Inspection·September 27, 2022

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few with breathing), sepsis (a life threatening complication of infection) due to pseudomonas, type 2 diabetes mellitus, hyperlipidemia (high cholesterol), major depressive disorder, seizures, bipolar disorder, anxiety disorder, chronic kidney disease, anemia, and gastrostomy tube (a tube inserted into the stomach for feeding). During an observation on 9/26/2022 at 11:35 AM, Staff D, LPN, entered Resident #234's room and donned gloves without performing hand hygiene, assisted the resident in repositioning in bed and elevated the residents head of the bed. Resident #234 was using her abdominal muscles to breath and nodded her head when asked if she was short of breath. Staff D did not auscultate breath sounds or check oxygen saturation. Staff D opened the tracheostomy suctioning kit and placed it on the overbed table, removed the package of sterile gloves, opened the package and smoothed out the packaging with gloved hands, removed her gloves and placed the used gloves on the packaging with the sterile gloves. Staff D donned the sterile gloves without performing hand hygiene. Staff D removed the connector tubing from a clear plastic bag with her right hand, attached the suction tubing to the connector tubing, uncoiled the suction tubing with her right hand and began to suction down the tracheostomy tube using her right hand to pass the suction catheter through Resident #234's tracheostomy. Staff D maintained the suction catheter in the Resident #234's tracheostomy for 55 seconds, maintaining continuous pressure on the suction catheter while having it inserted into the tracheostomy, in 12 seconds placed the suction catheter into the tracheostomy and maintaining continuous pressure on the suction catheter for 10 seconds. Staff D removed gloves and exited the room. Staff did not assess Resident #234's oxygen saturation or breath sounds after suctioning. During an interview on 9/26/2022 at 11:48 AM, Staff D, LPN, stated, I should have assessed her [Resident #234] breath sounds and oxygen saturation while I suctioned her. I did not wash my hands after I took off my gloves. During an interview on 9/26/2022 at 1:45 PM, the Assistant Director of Nursing stated, We would follow professional standards for suctioning residents. Oxygen should be administered according to doctors' orders. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105397 If continuation sheet Page 2 of 6 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 105397 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evergreen Woods 7045 Evergreen Woods Trl Spring Hill, FL 34608 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 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm Based on observation and interview, the facility failed to post nurse staffing data on a daily basis. Findings include: Residents Affected - Many During an observation upon entry to the facility on 9/25/22 at 9:20 AM, there was a staffing posting on the front desk dated 9/23/2022 (photographic evidence obtained). During an interview on 9/26/2022 at 9:16 AM, the Administrator stated it would be the responsibility of the manager in charge to update the staffing posting. During an interview on 9/26/2022 at 9:25 AM, Social Service Director, who was the manager on duty at the time of entry, stated that she was not aware of that being part of her responsibility as manager on duty. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105397 If continuation sheet Page 3 of 6 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 105397 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evergreen Woods 7045 Evergreen Woods Trl Spring Hill, FL 34608 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program to prevent the possible development and transmission of communicable diseases and infections. The facility failed to ensure staff performed hand hygiene during six of seven medication administration observations and during tracheostomy care. Residents Affected - Some Findings include: 1. During an observation of medication administration on 9/26/2022 at 8:10 AM, Staff A, Licensed Practical Nurse (LPN), poured medications without performing hand hygiene for Resident #82, entered Resident #82's room without performing hand hygiene, administered the medications and returned to the medication cart to prepare medications for another resident without performing hand hygiene. During an observation of medication administration on 9/26/2022 at 8:20 AM, Staff A, LPN, poured medications without performing hand hygiene for Resident #42, entered Resident #42's room without performing hand hygiene, administered the medications and returned to the medication cart to prepare medications for another resident without performing hand hygiene. During an observation of medication administration on 9/26/2022 at 8:26 AM, Staff A, LPN, poured medications without performing hand hygiene for Resident #56, entered Resident #56's room without performing hand hygiene, administered the medications and returned to the medication cart and began to prepare medications for another resident. During an interview on 9/26/2022 at 8:30 AM, Staff A, LPN, stated, I should have used the hand sanitizer or washed my hands. I just got nervous being watched. During an observation of medication administration on 9/26/2022 at 8:35 AM, Staff B, LPN, poured medications without performing hand hygiene for Resident #59, entered Resident #59's room, administered the medications, and returned to the medication cart and began preparing medications for another resident. During an observation of medication administration on 9/26/2022 at 8:40 AM Staff B, LPN prepared medications for Resident #66 without performing hand hygiene, entered Resident #66's room without performing hand hygiene, administered the medications and returned to the medication cart and began to prepare medications for another resident. During an observation of medication administration on 9/26/2022 at 8:46 AM, Staff B, LPN, prepared medications for Resident #31 without performing hand hygiene, entered Resident #31's room without performing hand hygiene, administered the medications and returned to the medication cart and began to prepare medications for another resident. During an interview on 9/26/2022 at 8:52 AM, Staff B, LPN, stated, Oh, I should have used the hand sanitizer before I went into the room. I didn't always remember to use it when I went out of the room. Review of the policy and procedure titled Medication Administration with the last approval date of 2/24/2022 reads, 7.1 General Guidelines. Policy: Medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices and only by persons (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105397 If continuation sheet Page 4 of 6 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 105397 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evergreen Woods 7045 Evergreen Woods Trl Spring Hill, FL 34608 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication. Procedure . Medication Administration . 11. Hands are washed with soap and water and gloves applied before administration of topical, ophthalmic, optic, parenteral, enteral, rectal, and vaginal medications. Hands are washed with soap and water again after administration and with any resident contact. Anti-microbial sanitizer may be used in place of soap and water as allowed per state nursing regulations and facility policy. Note: Soap and water should always be used after contact with resident with Clostridium difficile (c. diff.) as antimicrobial sanitizer does not kill the spores produced by C diff, which may result in the spread of infection. Review of the policy and procedure titled, Hand Hygiene with the last approval date of 2/24/2022 reads, Policy: The facility considers hand hygiene the primary means to prevent the spread of infections. Procedure . 2. Personnel shall follow the handwashing/hand hygiene guidelines to prevent the spread of infections to other personnel, residents, and visitors . 5. Employees must wash their hands for Twenty (20) seconds using anti-microbial or non-antimicrobial soap and water under the following conditions . * Upon and after coming in contact with the resident's intact skin (e.g., when taking a pulse or blood pressure, and lifting a resident .* After removing gloves or aprons . 7. Hand hygiene is the final step after removing and disposing of personal protective equipment. 8. The use of gloves does not replace handwashing/hand hygiene. 2. Review of Resident #234's admission record documented that the resident was admitted to the facility with the diagnoses including acute respiratory failure (a serious condition that happens when the blood doesn't have enough oxygen) with hypercapnia (a buildup of carbon dioxide in the bloodstream), atrophy (wasting away of muscles), pneumonia due to pseudomonas, aphonia (the loss of the ability to speak), dysphagia (a swallowing problem), tracheostomy (a surgical hole in the windpipe to assist with breathing), sepsis (a life threatening complication of infection) due to pseudomonas, type 2 diabetes mellitus, hyperlipidemia (high cholesterol), major depressive disorder, seizures, bipolar disorder, anxiety disorder, chronic kidney disease, anemia, and gastrostomy tube (a tube inserted into the stomach for feeding). During an observation on 9/26/2022 at 11:15 AM, Resident #234 was resting in bed with a tracheostomy mask covering a tracheostomy, coughing frequently with a small amount of yellow secretions in the tracheostomy mask. Resident #234 called staff and requested suctioning. During an observation on 9/26/2022 at 11:35 AM, Staff D, LPN, entered Resident #234's room and donned gloves without performing hand hygiene, assisted the resident in repositioning in bed and elevated the residents head of the bed. Staff D opened the tracheostomy suctioning kit and placed it on the overbed table, removed the package of sterile gloves, opened the package and smoothed out the packaging with gloved hands, removed her gloves and placed the used gloves on the packaging with the sterile gloves. Staff D donned the sterile gloves without performing hand hygiene. Staff D removed the connector tubing from a clear plastic bag with her right hand, attached the suction tubing to the connector tubing, uncoiled the suction tubing with her right hand and began to suction down the tracheostomy tube using her right hand to pass the suction catheter through Resident #234's tracheostomy three times. Staff D removed gloves and left the room without performing hand hygiene. During an interview on 9/26/2022 at 11:48 AM, Staff D, LPN, stated, I did not wash my hands before I put my gloves on. I should not have placed the dirty gloves on the resident's table. I didn't realize that they touched the sterile gloves. I should have kept one hand sterile and not used it to suction the patient. I did not wash my hands after I took off my gloves. I should have. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105397 If continuation sheet Page 5 of 6 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 105397 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evergreen Woods 7045 Evergreen Woods Trl Spring Hill, FL 34608 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 0880 During an interview on 9/26/2022 at 1:45 PM, the Assistant Director of Nursing stated, Staff should follow all infection control policies for suctioning. We would follow professional standards for suctioning residents. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105397 If continuation sheet Page 6 of 6