Health inspection·January 19, 2024

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some room [ROOM NUMBER] had an unfinished base board under the cabinet with a thick buildup of soil. (Photographic evidence obtained) room [ROOM NUMBER] had paint peeling above the head of the bed. (Photographic evidence obtained) room [ROOM NUMBER] had an unfinished cabinet sitting on a bare soiled floor underneath. There was a missing base board in the room as well. (Photographic evidence obtained) room [ROOM NUMBER] had peeling paint on the wall. (Photographic evidence obtained) On 1/18/24 at approximately 11:45 AM, a tour of the shower rooms was conducted with the Director of Nursing (DON). Shower room [ROOM NUMBER] had excess build up of a thick white substance in the first shower where the floor meets the wall. The shower gurney in the room had white hairs scattered over it. The DON was as ked to explain the process for cleaning the gurney. She held up a bottle of quaternary cleaner and explained that the gurney is supposed to be wiped down after and before each use. Shower room [ROOM NUMBER] had excess black build up on grout and build up of a thick white substance on the tiles and under the hand rails. Shower room [ROOM NUMBER] had a large hole in the tile on the wall. (Photographic evidence obtained). On 1/19/24 at approximately 12:00 PM, an interview was conducted with the maintenance supervisor. He was shown pictures of the shower rooms. He explained that he was not aware of the hole in the shower tile and that the wall in shower room [ROOM NUMBER] had already been patched. He was shown the environmental concerns in the rooms. The Maintenance Supervisor explained that they have been renovating many of the rooms on one side of the building and these areas would be corrected. On 1/19/24 at approximately 1:00 PM, an interview was conducted with the Housekeeping Manager. He was shown pictures of the areas outlined above. He was asked if the areas should look like that. The Housekeeping manager explained that all areas of concern would be corrected. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105282 If continuation sheet Page 2 of 5 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105282 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eden Springs Nursing and Rehab Center 4679 Crawfordville Hwy Crawfordville, FL 32326 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, record review, and policy review, the facility failed to provide assistance with nail care for 4 of 10 resident sampled for Activities of Daily Living (ADL) care. (Resident #10, #12, #14, and #16) Residents Affected - Few The findings include: On 1/18/24 at 10:30 AM, during an interview with Resident #10, it was observed that the residents nails were long. The surveyor asked resident if she would like her nails trimmed. She indicated that she recently had pneumonia, which has made herbeen weak and would like assistance with getting her nails done. On 1/19/24, a review of the care plan for Resident #10 was conducted. The care plan noted that the resident has an ADL self-care performance deficit r/t Activity Intolerance, Fatigue, Impaired balance, Limited Mobility, Pain, and Shortness of Breath. The resident had been diagnosed with pneumonia on 1/16/24. The care plan directs staff to provide assistance as needed with ADLs. On 1/19/24 at approximately 11:00 AM, it was noted that Resident #12 had long soiled nails. Certified Nursing Assistant (CNA) E was in the room at the time of the observation. She was asked who is responsible for assisting residents with nail care. CNA E explained that nursing assistants are responsible and that she would get his nails cleaned. On 1/19/24, a review of the care plan for Resident #12 was conducted. The care plan noted that Resident #12 has an ADL self-care performance deficit r/t impaired balance limited mobility, pain, and weakness. His care plan directed care staff to check nail length and trim and clean on bath day and as necessary and to report any changes to the nurse. On 1/19/24, during an interview with Resident #14, his nails were noted to be long. He was asked if he would like assistance trimming his nails. The resident indicated that he would love some assistance with nail care. On 1/19/24, a review of the care plan for Resident #14 was conducted. The care plan noted that Resident #14 has an ADL self-care performance deficit related to weakness and depression and bilateral below the knee amputation. The care plan directed staff to check nail length and trim and clean on bath day and as necessary. On 1/19/24 at approximately 12:30 PM, an observation was made of Resident #16. His nails appeared long and untrimmed. A review of the care plan for Resident #16 was conducted. The care plan noted that Resident #16 has an ADL self-care performance deficit related to Dementia with behavior and physical needs due to amputation of the right leg. His care plan directed staff to check nail length and trim and clean on bath day and as necessary. On 1/19/24 at approximately 1:00 PM, an interview was conducted with the Director of Nursing concerning the issues with nail care. She was asked to provide a copy of the facility's nail care policy. She provided a policy that included a CNA monthly check off sheet that mentioned, ensure residents nails are trimmed and clean report to nurse any diabetic residents who needs nail care. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105282 If continuation sheet Page 3 of 5 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105282 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eden Springs Nursing and Rehab Center 4679 Crawfordville Hwy Crawfordville, FL 32326 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews with staff and residents, the facility failed to maintain an effective pest control program. Residents Affected - Some The findings include: Observations: On 1/18/24 at approximately 10:15 AM, a live roach was observed crawling on the floor in room [ROOM NUMBER]A. (Photographic evidence obtained) On 1/18/24 at approximately 11:20 AM in room [ROOM NUMBER], there was a roach on the floor under an unfinished cabinet. (Photographic evidence obtained) Interviews: Based upon the observations made by surveyors, staff and residents were asked about the effectiveness of the pest control program at the facility. On 1/18/24 at approximately 10:15 AM, Certified Nursing Assistant (CNA) E said she sees roaches crawling around the facility frequently. On 1/18/24 at approximately 10:20 AM, CNA H was asked if she sees pests around the facility. She explained that she mostly sees roaches. She explained that it has been a consistent problem at the facility. On 1/18/24 at approximately 10:30 AM an interview was conducted with Resident #10. She said there are roaches in her room. She worries they will get into her food. On 1/19/24 at approximately 11:00 AM, an interview was conducted with Resident #15. When asked if she ever sees bugs, she responded by explaining that she sees roaches every day. She said, I had one on my hand the other day. They are everywhere. On 1/19/24 at approximately 11:30 AM, Resident #17 explained that she saw live roaches 2 days ago and killed them. On 1/19/24 at approximately 11:40 AM, Resident #18 was asked about pests. She explained that she has seen roaches in her room often. On 1/19/24 at approximately 12:00 PM, Resident #19 mentioned during an interview that she sees roaches in her room all the time. On 1/18/24 at approximately 3:00 PM, an interview was conducted with the Maintenance Supervisor. The surveyor notified him that there had been complaints about roaches. He was asked to provide pest control treatment invoices. He explained that the facility had discontinued using an outside pest control contractor to treat pests about a year ago. When asked to specify the type of pests he is treating and to explain how he is tracking the effectiveness of the treatments he is applying, he (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105282 If continuation sheet Page 4 of 5 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105282 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eden Springs Nursing and Rehab Center 4679 Crawfordville Hwy Crawfordville, FL 32326 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0925 Level of Harm - Minimal harm or potential for actual harm explained that he is doing treatments once a week and as needed. He explained that most of what they are treating is small roaches. The facility has a log book that was signed off when treatments are completed. He stated one half of the building gets treated once a week and then the other half the other week. Treatments are also applied as needed. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105282 If continuation sheet Page 5 of 5