Public Record
Evergreen Woods
From CMS
Facility profile
- CMS overall rating
- 3 / 5
- Certified beds
- 120
- Avg. residents per day
- 111.8
*CMS Five-Star
*CMS
*CMS
Inspection record
On record from CMS
- Citations on record
- 28
- Inspections on file
- 7
- Last inspection
- 2025-07-22
*CMS
*CMS
*CMS
Citations
28 citations on record
Each deficiency cited on a CMS health inspection of this facility, sourced from the federal record. Open a report for the raw CMS Scope and Severity grade on each finding.
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
- 0806Seriousimmediate jeopardy
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
- 0641Generalpotential for harm
Ensure each resident receives an accurate assessment.
- 0004Generalpotential for harm
Develop and maintain an Emergency Preparedness Program (EP).
- 0291Generalpotential for harm
Install emergency lighting that can last at least 1 1/2 hours.
- 0761Generalpotential for harm
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
- 0732Generalpotential for harm
Post nurse staffing information every day.
- 0578Generalpotential for harm
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
- 0838Generalpotential for harm
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
- 0842Generalpotential for harm
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
- 0880Generalpotential for harm
Provide and implement an infection prevention and control program.
- 0690Generalpotential for harm
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
- 0695Generalpotential for harm
Provide safe and appropriate respiratory care for a resident when needed.
- 0655Generalpotential for harm
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
- 0684Generalpotential for harm
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- 0689Generalpotential for harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- 0363Generalpotential for harm
Install corridor and hallway doors that block smoke.
- 0920Generalpotential for harm
Ensure proper usage of power strips and extension cords.
- 0923Generalpotential for harm
Have proper medical gas storage and administration areas.
- 0695Generalpotential for harm
Provide safe and appropriate respiratory care for a resident when needed.
- 0812Generalpotential for harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- 0741Generalpotential for harm
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
- 0915Generalpotential for harm
Have proper power supply for life support equipment.
- 0695Generalpotential for harm
Provide safe and appropriate respiratory care for a resident when needed.
- 0732Generalno actual harm
Post nurse staffing information every day.
- 0880Generalpotential for harm
Provide and implement an infection prevention and control program.
- 0222Generalpotential for harm
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
- 0300Generalpotential for harm
Meet other general requirements that are deficient.
- 0353Generalpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
Inspection findings
What the surveyors documented
The verbatim CMS Form 2567 statement of deficiencies for each survey, straight from the federal record. Open a report for the full findings and plan of correction.
- Inspection1 deficiency
F 0806 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED…
Read full statement of deficiencies - Inspection14 deficiencies
F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN…
Read full statement of deficiencies - Inspection6 deficiencies
F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure oxygen…
Read full statement of deficiencies - Inspection7 deficiencies
F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the…
Read full statement of deficiencies
FAQ
Questions and answers
- What is Evergreen Woods?
- Evergreen Woods is a Medicare- and Medicaid-certified nursing home in Spring Hill, FL, tracked by the Centers for Medicare & Medicaid Services (CMS). Its CMS Certification Number (CCN) is 105397.
- What is the CMS rating for Evergreen Woods?
- Evergreen Woods has a CMS overall rating of 3 out of 5 stars. CMS rates nursing homes on health inspections, staffing, and quality measures.
- How many beds does Evergreen Woods have?
- Evergreen Woods is certified for 120 beds. It serves an average of 111.8 residents per day.
- How many citations does Evergreen Woods have?
- Evergreen Woods has 28 citations on record from CMS health inspections, each tied to a federal deficiency tag.
- When was Evergreen Woods last inspected?
- Evergreen Woods was last inspected on July 22, 2025. CMS surveys nursing homes about once a year and after complaints.
- What can I do if I have concerns about care at this facility?
- Start by raising the concern with the facility administrator or director of nursing. Every state also runs a free long-term care ombudsman program that advocates for residents and families; the federal Eldercare Locator at eldercare.acl.gov can connect you with yours. Complaints about quality of care can also be filed with your state survey agency.
*Sourced from the Centers for Medicare & Medicaid Services (CMS). See the official record on CMS Care Compare. If you believe any information is inaccurate, report it here.
/nursing-home/105397-evergreen-woods