Average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Hillside Health And Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors found two containers of expired cottage cheese in the refrigerator and observed a meat slicer covered as if clean but with visible food debris on its base and blade. The Dietary Manager confirmed both the expired food and the improper cleaning of the equipment, in violation of facility policies on food storage and sanitation.
Surveyors found that several residents did not receive respiratory care in accordance with physician orders and facility policy. Oxygen was administered at incorrect flow rates for two residents, and nebulizer equipment for two others was not stored in a hygienic, labeled manner as required. Staff interviews revealed a lack of awareness of proper oxygen settings and inconsistent adherence to respiratory care protocols.
A resident with type 2 diabetes did not receive insulin as ordered on several occasions, with documentation indicating the dose was held due to low blood sugar. An LPN held the morning insulin dose without notifying the provider, contrary to expectations. The DON and APRN both stated that insulin orders should be followed and the provider should be notified if insulin is withheld.
A resident with multiple chronic conditions received Metoprolol for hypertension on numerous occasions when their blood pressure readings were below the physician-ordered parameters. Medication administration records and staff interviews confirmed that the medication was given outside of the specified limits, and staff were not consistently aware of or adhering to the required parameters.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
A resident's urinary catheter bag was left uncovered and visible in the room, causing embarrassment to the resident. The DON confirmed that all Foley catheter bags should have a dignity cover, and facility policy requires maintaining resident dignity. The failure to cover the catheter bag was contrary to both policy and the resident's expressed wishes.
A resident with multiple medical conditions was found to have unsupervised access to cigarettes and lighters in their room, contrary to facility policy requiring smoking materials to be secured and only distributed during supervised smoking times. Staff interviews and observations confirmed that the facility did not enforce its own procedures for securing smoking materials.
A resident with a midline catheter had a dressing with gauze that was not changed according to physician orders and professional standards, remaining in place for at least seven days instead of every two days as required. Facility staff, including an LPN and the DON, demonstrated a lack of knowledge regarding the correct frequency for changing such dressings, and no midline catheter policy was provided during the survey.
The facility did not ensure monthly medication regimen reviews were completed by a pharmacist for two residents, and physicians failed to provide clinical rationales when disagreeing with pharmacy recommendations regarding medication management. The DON confirmed missing documentation for both the reviews and the required physician rationales.
A resident with multiple health conditions did not receive timely incontinence care due to staffing shortages, leading to inadequate wound care and improper hygiene practices by a CNA. The facility's staffing adjustments based on census and an aide's absence resulted in fewer available aides, impacting the resident's care. The DON confirmed that the expected two-hour incontinence care schedule was not followed.
A resident with multiple wounds did not receive proper wound care and infection control practices. An LPN failed to clean the overbed table, use a barrier for supplies, and follow hand hygiene protocols during wound care. The resident's care plan was not followed, and the antifungal powder was not used correctly. Interviews with the NHA and DON confirmed that infection control policies were not adhered to, contributing to the deficiency.
Expired Food and Unclean Equipment in Kitchen
Penalty
Summary
During a kitchen tour with the Dietary Manager, surveyors observed two containers of cottage cheese in the walk-in refrigerator that were past their expiration date. Additionally, a covered meat slicer was found to have food particle debris on its base and blade, despite being covered as if it were clean. The Dietary Manager confirmed both the presence of expired food and the unclean condition of the meat slicer, acknowledging that expired foods should be disposed of by or on their expiration date and that equipment should not be covered until properly cleaned. A review of facility policies indicated that food should be stored according to safe food handling practices and that all utensils and equipment should be kept clean except during active use.
Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards of practice for four residents requiring oxygen therapy or nebulizer treatments. For one resident with COPD, the oxygen was not set at the physician-ordered rate of 2 liters via nasal cannula as needed for shortness of breath or oxygen saturation below 93%. The resident stated reliance on staff for oxygen management, and the LPN was unaware the oxygen setting was incorrect, attributing it to possible accidental adjustment during care. The DON confirmed there was no specific policy for oxygen administration. Another resident with Parkinson's disease and congestive heart failure was observed with an oxygen concentrator set at 4 liters per minute, contrary to the physician's order for continuous oxygen at 2 liters via nasal cannula. The oxygen concentrator was also placed out of the resident's reach. The LPN acknowledged the discrepancy and stated the need to follow physician orders. Additionally, two residents receiving nebulizer treatments had their nebulizer masks improperly stored. One resident's nebulizer mask was left unbagged and unlabeled on the bedside table, and another's was left on a blanket on a chair after use. Facility policy required nebulizer equipment to be stored hygienically, bagged, and labeled when not in use. The DON confirmed the expectation for proper storage of respiratory equipment, and facility policy supported this requirement.
Failure to Administer Insulin per Physician Orders and Notify Provider
Penalty
Summary
The facility failed to administer insulin according to physician orders for a resident diagnosed with type 2 diabetes mellitus. The physician's order specified that the resident should receive 50 units of Insulin Glargine at bedtime and 5 units in the morning. Review of the medication administration records showed that on multiple occasions, the morning dose of insulin was not administered, and a chart code indicating 'Pulse below 60/min Ineffective' was documented. During interviews, an LPN confirmed holding the morning insulin dose due to low blood sugar and referenced parameters for another insulin, but did not notify the physician as required. The DON stated that staff are expected to follow insulin orders, and the APRN confirmed that they expect to be notified if insulin is held and that parameters should be followed.
Failure to Follow Physician-Ordered Parameters for Antihypertensive Medication
Penalty
Summary
The facility failed to ensure that physician-ordered parameters for antihypertensive medication administration were followed, resulting in the administration of unnecessary medications to a resident. The resident had multiple diagnoses, including atrial fibrillation, heart failure, malnutrition, COPD, diabetes, osteoarthritis, esophageal cancer, and atherosclerotic heart disease. The physician's order for Metoprolol Succinate ER specified that the medication should be held if the systolic blood pressure (SBP) was less than 100, diastolic blood pressure (DBP) was less than 60, or heart rate (HR) was less than 60. Despite these parameters, medication administration records showed that the resident received Metoprolol on multiple occasions when their blood pressure readings were below the specified thresholds. Interviews with staff revealed a lack of awareness and adherence to the ordered parameters. One LPN admitted to administering the medication even when the resident's blood pressure was outside the prescribed limits, stating they did not realize the error at the time. The Director of Nursing confirmed that all medications should be administered or held according to written parameters. This failure to follow physician orders led to the administration of unnecessary antihypertensive medication to the resident.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report notes the absence of a comprehensive infection prevention and control program but does not provide further details regarding specific actions, inactions, or events, nor does it mention any particular residents or staff involved.
Failure to Maintain Resident Dignity by Leaving Catheter Bag Uncovered
Penalty
Summary
A deficiency was identified when a resident's urinary catheter collection bag was observed hanging uncovered on the left side of the bed, containing 300 milliliters of yellow fluid, with a towel placed underneath on the floor. The resident reported that the urine bag had not been covered, expressing embarrassment that it was visible to anyone entering or passing by the room. This observation was confirmed during an interview, and the resident's medical record indicated a history of urinary retention and other medical conditions requiring the use of an indwelling urinary catheter. The facility's Director of Nursing stated that all Foley catheter bags should have a dignity cover. Review of the facility's catheter care policy indicated that dignity should be maintained and catheter coverings are not required only when drainage bags are out of public sight or per resident preference. The facility's resident rights policy also emphasized the right to a dignified existence and to be treated with respect. In this case, the resident's dignity was not maintained as the catheter bag was left uncovered and visible, contrary to both facility policy and the resident's expressed wishes.
Failure to Secure Smoking Materials and Enforce Smoking Policy
Penalty
Summary
The facility failed to provide a safe environment and did not implement its policy on securing smoking materials for one resident. Observation revealed that the resident, who had multiple medical diagnoses including fractures, COPD, diabetes, heart failure, and hypertension, kept a pack of cigarettes and two lighters in a clear plastic bag attached to the bedside table. The resident confirmed during an interview that they kept their cigarettes and lighter in the room and stated that staff did not object to this practice. Further observation showed the resident moving independently in a wheelchair and inquiring about missing cigarettes, indicating unsupervised access to smoking materials. The facility's policy requires that residents with independent smoking privileges are not permitted to keep smoking materials or lighters in their possession and that these items must be secured by nursing personnel except during supervised smoking times. The Nursing Home Administrator confirmed that it is the facility's responsibility to ensure smoking materials are locked up and only distributed during scheduled smoking breaks, with staff responsible for returning them to secure storage afterward. Despite this policy, the resident was able to keep and access smoking materials unsupervised, constituting a failure to follow established safety procedures.
Failure to Change Midline Catheter Dressing with Gauze per Standards
Penalty
Summary
A deficiency was identified when a resident with a left upper arm single lumen midline catheter was observed with a dressing dated seven days prior, and gauze was present under the transparent semi-permeable dressing. According to the physician's order, the dressing was to be changed within 24 hours of admission, insertion, or reinsertion, and then every seven days or as needed, using sterile technique. The order also specified that dressings with gauze should be changed every two days. However, the dressing with gauze remained in place for at least seven days, contrary to both the physician's order and professional standards of practice. Interviews with facility staff revealed a lack of knowledge regarding the appropriate frequency for changing midline catheter dressings, particularly when gauze is used. The LPN interviewed was unaware that dressings with gauze required more frequent changes, and the DON confirmed that such dressings should be changed every two days. The facility was unable to provide a midline catheter policy and procedure upon request. Review of CDC guidelines also indicated that dressings should be replaced when soiled or when gauze is used, supporting the need for more frequent changes than what was observed.
Failure to Complete Monthly Medication Regimen Reviews and Document Physician Rationale
Penalty
Summary
The facility failed to ensure that a licensed pharmacist performed monthly medication regimen reviews (MRRs) for residents, as required by policy and regulation. Specifically, for one resident, there was no documentation of a pharmacist-conducted MRR for three separate months, despite the resident being continuously admitted during that period. Additionally, a pharmacy review identified a significant drug interaction and made a recommendation regarding the resident's medication regimen, but while the physician disagreed with the recommendation, no clinical rationale was documented for this disagreement. For another resident, the consultant pharmacist recommended a gradual dose reduction of an antidepressant medication, but the physician disagreed without providing a clinical rationale either on the form or in a progress note. The facility's policy requires that physicians and staff identify and address potentially significant medication-related problems, and that consultant pharmacists use monthly reviews to identify problematic medications. Interviews with the DON confirmed the lack of required documentation and rationale in both cases.
Inadequate Incontinence Care Due to Staffing Issues
Penalty
Summary
The facility failed to ensure that Activities of Daily Living (ADLs), specifically incontinence care, were adequately performed for a resident. During an observation, it was noted that the resident, who was sitting in a wheelchair, had not received timely incontinence care. Staff C, a CNA, admitted that she had been trying to change the resident since 11:00 a.m. but was unable to do so due to being pulled to other duties, such as passing meal trays. The resident was found with a saturated dressing on her buttocks, indicating a lack of timely wound care, and the CNA did not follow proper hand hygiene protocols during the care process. The resident involved had a medical history that included atrial fibrillation, morbid obesity, dementia, hypertension, osteoarthritis, and a disorder of the kidney and ureter. The resident was at risk for skin impairment due to fragile skin, incontinence, and decreased mobility. The care plan indicated that the resident required extensive assistance with ADLs, including toileting and transfers, and was at risk for complications related to bowel and bladder incontinence. Despite these needs, the facility's staffing issues led to inadequate care, as there were fewer aides available than usual, and the CNA responsible for the resident was assigned additional duties. Interviews with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) revealed that staffing was adjusted based on census, and an aide had called off for the shift, leading to a shortage. The DON stated that residents should receive incontinence care every two hours, but this was not adhered to in the case of the resident. The facility's policy on ADL care and services emphasized the importance of providing necessary care to maintain residents' ability to carry out ADLs, but this standard was not met due to the staffing challenges and the subsequent delay in providing incontinence care.
Inadequate Wound Care and Infection Control Practices
Penalty
Summary
The facility failed to provide adequate wound care and adhere to infection control practices for a resident with multiple wounds. During an observation, a Licensed Practical Nurse (LPN) was seen performing wound care without cleaning the overbed table or placing a barrier before setting down supplies. The LPN also failed to follow proper hand hygiene protocols, as she did not sanitize her hands between glove changes and handled contaminated items without changing gloves. The antifungal powder bottle lid fell on the floor, and the LPN picked it up and placed it back on the bottle without sanitizing her hands or changing gloves. The resident in question had a history of multiple medical conditions, including atrial fibrillation, morbid obesity, dementia, and moisture-associated skin damage (MASD) on the buttocks and coccyx. The resident's care plan included specific wound care orders, which were not followed during the observed procedure. The LPN used calcium alginate, which was not ordered for the resident, and failed to use the prescribed antifungal powder correctly. The resident's wounds were documented as not healed, with some showing signs of deterioration. Interviews with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) revealed that the facility's infection control policies were not followed. Supplies taken into the resident's room were not placed on a barrier, and contaminated items were not disposed of properly. The DON confirmed that hand hygiene should be performed before and after resident contact, between glove changes, and when handling contaminated items. The facility's failure to adhere to these protocols contributed to the deficiency in providing quality care and infection control for the resident.
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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) |
|---|---|---|---|---|
| Solaris Healthcare Zephyrhills | 1.1 mi | ★★★★★ | 0 | 0 |
| Solaris Healthcare Lake Zephyr | 1.3 mi | ★★★★★ | 2 | 0 |
| Adventhealth Dade City | 6.9 mi | — | 0 | 0 |
| Royal Oak Nursing Center | 7.2 mi | ★★★★★ | 1 | 0 |
| Dade City Health And Rehabilitation Center | 7.7 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 July 2026) and official state health department websites.