|
No Different than the National Rate · Eligible stays 152 · Observed rate 4.61% · Lower 95% interval 3.63% |
| Staff COVID-19 vaccination coverage | 4.43% |
8.2%
3.8 pts worse
|
Numerator 7 · Denominator 158 |
| Staff flu vaccination coverage | 44% |
42%
2 pts better
|
Numerator 99 · Denominator 225 |
| Discharge function score | 48.07% |
56.45%
8.4 pts worse
|
Numerator 87 · Denominator 181 |
| Transfer of health information to provider | 97.73% |
95.95%
1.8 pts better
|
Numerator 86 · Denominator 88 |
| Transfer of health information to patient | 99.06% |
96.28%
2.8 pts better
|
Numerator 105 · Denominator 106 |
| Resident COVID-19 vaccinations up to date | 34.04% |
25.2%
8.8 pts better
|
Numerator 48 · Denominator 141 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.3 |
2.1
1.2 pts worse
|
1.9
1.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.3 · Observed 2.9 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.9 |
1.2
0.3 pts better
|
1.8
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.8 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
97.8%
2.2 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
99.2%
0.8 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.6% |
2.6%
About the same
|
3.3%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 2.5% · Q3 0.0% · Q4 2.2% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.9% |
3.7%
1.8 pts better
|
11.4%
9.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 6.7% · Q3 0.0% · Q4 0.0% · 4Q avg 1.9% |
| Percentage of long-stay residents who lose too much weight | 3.9% |
5.9%
2 pts better
|
5.4%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 9.1% · Q3 6.2% · Q4 0.0% · 4Q avg 3.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 3.7% |
15.7%
12 pts better
|
19.6%
15.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 4.3% · Q3 0.0% · Q4 6.0% · 4Q avg 3.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 2.0% |
9.8%
7.8 pts better
|
16.7%
14.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 3.4% · Q3 0.0% · Q4 3.0% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 8.1% |
11.7%
3.6 pts better
|
16.3%
8.2 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 8.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.1% |
9.8%
0.3 pts worse
|
14.9%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.1% · Q2 18.2% · Q3 6.5% · Q4 8.5% · 4Q avg 10.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.4%
0.4 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.5% |
0.8%
0.7 pts worse
|
1.7%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 2.6% · Q3 1.2% · Q4 1.1% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 9.8% |
12.5%
2.7 pts better
|
19.8%
10 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.1% · Q2 7.6% · Q3 8.9% · Q4 8.2% · 4Q avg 9.8% |
| Percentage of long-stay residents with pressure ulcers | 3.5% |
5.1%
1.6 pts better
|
5.1%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 3.6% · Q3 4.7% · Q4 2.0% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.3% |
94.3%
4 pts better
|
81.7%
16.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.6% · Q2 98.2% · Q3 98.8% · Q4 100.0% · 4Q avg 98.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.7% |
9.3%
2.6 pts better
|
12.0%
5.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.7% · Observed 7.2% · Expected 12.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.5% |
94.7%
0.8 pts better
|
79.7%
15.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.3% |
26.2%
0.9 pts better
|
23.9%
1.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.3% · Observed 27.6% · Expected 26.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-08-18 · Fire 2022-08-18
6 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2021-04-02 · Fire 2021-04-02
5 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2022-08-18
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-09-18
D · Potential for more than minimal harm
2022-08-18
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-09-18
D · Potential for more than minimal harm
2022-08-18
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-09-18
D · Potential for more than minimal harm
2022-08-18
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-09-18
D · Potential for more than minimal harm
2021-04-02
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-04-07
D · Potential for more than minimal harm
2021-04-02
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2021-05-02
D · Potential for more than minimal harm
2021-04-02
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2021-04-03
D · Potential for more than minimal harm
2021-04-02
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2021-04-09
D · Potential for more than minimal harm
2021-04-02
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2021-04-01
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-11-24
F585 · Resident Rights Deficiencies
Health
Honor 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.
Corrected 2025-12-18
D · Potential for more than minimal harm
2025-11-24
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-12-18
E · Potential for more than minimal harm
2024-07-30
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-08-30
E · Potential for more than minimal harm
2024-07-30
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-08-30
D · Potential for more than minimal harm
2024-07-30
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-08-30
D · Potential for more than minimal harm
2024-07-30
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-08-30
D · Potential for more than minimal harm
2024-07-30
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-08-30
E · Potential for more than minimal harm
2022-08-18
F885 · Infection Control Deficiencies
Health
Report COVID19 data to residents and families.
Corrected 2022-09-18
D · Potential for more than minimal harm
2022-08-18
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-09-18
D · Potential for more than minimal harm
2022-08-18
F700 · Quality of Life and Care Deficiencies
Health
Try 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.
Corrected 2022-09-18
D · Potential for more than minimal harm
2022-08-18
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-09-18
E · Potential for more than minimal harm
2021-04-02
F800 · Nutrition and Dietary Deficiencies
Health
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Corrected 2021-05-02
D · Potential for more than minimal harm
2021-04-02
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2021-05-02
D · Potential for more than minimal harm
2021-04-02
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2021-05-02
D · Potential for more than minimal harm
2021-04-02
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2021-05-02
D · Potential for more than minimal harm
2021-04-02
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2021-05-02
Penalties and ownership
What sits behind the stars
Ownership
Zephyrhills South SNF Operations Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
Acc SNF Operations Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Ch Acc Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Klein, Solomon
Corporate Officer · Individual
Seam Trust
5% Or Greater Indirect Ownership Interest · Organization
Sk Holdings Acc Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Wilkins, Stacey
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Hillside Health And Rehabilitation Center
Zephyrhills, FL
3-star overall rating with 2-star inspections with $3,728 in total fines with 9 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Solaris Healthcare Zephyrhills
Zephyrhills, FL
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Royal Oak Nursing Center
Dade City, FL
4-star overall rating with 3-star inspections with 6 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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