Inspection·May 21, 2025

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Emergency response would come and they can call family and confirm or ask the residents if they have an emergency while they are outside of the facility they will be consider a full code. If the resident goes to the hospital, they will do their own advanced directives. During an interview on [DATE] at 11:41 AM, the Medical Director stated, We usually have the certificate which is the yellow form filled out by the resident and I would sign it. Of course, we need to have that form in order for the resident to be considered a DNR. It is the rule. During an interview on [DATE] at 3:20 PM, the Director of Nursing stated, We do need to have a DNR form filled out for every resident that requests to be a DNR. [Resident #105's name] and [Resident #272's name] did not have one. Review of the facility policy and procedure titled, CPR [Cardiopulmonary Resuscitation] Code Status Orders & Response with the last review date of [DATE] read, Policy: The facility provides Basic Life Support (BLS) CPR only. The physician's order for full code or Do Not Resuscitate is written based on the wishes of the resident/resident representative. Advanced Directives will be honored. Do Not Resuscitate (DNR) ORDER: Cardiopulmonary resuscitation will not be initiated in the absence of pulse or respirations. In the absence of Advance Directives or physician orders, the resident will be considered a Full Code status, unless the resident and/or resident representative verbalizes wishes on admission assessment to change to withhold CPR . Code status orders will be renewed by physician's review and signature on monthly orders. Code status physician's order (DNR or Full Code), state specific forms and/or resident preference documentation will be filed as he first item within the medical record. Social Services will be notified if resident has any general questions and concerns about advance directives. The facility does not provide Advance Life Support. Review of the facility policy and procedure titled, Advance Medical Directives- Do Not Resuscitate (DNR) with the last review date of [DATE] read, Policy: Every person has the right to make decisions regarding their medical treatment, provided that person is capable of understanding the treatment, risks, complications, and alternatives. Individuals are presumed to have decision-making capacity until deemed otherwise. An Advance Medical Directive is a written instruction regarding care and treatment, such as Living Will, Designation of Healthcare Surrogate, Power of Attorney, or Durable Power of Attorney for Health Care. It is recognized under state law and relates to the provision of such care when a person becomes incapacitated. On admission or readmission, the facility team should ask the resident if the information is still current and notify the Attending Physician and staff if the resident wishes to change resuscitation status. Document the conversation in the medical record. Contact the physician for an order, however, if the physician is not immediately able to provide a written order, two (2) nurses may take a verbal order document in the resident record, print the order, and place as the first document on the chart, while awaiting a written physician's order to change status. The facility will confirm the physician's order and document the chosen code status. The difference between an Advance Medical Directive and a Do Not Resuscitate (DNR) order is that a DNR deals specifically with the declination of cardiopulmonary resuscitation in the event of cardiac or respiratory arrest. Living Wills, and/or Advance Directive, deal with a broader spectrum of end-of-life related issues. At the time of admission, the admission Coordinator/designee shall furnish residents, family members, and/or the legal representative with information regarding Advance Medical Directives. The resident and/or their representative shall be instructed to provide the facility with a copy of any current Advance Directives that will be placed by Social Services in the medical record. Completion of an Advance Directive is not a requirement for admission or continued stay in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105397 If continuation sheet Page 2 of 22 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 05/21/2025 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure resident assessments accurately reflected the residents' status for 2 of 8 residents reviewed (Residents #269 and #69). Residents Affected - Few Findings include: Review of Resident #269's physician order dated 2/9/2025 read, Oxygen at 2 LPM [liter per minute] via NC [nasal cannula] PRN [as needed] for SOB [shortness of breath] as needed for shortness of breath. Review of Resident #269's Minimum Data Set (MDS) assessment dated [DATE] showed no oxygen therapy for the resident under Section O- Special Treatments, Procedures, and Programs. Review of Resident #269's Weights and Vitals Summary showed the resident received oxygen via nasal cannula on 4/26/2025 at 12:31 PM and 7:45 PM, 4/27/2025 at 8:13 AM and 7:24 AM, 4/28/2025 at 11:23 AM and 10:05 PM, 4/29/2025 at 2:41 AM, and 5/3/2025 at 11:46 AM and 8:33 PM. During an interview on 5/20/2025 at 3:00 PM, Staff H, MDS Registered Nurse, stated, I was looking at [Resident #269's name] medication and treatment records. I was not looking at the vital task for the three-day lookback. I will have to find out with the nurses if the documentation is accurate to see if it needs to be modified. During an interview on 5/21/2025 at 8:30 AM, the Director of Nursing (DON) stated, The MDS for [Resident #269's name] had to be modified because she did receive oxygen during the three-day lookback. We follow the RAI [Resident Assessment Instrument] manual.2) Review of Resident #69's annual MDS assessment dated [DATE] showed the resident used wander/elopement alarm daily under Section P- Restraints. During an observation on 5/19/2025 at 8:31 AM, Resident #69 had no Wanderguard on any of her wrists. Review of Resident #69's active physician orders showed no order for a Wanderguard. During an interview on 5/21/2025 at 9:09 AM, Staff D, Licensed Practical Nurse (LPN), confirmed that Resident #69 did not have a Wanderguard on. During an interview on 5/21/2025 at 9:44 AM, Staff H, MDS Registered Nurse, stated that the Wanderguard documentation in Resident #69's annual MDS dated [DATE] under Section P was an error in documentation and the resident did not have a Wanderguard. During an interview on 5/21/2025 at 12:25 PM, the DON stated that her expectation was that orders would be read completely and all information documented in a resident's chart to be accurate. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105397 If continuation sheet Page 3 of 22 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 05/21/2025 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement a baseline care plan for urinary catheter care for 1 of 4 residents reviewed (Resident #421). Findings include: Review of Resident #421's admission record showed the resident was admitted to the facility on [DATE]. Review of Resident #421's Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form (AHCA Form 5000-3008) dated 5/13/2025 read, P. Patient Health Status: Bladder: Incontinent . Catheter. During an observation on 5/18/2025 at 9:50 AM, Resident #421 was sitting in her wheelchair. There was a foley catheter secured to the right side of the wheelchair. During an observation on 5/19/2025 at 10:26 AM, Resident #421 was sitting up in her bed drinking coffee. There was a Foley catheter hooked to left side of the bedframe. There was clear, straw-colored urine present in the catheter tubing. There was a navy blue cover overing the collection bag. Review of Resident #421's Admission/readmit: Data Collection and Baseline Care Plan dated 5/13/2025 read, 34. Bladder. Current Bladder Status: Incontinent. A1. Care Plan Update. Focus . The Resident is Incontinent of Bladder/ Bowel and will be evaluated for ability to participate with toileting program . b. Is the Resident interested in a toileting program? 2. No. Further review of Resident #421's baseline care plan dated 5/13/2025 showed no care plan focus for urinary catheter care. Review of Resident #421's physician orders showed no order for catheter care or catheter changes. During an interview on 5/20/2025 at 9:00 AM, Staff F, Registered Nurse (RN), stated, [Resident #421's name] had the catheter when she came into the facility. Residents with Foley catheters should have orders for daily catheter care and peri care. During an interview on 5/20/2025 at 5:03 PM, Staff H, Minimum Data Set (MDS) RN, stated, A baseline care plan is to be completed within 48 hours of admission, and is based off of the information obtained from the nursing assessment. Review of facility policy and procedure titled Care Plan- Interdisciplinary Plan of Care from Interim to Meeting with the last review date of 1/1/2025 read, Policy: The facility shall support that each resident must receive, and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. The facility shall assess and address care issues that are relevant to individual residents, to include, but may not be limited to, monitoring resident condition, and responding with appropriate interventions. Procedure: 1. Interim Plan of Care: a. The immediate needs of the resident are addressed following admission by initiating an interim plan of care . c. The interim plan of care is developed utilizing the admission Data Collection format or other data collected. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105397 If continuation sheet Page 4 of 22 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 05/21/2025 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Review of the facility policy and procedure titled Admission/readmission Data Collection Baseline with the last review date of 1/1/2025 read, Policy: The Resident's Admission/readmission Data Collection will provide a comprehensive description of the Resident's status on admission. The assessment can be used for Residents who have left the facility and return with a significant change of condition. The assessment is designed to identify past history, current findings, & factors that may put the resident at risk. The baseline plan of care must be created in the system after completion of the assessment. Event ID: Facility ID: 105397 If continuation sheet Page 5 of 22 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 05/21/2025 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure residents received care and services in accordance with professional standards of practice for medication administration via Gastrostomy Tube (G-tube) for 1 of 3 residents reviewed for enteral medication administration (Resident #56), for 1 of 1 resident reviewed for intravenous (IV) medication administration (Resident #420), and for 3 of 6 residents reviewed for wound care (Residents #51, #419, and #421). Residents Affected - Some Findings include: 1) During an observation on 5/19/2025 at 8:25 AM, Resident #421 had a foam-bordered dressing to her left elbow, which was dislodged and dated 5/16/2025. During an interview on 5/19/2025 at 8:25 AM, Resident #421 stated that the dressing on her left elbow had not been changed in a week. During an observation on 5/20/2025 at 9:00 AM, Resident #421 was lying in bed, with no dressing present over the left elbow wound. Review of Resident #421's physician order dated 5/14/2025 read, Treatment: cleanse left elbow with normal saline pat dry apply xeroform and cover with dcd [dry clean dressing] every other day and as needed, every evening shift every other day. During an interview on 5/20/2025 at 9:02 AM, Staff F, Registered Nurse (RN), stated, [Resident #421's name] should have a dressing on her left elbow. There are orders for dressing changes every other day. Dressing changes are always supposed to be documented on the TAR [Treatment Administration Record]. Her wound care should have been done on 5/18. During an interview on 5/20/2025 at 10:10 AM, the Director of Nursing (DON) stated, I expect the nurses to document every time they change a dressing. They should follow what is written in the wound care order. If the nurses need to use another type of dressing, make any changes to the order, or if we are out of certain wound care supplies, they are expected to call the physician and obtain a new order. During an interview on 5/20/2025 at 1:28 PM, Staff J, Licensed Practical Nurse (LPN), stated, I did work second and third shift on May 18th. I cannot recall any wound care orders for that resident. Actually, I believe she refused wound care. We had her sitting in a chair by the nurses' station. I don't believe I changed her dressing. We assisted her back to bed and she refused to allow me to change it. Normally, we document that the patient refused in a progress note. We are supposed to notify the doctor if residents refuse, and put in a note that we notified the doctor. It must have gotten by me. Review of Resident 421's TAR for May 2025 for left elbow wound care showed no entries documented on 5/16/2025 and 5/18/2025 during evening shift. 2) During an observation on 5/18/2025 at 9:45 AM, Resident #419 was sitting in her wheelchair with her spouce present. The resident had a dressing to left lower extremity dated 5/14/2025. During an interview on 5/18/2025 at 1:45 PM, Resident #419's Spouse stated that the skin tear to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105397 If continuation sheet Page 6 of 22 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 05/21/2025 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 0684 resident's left shin occurred from a fall prior to arriving in the facility. Level of Harm - Minimal harm or potential for actual harm During an observation on 5/19/2025 at 8:29 AM, Resident #419 was lying in bed. The resident had a dressing to left lower extremity dated 5/14/2025. Residents Affected - Some During an interview on 5/19/2025 at 8:30 AM, Staff F, RN, stated, We normally do all of the treatments, but the Unit Manager does the treatments on Tuesdays. I don't see any orders on the TAR for wound care to [Resident #419's name] left leg. During an interview on 5/20/2025 at 9:35 AM, the DON stated, I already spoke with the nurse regarding [Resident #419's name]. The nurse said that she thought that another nurse was putting the wound care order in, but it was just missed. During an interview on 5/20/2025 at 3:02 PM, Staff K, LPN, stated, I was the nurse that completed the Admission/readmission evaluation of Resident #419 on 5/15/24. I assessed the resident's skin, and noted that the resident had a wound to the left lower extremity. I don't believe I put any orders in. We got 5 admissions back to back and I passed it on to the next shift. Review of Resident #419's physician orders on 5/18/2025 at 1:55 PM showed no current physician orders for wound care to the left lower extremity. Review of the facility policy and procedure titled Physician Orders with the last approval date of 1/1/2025 read, Policy: At the time each resident is admitted , the facility will have physician orders for their immediate care. Physician orders will be dated and signed at next physician visit Procedure: 1. Obtain one of the following types of physician orders: Verbal, Telephone Order, Transmitted by facsimile machine, Written by the physician. 5) During an observation on 5/18/2025 at 12:10 PM, Resident #51 was sitting in her wheelchair. The resident had a dressing on her left lateral leg with no date or initials. The dressing was lifting form the left side. Review of Resident #51's physician order dated 5/12/2025 read, Cleanse skin tear left lateral calf with NS [normal saline], apply DCD daily and as needed. During an interview on 5/20/2025 at 9:10 AM, Staff F, RN, sated, Dressings should always have date, time and initials written on the dressing. During an interview on 5/20/2025 at 9:24 AM, the DON stated, Dressing should be initialed and dated. The date should always be on the dressing. Review of the facility's Clean Dressing Change Competency Checklist read, Competency Criteria: 1. Check Physician orders to verify dressing orders . 12. Open dressing packs. Write date, time and initials on cover dressing or pre-cut tape . 26. Document on ETAR [electronic Treatment Administration Record] after completion of dressing change. 3) During an observation on 5/19/2025 at 12:43 PM, Staff A, Licensed Practical Nurse (LPN), crushed Tramadol HCl (Hydrochloride) pain medication with 15 ml (milliliters) of water. Staff A instilled 30 ml of water via G-tube by gravity, administered crushed Tramadol HCl in 15 ml of water via G-tube by gravity and then flushed with 30 ml of water by gravity. Staff A did not aspirate or check for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105397 If continuation sheet Page 7 of 22 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 05/21/2025 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 0684 placement prior to medication administration or water flushes. Level of Harm - Minimal harm or potential for actual harm Review of Resident #56's physician order dated 5/13/2025 read, Tramadol HCl Oral Tablet 25 MG (Tramadol HCl), Give 2 tablets via G-Tube every 6 hours for C [chronic]. Residents Affected - Some Review of Resident #56's physician order dated 12/12/2024 read, Enteral Feed Order every shift Dilute each crushed/sprinkles/powdered med [medication] with at least 15 ML of water and rinse the cup with 5 to 15 ml to ensure all residual is out of the cup. Review of Resident #56's physician order dated 12/12/2024 read, Flush tube with 30 ml of water before and after med administration and feeding every shift for Patency and hydration. During an interview on 5/19/2025 at 12:42 PM, Staff A, LPN, stated, We do not aspirate or check for placement unless we have an order. That has all changed. During an interview on 5/19/2025 at 1:15 PM, the Assistant Director of Nursing (ADON) stated, We do not check for placement or patency according to our corporate. I do not educate the staff to check for residual or placement unless the physician has written an order to do so. During an interview on 5/20/2025 at 12:05 PM, the Medical Director stated, I was not aware that they were not checking for placement prior to administering medications. I would not recommend continuing with that process. During an interview on 5/20/2025 at 1:56 PM, the Director of Nursing stated, Checking for G-tube patency and/or residual is not part of our policy prior to medication administration. 4) During an observation on 5/20/2025 at 8:28 AM, Staff F, Registered Nurse (RN), flushed Resident #420's midline located in the upper right arm with 10 ml of normal saline without aspirating for patency prior to flushing. Review of Resident #420's physician order dated 5/18/2025 read, Use 10 ml syringe with all flushes for patency. During an interview on 5/20/2025 at 8:30 AM, Staff F, RN, stated, We just flush the IV. We do not aspirate prior to flushing, and I do not have any orders to aspirate first. During an interview on 5/20/2025 at 1:56 PM, the Director of Nursing stated, We do not aspirate and check for patency prior to flushing IV's. Review of the facility policy and procedure titled Vascular Access Devices and Infusion Therapy Procedures. Maintaining Patency of Peripheral and Central Vascular Access Devices with the last review date of 1/1/2025 read, Policy: Vascular access devices are aspirated for a blood return and flushed prior to each infusion to assess catheter function and prevent complications. Vascular access devices are flushed after each infusion to clear the infused medication from the catheter lumen. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105397 If continuation sheet Page 8 of 22 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 05/21/2025 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 0689 Level of Harm - Minimal harm or potential for actual harm Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, interview, and record review, the facility failed to ensure resident environment was free of accident hazards in 1 of 2 units (Photographic evidence obtained). Residents Affected - Few Findings include: During an observation on 5/18/2025 at 1:10 PM, Resident #319 was lying in a bariatric bed. The bed remote control had exposed wires hanging on side rail next to the resident's right arm. During an observation on 5/19/2025 at 9:30 AM, Resident #319 was in bed. The bed remote control had exposed wires. During an interview on 5/19/2025 at 3:25 PM, Staff C, Licensed Practical Nurse (LPN), Unit Manager, stated that she was unaware that there was an issue with exposed wires on Resident #319's bed remote. During an interview on 5/19/2025 at 3:29 PM, Resident #319 stated that the remote wire had been like that. During an interview on 5/20/2025 at 10:45 AM, the Maintenance Director stated, We do not check rented medical equipment when they are brought into the facility. Review of the facility policy and procedure titled Physical Environment with the last review date of 1/1/2025 read, Policy: A safe, clean, comfortable, and home-life [Sic.] environment is provided for each resident, allowing the use of personal belongings to the greatest extent possible. Sufficient space and equipment in dining, health services, recreation, and program areas are provided to enable staff to provide residents with needed services. All essential mechanical, electrical, and resident care equipment is maintained in safe operating condition through the facility's Preventive Maintenance Program. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105397 If continuation sheet Page 9 of 22 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 05/21/2025 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 0690 Level of Harm - Minimal harm or potential for actual 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. Based on observation, interview, and record review, the facility failed to ensure residents received appropriate urinary catheter care and services for 1 of 4 residents reviewed (Resident #421). Residents Affected - Few Findings include: During an observation on 5/18/2025 at 9:50 AM, Resident #421 was sitting in her wheelchair. There was a foley catheter secured to the right side of the wheelchair. During an observation on 5/19/2025 at 10:26 AM, Resident #421 was sitting up in her bed drinking coffee. There was a Foley catheter hooked to left side of the bedframe. There was clear, straw-colored urine present in the catheter tubing. There was a navy blue cover overing the collection bag. Review of Resident #421's Admission/readmit: Data Collection and Baseline Care Plan dated 5/13/2025 read, 34. Bladder. Current Bladder Status: Incontinent. A1. Care Plan Update. Focus . The Resident is Incontinent of Bladder/ Bowel and will be evaluated for ability to participate with toileting program . b. Is the Resident interested in a toileting program? 2. No. Review of Resident #421's physician orders showed no order for catheter care or catheter changes. During an interview on 5/20/2025 at 9:00 AM, Staff F, Registered Nurse (RN), stated, [Resident #421's name] had the catheter when she came into the facility. Residents with Foley catheters should have orders for daily catheter care and peri care. During an interview on 5/20/2025 at 9:15 AM, the Director of Nursing (DON) stated, When residents with urinary catheters are admitted to the facility, batch orders should be put into the system for catheter management and care. The nurse doing the evaluation on the resident is responsible for putting in the orders, and there is no specified timeframe to discontinue urinary catheters. During an interview on 5/21/2025 at 8:27 AM, the DON stated, I do expect the nurses to assess bowel and bladder function, how residents use the bathroom during the initial evaluation/assessment. During an interview on 5/21/2025 at 11:22 AM, the Infection Preventionist stated, We run reports on residents with Foley catheters weekly. We do a lot of education with the CNAs [Certified Nursing Assistants] and nurses about Foleys-peri care education, signs and symptoms of UTIs [Urinary Tract Infections], and monitoring output. Residents with Foley catheters have an increased risk of infection and an increased risk of falls. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105397 If continuation sheet Page 10 of 22 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 05/21/2025 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, record review, the facility failed to ensure residents received respiratory care as ordered by physician order for 3 of 5 residents reviewed for respiratory services (Residents #62, #69, and #270). Residents Affected - Some Findings include: 1) During an observation on 5/18/2025 at 10:02 AM, Resident #270 was lying in bed, receiving no oxygen. There was no oxygen concentrator in his room. During an observation on 5/18/2025 at 1:30 PM, Resident #270 was lying in bed, receiving no oxygen. There was no oxygen concentrator in his room. During an observation on 5/19/2025 at 9:12 AM, Resident #270 was lying in bed, receiving no oxygen. There was no oxygen concentrator in his room. During an interview on 5/19/2025 at 9:12 AM, Resident #270 stated, I don't use oxygen. I do need it. Review of Resident #270's physician order dated 5/15/2025 read, Oxygen at 2 LPM [liters per minute] via nc [Nasal Cannula] continuously for SOB [Shortness Of Breath] every shift for Shortness of Breath. During an interview on 5/19/2025 at 2:27 PM, Staff F, Registered Nurse (RN), stated, [Resident #270's name] is on oxygen and he is not compliant with it. [Resident #270's name] has a new diagnosis of lung cancer and automatically the doctors put orders in for oxygen. I would expect the oxygen concentrator be in the room with tubing and a bag. During an observation on 5/19/2025 at 2:30 PM with Staff F, RN, Resident #270 was lying in bed. There was no oxygen concentrator in the room and the resident was not receiving continuous oxygen. During an interview on 5/20/2025 at 9:11 AM, the Director of Nursing (DON) stated, If a resident has orders for oxygen, there should be an oxygen concentrator in the room with the oxygen tubing. If the resident was not using the oxygen, they should have contacted the provider to discontinue the orders. 2) During an observation on 5/18/2025 at 9:54 AM, Resident #62 was laying in her bed, with a nasal cannula in her nose. The cannula was attached to an oxygen concentrator, running at 3.5 LPM (Photographic evidence obtained). Review of Resident #62's physician orders showed an order for oxygen at 2 LPM via nasal cannula continuously for shortness of breath. During an observation on 5/18/2025 at 2:00 PM, Resident #69 was lying in her bed, receiving humidified oxygen at the rate of 2.5 LPM. During an observation on 5/21/2025 at 9:05 AM, Resident #69 was lying in her bed, receiving humidified oxygen at the rate of 3 LPM. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105397 If continuation sheet Page 11 of 22 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 05/21/2025 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 0695 Level of Harm - Minimal harm or potential for actual harm Review of Resident #69's physician order dated 5/13/2025 read, Oxygen at 3 LPM via NC continuously for SOB every shift for shortness of breath. During an interview on 5/21/2025 at 9:08 AM, Staff D, Licensed Practical Nurse (LPN), stated that Resident #69 was on humidified oxygen and her oxygen order did not include humidification. Residents Affected - Some During an interview on 5/21/2025 at 12:25 PM, the DON stated, Orders need to be read completely and all information documented in a resident's chart to be accurate. Review of the facility policy and procedure titled Oxygen Therapy with the last review date of 1/1/2025 read, Policy: Oxygen is provided to residents based on physician's orders to supplement oxygen as needed per disease process. Procedure: 1. Verify physician order . 3. Gather equipment (liquid, cylinder, concentrator), 4. Obtain the appropriate oxygen delivery device. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105397 If continuation sheet Page 12 of 22 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 05/21/2025 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 - Minimal harm or potential for actual harm Based on observation and interview, the facility failed to ensure accurate nurse staffing information was posted on a daily basis. Residents Affected - Few Findings include: During an observation on 5/18/2025 at 9:30 AM, the facility's nurse staffing report dated 5/18/2025 (Sunday) did not include a resident census (Photographic evidence obtained). During an interview on 5/20/2025 at 12:01 PM, the Staffing Coordinator stated, I work Monday through Friday and come in at 5:00 AM and I do the federal report. I do it no later than 6:30 AM. It has to be done before the 7-3 shift starts. I put the date and the census on there. I write out over the weekend the information on the form and then who is supervisor or manager on duty will put the census on it. During an interview on 5/20/2025 at 4:03 PM, the Social Services Assistant stated, I was the manager on duty this past Sunday (5/18/2025). I normally make sure the day is correct and the staffing numbers are correct. I also include the census on the form. I did not realize the census was not written on the form. During an interview on 5/21/2025 at 9:45 AM, the Director of Nursing stated, Federal Report should be updated every day and should include the staffing numbers, date and census. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105397 If continuation sheet Page 13 of 22 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 05/21/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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. 3) During an observation on 5/18/2025 at 9:53 AM in Resident #169's room, there were four 10-ml normal saline syringes at the resident's bedside. During an interview on 5/18/2025 at 9:53 AM, Resident #169 stated, I don't know who put those there. I didn't see the nurse when she came in. During an observation on 5/18/2025 at 11:00 AM in Resident #55's room, there was one medication cup containing white cream on the resident's over the bed table. During an interview on 5/18/2025 at 11:00 AM, Resident #55 stated, It is medicine for my legs. Resident #55 did not recall the name of the medication. During an interview on 5/21/2025 at 8:40 AM, the DON stated, That does look like Silvadene. No medications should be left at bedside. Based on observation, interview, and record review, the facility failed to ensure medications were properly secured in 4 of 6 halls and failed to ensure medications were properly stored in 1 of 3 medication carts reviewed (Photographic evidence obtained). 1) During an observation on 5/18/2025 at 10:05 AM in Resident #21's room, there were white powder substance in a medication cup and spilled over onto the bedside table, and one container of Nystatin CR (cream)/ Zinc/HC (hydrochloride) 1% Cream on the resident's bedside table, with the label reading, [Resident #21's name ]- Apply cream topically every shift apply topically to buttocks every shift for redness large area. During an observation on 5/18/2025 at 10:13 AM in Resident #56's room, there was one 10-ml (milliliter) Normal Saline syringe on the resident's bedside table. During an observation on 5/18/2025 at 10:20 AM in Resident #7's room, there was one white pill in a medication cup on the resident's bedside table. During an interview on 5/18/2025 at 10:20 AM, Resident #7 stated, I don't know what it is. It must have got stuck in the cup, but I will take it now. During an observation on 5/18/2025 at 10:22 AM in Resident #33's room, there was one medication cup containing unidentified white powder on the resident's bedside table. During an interview on 5/18/2025 at 10:48 AM, Staff A, Licensed Practical Nurse (LPN), verified that Normal Saline syringe in Resident #56's room and Nystatin cream in Resident #21's room were unsecured, and stated, No medications can be in the room. I do not know what the powder is and I never saw it. I did not dispose of the powder. During an interview on 5/18/2025 at 2:29 PM, Staff C, LPN, Unit Manager, confirmed Nystatin cream in Resident #21's room and Normal Saline syringe in Resident #56's room were unsecured, and stated, I do not know who disposed of the white powder in the medication cups in the resident rooms. I think (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105397 If continuation sheet Page 14 of 22 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 05/21/2025 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 0761 it was baby powder. Level of Harm - Minimal harm or potential for actual harm During an observation on 5/19/2025 at 8:40 AM, there were one vial of Novolin R100 for Resident #21 with an opened date of 4/1/2025 and expiration date of 5/12/2025, and one vial of Lantus 100 unit/ml insulin for Resident #88 with an opened date of 4/12/2025 and expiration date of 5/10/2025 in Unit 2 Medication Cart 2. Residents Affected - Some During an interview on 5/19/2025 at 8:42 AM, Staff A, Licensed Practical Nurse (LPN), verified that insulin for Resident #21 and Resident #88 were expired and stated, These medications are expired. All medication carts are checked daily, and all expired medication should be disposed of and replaced. During an interview on 5/19/2025 at 10:42 AM, the Director of Nursing (DON) stated, No medication are to be stored in the room and all carts are checked daily and expired medications are to be removed and disposed of and replaced. Review of the facility policy and procedure titled Storage of Medication with the last review date of 1/1/2025 read, Policy: Medications and biologicals are stored properly, following manufacturer's or provider pharmacy recommendations, to keep their integrity and to support safe, effective drug administration . Procedures: 1. The provider pharmacy dispenses medications in containers that meet state and federal labeling requirements, including those established by the United States Pharmacopeia (USP). Medications are to remain in these containers and stored in a controlled environment. This may include such containers as medication carts, medication rooms, medication cabinets, or other suitable containers . 14. Outdated, contaminated, discontinued or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal. 4) During an observation on 5/18/2025 at 10:04 AM, Resident #271 was sitting in her room. There was one medication cup containing white powder on the resident's bedside table. During an interview on 5/18/2025 at 10:04 AM, Resident #271 stated, I get sweat in my groin area and I have a wound. I asked the staff last night and they brought it in. During an interview on 5/18/2025 at 10:20 AM, Staff G, LPN, stated, [Resident #271's name] has Nystatin ordered and I applied it for her this morning. 5) During an observation on 5/18/2025 at 10:13 AM in Resident #51's room, there was one medication cup containing white powder on top of the resident's bedside table. During an interview on 5/18/2025 at 10:13 AM, Resident #51 stated, I have a rash on my abdomen and the staff will put the powder on the rash. During an interview on 5/18/2025 at 10:25 AM, Staff G, LPN, stated, [Resident #51's name] has no orders for Nystatin powder. I am not sure why it was left in her room. 6) During an observation on 5/18/2025 at 10:19 AM, Resident #272 was sitting at the edge of the bed, wearing a hospital gown. There was one Diclofenac Sodium topical gel placed on top of the resident's room chair. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105397 If continuation sheet Page 15 of 22 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 05/21/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 5/18/2025 at 10:19 AM, Resident #272 stated, It is a pain cream. I brought it from home. Staff assist me and apply it for me. During an interview on 5/18/2025 at 10:26 AM, Staff G, LPN, stated, I am not sure how she [Resident #272] got the cream in room. [Resident #272's name] does not have orders and it should not be left in her room. Family bring medication all the time. 7) During an observation on 5/18/2025 at 10:37 AM, Resident #105 was lying in bed. There was one Phenaseptic throat spray on top of the nightstand. During an interview on 5/18/2025 at 10:37 AM, Resident #105 stated, I brought the spray from home and use it when my throat bothers me. During an interview on 5/18/2025 at 10:40 AM, Staff G, LPN, stated, [Resident #105's name] does not have orders for throat spray. Maybe the daughter brought it from home. I will keep it in a lock box and give it to the daughter when she comes in. During an interview on 5/20/2025 at 9:20 AM, the DON stated, Residents need to have a self-administration evaluation completed in order to be able to administer medications by themselves. Medications should have an order and not be left unattended in resident room. [names of Resident #51, Resident #105, Resident #271, and Resident #272] do not have self-administration evaluations completed. 2) During an observation on 5/18/2025 at 9:45 AM in Resident #35's room, there was a cup containing a liquid identified as Med Pass on the resident's over the bed table. Review of Resident #35's physician order dated 4/29/2025 read, Medpass three times a day for nutritional supplementation, administer 120 ML 3 times a day. Record the % consumed. During an interview on 5/21/2025 at 1:16 PM, the DON stated that those medications should not have been left there, and her expectations are that the nurses would stay at bedside until the medications are taken. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105397 If continuation sheet Page 16 of 22 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 05/21/2025 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 0838 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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. Based on record review and interview, the facility failed to evaluate residents' needs and acuity in the facility assessment to determine the number of qualified staff needed to meet each resident's needs. Findings include: Review of the facility assessment showed no review of the residents' needs and acuity to determine the number of qualified staff needed to meet each resident's needs. Review of the Labor Detail Report dated 5/4/2025 showed nursing hours of 0.95. During an interview on 5/20/2025 at 1:20 PM, the Business Office Assistant stated, On 5/4/2025, we were 6 hours and a half low on nursing staff. During an interview on 5/20/2025 at 1:51 PM, the Staff Coordinator stated, The supervisor who was working on 5/4/2025 got sick and left. She only worked one hour. No one came to replace her. The supervisor does staffing on the weekend and she canceled an LPN [Licensed Practical Nurse] who requested to be canceled and did not get coverage for that shift either. On 7-3, there were 5 nurses who worked, but the census was high. They should have kept the LPN because the census was high, so it would have been 5 nurses plus a desk nurse and that is the same for the 3-11 shift, but the supervisor called out. There were text messages sent, but staff did not come in. During an interview on 5/20/2025 at 3:45 PM, the Director of Nursing (DON) stated, On 5/4/2025, the nurse was sick and could not get the nurse who canceled to come back and no one came in. We had 5 nurses for 119 residents. We just did not have the free nurse we normally have for that census. During an interview on 5/21/2025 at 9:45 AM, the Administrator stated, A nurse manager should have come in and covered for the shift if no staff was coming in. During an interview on 5/21/2025 at 2:18 PM, the Administrator stated, I reviewed the facility assessment and did not find an area that talks about acuity and staffing ratios. Review of the facility policy and procedure titled Staffing with the last review date of 1/1/2025 read, Policy: The Administrator and Director of Nursing are responsible to ensure sufficient nursing staff to provide nursing and related services to attain or maintain the highest practical, physical, mental, and psychosocial well-being of each resident, as required by federal law and sufficient staff to meet applicable state law requirements (including minimum staffing ratios). Review of the facility policy and procedure titled Facility Assessment with the last review date of 1/1/2025 read, Policy: The facility will conduct and document a facility wide assessment to determine what resources are necessary to care for its residents 24 hours a day. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105397 If continuation sheet Page 17 of 22 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 05/21/2025 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on observation, interview, and record review, the facility failed to maintain complete and accurate medical records for 4 of 8 residents reviewed for medication management (Residents #51, #62, #59, and #81) and 1 of 5 residents reviewed for respiratory services (Resident #270). Findings include: 1) Review of Resident #51's physician order dated 5/11/2025 read, Midodrine HCl Oral Tablet 2.5 MG [milligram] (Midodrine HCl), Give 1 tablet by mouth every 8 hours for hypotension. For BP [blood pressure] less than 90/60. Review of Resident #51's Medication Administration Record (MAR) for May 2025 showed the resident received Midodrine on 5/11/2025 at 10:00 PM for blood pressure of 122/76, on 5/12/2025 at 6:00 AM for blood pressure of 108/72, on 5/13/2025 at 6:00 AM for blood pressure 121/68 and at 10:00 PM for blood pressure of 100/68, on 5/14/2025 at 6:00 AM for blood pressure of 108/60, on 5/15/2025 at 10:00 PM for blood pressure of 94/66, on 5/16/2025 at 6:00 AM for blood pressure of 108/70 and at 10:00 PM for blood pressure of 96/66, and on 5/17/2025 at 6:00 AM for blood pressure of 100/61 and at 10:00 PM for blood pressure of 103/62. Review of Resident #51's progress note did not document communication with a provider regarding Midodrine. During an interview on 5/20/2025 at 2:43 PM, Staff L, Licensed Practical Nurse (LPN), stated, I do not recall, but if there is a check it means it was given. Normally I triple check [Resident #51's name] blood pressure before giving her blood pressure medication and communicate with the provider before administration. During an interview on 5/21/2025 at 11:21 AM, the Advance Registered Nurse Partitioner (ARNP) #2, stated, The nurses call me all the time. [Resident #51's name] came in and was very hypotensive. In a perfect world, we would like for them [nursing staff] to document all communications, but we get busy and I trust the nurse and they do call me and take good care of the residents. During an interview on 5/21/2025 at 11:25 AM, the Director of Nursing (DON) stated, Nurses should document either on the supplementary documentation or via a progress note that they are communicating with the provider. I did not see any documentation stating that they were in communication with the provider for the administration out of the parameters indicated. Review of the facility policy and procedure titled Medication Administration with the last review date of 1/1/2025 read, Procedures . Medication Administration: 1. Medications are administered in accordance with written orders of the prescriber. If a dose seems excessive considering the resident's age and condition, or a medication order seems to be unrelated to the resident's diagnosis or condition, the nurse calls the provider pharmacy for clarification prior to the administration of the medication. If necessary, the nurse contacts the prescriber for clarification. This interaction with the pharmacy and the resulting order clarification are documented in the nursing notes and elsewhere in the medical record as appropriate. 2) During an observation on 5/18/2025 at 10:02 AM, Resident #270 was lying in bed, receiving no (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105397 If continuation sheet Page 18 of 22 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 05/21/2025 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 0842 oxygen. There was no oxygen concentrator in his room. Level of Harm - Minimal harm or potential for actual harm During an observation on 5/18/2025 at 1:30 PM, Resident #270 was lying in bed, receiving no oxygen. There was no oxygen concentrator in his room. Residents Affected - Some During an observation on 5/19/2025 at 9:12 AM, Resident #270 was lying in bed, receiving no oxygen. There was no oxygen concentrator in his room. During an interview on 5/19/2025 at 9:12 AM, Resident #270 stated, I don't use oxygen. I do need it. Review of Resident #270's physician order dated 5/15/2025 read, Oxygen at 2 LPM [liters per minute] via nc [Nasal Cannula] continuously for SOB [Shortness Of Breath] every shift for Shortness of Breath. Review of Resident #270's Treatment Administration Record (TAR) for May 2025 showed the resident received oxygen at 2 LPM on 5/18/2025 and 5/19/2025 during the day shift. During an interview on 5/20/2025 at 9:11 AM, the DON stated, A check mark on the treatment record means that the oxygen is being administered. The staff should contact the provider and notify them that it needs to be discontinued if the resident is not using the oxygen and document accurately. During an interview on 5/20/2025 at 3:08 PM, Staff G, LPN, stated, I was not aware [Resident #270's name] has orders for oxygen. When I check off on the medication record, it means that the oxygen is being administered. 3) Review of Resident #62's physician orders showed an order that read, Amlodipine Besylate oral tablet 5 MG, Give 0.5 tablet by mouth one time a day for hypertension 2.5 MG. Hold if blood pressure is less than 110/60 or heart rate less than 60. Review of Resident #62's MAR for March 2025 showed the resident received Amlodipine on 3/2/2025 at 9:00 AM for the blood pressure of 106/70. During an interview on 5/21/2025 at 11:45 AM, Staff O, LPN, stated that the blood pressure that was documented for Resident #62's Amlodipine administration on 3/2/2025 at 9:00 AM was incorrectly documented. The correct blood pressure was 116/70. 4) Review of Resident #81's physician order dated 8/26/2023 read, Hydralazine HCl Oral Tablet 50 MG (Hydralazine HCl), Give 1 tablet by mouth every 6 hours for HTN [hypertension], hold if SBP [Systolic Blood Pressure] is < [less than] 100, call if SBP is > [greater than] 160. Review of Resident #81's MAR for April 2025 showed the resident received Hydralazine on 4/11/2025 at 12:00 PM for the blood pressure of 97/70. During an interview on 5/21/2025 at 12:23 PM, Staff N, Registered Nurse (RN) stated that she incorrectly documented Resident #81's blood pressure as 91/70 when she administered the Hydralazine on 4/11/2025 at 12:00 PM. The blood pressure that was entered was rechecked and the second blood pressure was within administration parameters, and she accidently documented the first blood pressure instead of the second. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105397 If continuation sheet Page 19 of 22 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 05/21/2025 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 5) Review of Resident #59's physician order dated 12/3/2024 read, Dofetilide Oral Capsule 125 MCG [microgram] (Dofetilide), Give 1 capsule by mouth one time a day for heart rate related to chronic atrial fibrillation, hold for heart rate less than 60. Review of Resident #59's MAR for April 2025 showed the resident received Dofetilide on 4/10/2025 at 9:00 AM for the heart rate of 56, and on 4/11/2025 at 9:00 AM for the heart rate of 54. During an interview of 5/21/2025 at 11:37 AM, Staff C, LPN, stated, I did not give the medication outside of parameters. I rechecked the HR [heart rate] prior to administration and the HR was within parameters. During an interview on 5/21/2025 at 12:25 PM, the DON stated, Orders will be read completely and all information documented in a resident's chart to be accurate. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105397 If continuation sheet Page 20 of 22 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 05/21/2025 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 ensure staff used appropriate Personal Protective Equipment (PPE) while providing high-contact care for 1 of 6 residents reviewed (Resident #420), and failed to ensure respiratory treatment equipment was appropriately stored for 1 of 5 residents reviewed for respiratory services (Resident #68) to prevent the possible spread of the infection and communicable diseases. Residents Affected - Few Findings include: 1) During an observation on 5/18/2025 at 9:45 AM, there was an Enhanced Barrier Precautions (EBP) signage on Resident #420's door. Staff I, Certified Nursing Assistant (CNA), entered the room and proceeded to assist the resident in the bathroom. Staff I was not wearing a gown while assisting Resident #420 in the bathroom. During an interview on 5/18/2025 at 10:09 AM, Staff I, CNA, stated, Gowns and PPE are supposed to be on all of the doors of patients that are ordered for EBP. [Resident #420] is a new patient. Usually, they will tell us in report which patients are on EBP. I was not told that [Resident 420's name] is on EBP. I took her to the bathroom without wearing a gown, but I always wear gloves. During an interview on 5/20/2025 at 9:32 AM, the Director of Nursing (DON) stated, I do expect staff to wear a gown when toileting a resident on enhanced barrier precautions. Review of Resident #420's physician order dated 5/16/2025 read, Enhanced Barrier Precautions- r/t [related to] skin alteration. Review of the facility policy and procedure titled Barrier Precautions with the last review date of 1/1/2025 read, Policy . Enhanced Barrier Precautions (EBP) refers to an infection control intervention designed to reduce transmission or [Sic.] multi-drug resistant organisms that employ targeted gown and glove use during high contact resident activities. EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs [Multi-Drug Resistant Organisms] to staff hands and clothing. Review of the webpage of the Centers for Disease Control and Prevention (CDC) titled Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) dated April 2, 2024 (https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html) read, Enhanced Barrier Precautions . Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include: Dressing, Bathing/showering, Transferring, Providing hygiene, Changing linens, Changing briefs or assisting with toileting, Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator, Wound care: any skin opening requiring a dressing. 2) During an observation on 5/18/2025 at 9:47 AM, Resident #68 was lying in bed. There was a nebulizer mask out of the bag lying on top of the resident's rollator walker seat (Photographic evidence obtained). Review of Resident #68's physician order dated 5/5/2025 read, Ipratropium-Albuterol Inhalation (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105397 If continuation sheet Page 21 of 22 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 05/21/2025 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 Solution 0.5-2.5 (3) MG [milligram]/3 ML [milliliter] (Ipratropium-Albuterol), 3 ml inhale orally every 6 hours as needed for sob [shortness of breath]. During an interview on 5/20/2025 at 8:59 AM, Staff F, Registered Nurse (RN), stated, The nebulizer mask and tubing should be stored in a bag when it is not in use. Residents Affected - Few Review of Resident #68's physician orders showed no order for tubing changes for nebulizer machine. During an interview on 5/20/2025 at 9:08 AM, the Director of Nursing (DON) stated, The nebulizer mask has prongs and it can be placed on the nebulizer machine. If it is not stored in that manner, then the mask should be bagged. There should also be weekly tubing changes, which is an order batch we put in the system for the residents. Review of the facility policy and procedure titled Medication Administration via Nebulizer with the last review date of 1/1/2025 read, Procedure . 14. Store the dry nebulizer in a storage bag labeled with resident name and date. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105397 If continuation sheet Page 22 of 22