Inspection·July 22, 2025

F 0806 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few that was completed include the following: no visible skin alterations, no rash. Patient reports mild itching all over. Treatment as follows was provided to the area or areas of concern: Benadryl 25 mg [milligrams] one time now, then QHS PRN [as needed] x 10 days. The description of the event as provided by licensed staff is as follows: patient states all over mild itching, no SOB, no mouth or throat itching/tightness. [The ARNP #1's name] notified, give Benadryl now, then QHS PRN x10 days. The resident has provided the following description of the event: Patient reports mild itching all over. The following type of event is noted: no areas of concern Details of the event are as follows: patient assessed, she reports all over mild itching, no mouth or throat itching or tightness, no SOB. Preventative interventions related to this event include: n/a [not applicable]. The name of the practitioner notified is: [the ARNP #1's name] The date and time of practitioner notification: 06/06/2025 12:40 PM Please note the following new order orders: Benadryl one time now, then QHS PRN x 10 days The name of the Resident Representative notified: Daughter [name of daughter]. The date and time the Resident's Representative was notified: 06/06/2025 12:45 PMReview of Resident #1‘s order dated 6/6/2025 read, Benadryl Allergy Oral Tablet 25 MG (Diphenhydramine HCl) Give 25 mg by mouth one time only for Allergy for 1 day.Review of Resident #1's Medication Administration Record for the month of June 2025 for Benadryl 25 mg was documented as given on 6/6/2025 at 12:52 PM.Review of Resident #1's physician order dated 6/6/2025 read, Benadryl Allergy Oral Tablet 25 MG (Diphenhydramine HCI) Give 25 mg by mouth as needed for Allergy for 10 days may have 25 mg Q HS PRN x 10 days.Review of Resident #1's progress note dated 6/6/2025 at 1:10 PM read, Patient c/o [complaint of] tongue feels like it is swelling, ARNP notified, new order to send to ER [Emergency Room] for eval and treat.Review of Resident #1's physician order dated 6/6/2025 read, Send to ER for evaluation one time only for allergy for 1 day.Review of Resident #1's Emergency Department note dated 6/6/2025 read, Chief Complaint: Anaphylactic Reaction. HIP: [AGE] year old female with past medical history of CKD [chronic kidney disease] stage III, DM [diabetes mellitus] type 2, HTN [hypertension], AFib [atrial fibrillation], CAD [coronary artery disease] s/p [status post] stents x 7 hyperlipidemia and strokes x 3 with permanent LLE [left lower extremity] weakness that arrives to the ED [emergency department] from assisted living facility [Sic.] due to anaphylactic reaction. Patient states she has a history of allergies with multiple medications and fish. This evening she was eating what she thought was chicken when she began developing tongue, throat and mouth swelling in addition to lightheadedness, dizziness, and shortness of breath. She alerted the nurses at the ALF [ALF] when they noticed she was fed fish. She received Benadryl and steroids at this institution and was brought by EMS [Emergency Medical Service] to the emergency room. She endorsed palpitations, SOB, DOE [dyspnea on exertion], orthopnea, paroxysmal dyspnea and increased urinary urgency. She denied chest pain, cough, abdominal pain, nausea, vomiting, diarrhea, dysuria, LC [low cerebrospinal fluid pressure] headaches, no recent travels, traumas, sick contacts, or fever. Patient currently admitted for observation due to anaphylactic reaction. Assessment and plan: Anaphylactic reaction. Hx: [history] Previous episodes of anaphylactic shock on consumption of fish. Complain of lightheadedness, dizziness, SOB, and swelling after mistakenly eating fish. At ALF she was given Benadryl and steroid. On evaluation, patient with improvement of swelling without symptoms. In ED: Pepcid 20 mg, albuterol 2.5 mg, EpiPen [epinephrine, used to treat severe allergic reactions, also known as anaphylaxis] 0.3 mg x 2. Start patient on prednisone 40 mg daily for 5 days. Disposition: Start patient on prednisone 40 mg daily for 5 days. Patient currently stable. Will evaluate patient for the next 24 hours for signs suggestive of delayed anaphylactic reaction.Review of Resident #1's physician order dated 6/7/2025 read, Prednisone Oral Tablet 20 MG (Prednisone) give 2 tablets by mouth at bedtime for allergic reaction for 4 days until finished.Review (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105397 If continuation sheet Page 2 of 8 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 07/22/2025 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 0806 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few of Resident #1's Medication Administration Record for the month of June 2025 Prednisone 20 MG 2 tablets were documented as administered at 9:00 PM from 6/7/2025 through 6/11/2025.Review of Resident #1's physician order dated 6/8/2025 read, Epinephrine Injection Solution Auto-injector 0.3 MG/0.3ML inject 1 unit intramuscularly every 8 hours as needed for allergic reaction follow directions as directed on pen.Review of Resident #1's physician note dated 6/9/2025 at 2:05 PM read, Chief complaint: Patient recently went to the hospital after consuming fish. Benadryl given at facility but patient c/o throat still itchy sent to ER due to air way compromise. Sent out 6/6 to [name of hospital] returned 6/7. Plan: Allergic rxn [reaction] return w/epi 1 app [application] q8 hr prn [every 8 hours as needed].Review of the Risk Management Statement Document dated 6/6/2025 written by Staff E, Registered Nurse (RN), read, I assessed patient [Resident #1] approximately 10 mins [minutes] after she took Benadryl. She [Resident #1] mumbled her tongue was swelling, she said she could not stick out her tongue when I asked. I asked if she could open her mouth so I could assess and she mumbled that she could not. When EMS arrived she said I told them I didn't like the fish without any difficulty opening mouth and speech clear. Patient continued to speak with EMS as she left facility without difficulty.Review of written statement dated 6/6/2025 written by Staff D, Certified Nursing Assistant (CNA), read, I [Staff D's name] went to pick up the lunch tray from pt [patient] room in [Resident #1's room number] that's when she told me she was allergic to the fish. Immediately went and got the nurse.Review of written statement dated 6/6/2025 written by Assistant Director of Nursing (ADON) read, This nurse was notified that resident received a lunch tray that had a fish patty on it and that resident had eaten the fish patty. Resident has allergy to fish. I asked the nurse who was the CNA for Resident was [Sic.], and was informed it was [Staff D's name] CNA. This nurse asked CNA if she had checked the tray before serving it to Resident. CNA replied No I asked CNA if she knew she was supposed to check all trays before serving she stated Yes and apologized.Review of written statement written by Staff A, Licensed Practical Nurse (LPN), dated 6/6/2025 read, Today at approximately 12:30 PM, this writer was sitting at the nurses station on Unit 2 and was approached by [Staff D's name]. She stated to this writer that she picked up [Resident #1's name] lunch tray and at that time the resident asked [Staff D's name] if that was fish on her tray because she ate it and she is allergic to fish. Writer then enters the room and asks the resident if she ate the fish on the tray, and the resident states yes. Writer then asks how she feels, and the resident states she feels ok. Writer informs resident that she is going to call the NP [Nurse Practitioner] to inform them. Resident at this time has no c/o pain, discomfort, difficulty breathing or swelling of any kind. Resident's breathing is even and unlabored and is able to talk without any difficulty. Writer ensures the call light is at reach, pulls curtain back so staff can more easily see the resident and educates resident to use call light if she understands. Writer takes tray and lunch ticket to nurses station and calls NP, a message is left. At this time the ADON is now at the nurses station and ask who the CNA was. I stated that [Staff D's name] is the CNA for the assignment and is the CNA that informed me about [Resident #1's name] eating the fish. At this time the {sic} [Staff D's name] CNA is now walking up to the nurses station. The ADON then states to the CNA that she should be checking each ticket before each tray is passed to a resident, the CNA then states that she is absolutely correct and from now on she will make sure that she is checking each ticket. RN [Staff E's name] then returns to the nurses station from lunch. I inform her of the incident and she then takes over the situation and patient care, and places another call to NP for orders. Writer does take a retuned phone call from NP and receives ordered to give 1 x dose of Benadryl 25 mg now and then Benadryl 25 mg Q HS PRN x 10 days. Writer informs [Staff E's name] RN of the call back with orders, who then gives medication and this writer (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105397 If continuation sheet Page 3 of 8 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 07/22/2025 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 0806 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few enters the order into [name of medical records software].Review of written statement written by Staff B, Dietary Aide, dated 6/6/2025 read, I was calling tickets on the line today for lunch when we had fish. The fish was for soft and bite sized too and when [Resident #1's name] ticket came up I was helping find tickets for the dining room also. When I went back to setting up trays, I missed her allergy and placed the soft and bite sized plate on her tray, placed the lid on it to keep the food hot and sent it down the line. I didn't mean to give her the fish and I hope [Resident #1's name] is going to be ok.Review of written statement written by the Food Service Manager dated 6/6/2025 read, On the date of June 6th we had our three year veteran employee [Staff B's name] working as dietary aid in the tray setup and calling station tasked with calling tickets and placing completed plates on hot plates and covering. Our other aid that day was [Staff C's name] who recently completed three shifts of one on one [Sic.] training on the line with myself. [Staff C's name] was tasked with beverage, dessert, and supplement placement. Drawing on her previous experiences as a dietary aid [Staff C's name] was proficient at this task and had performed well. Cooking was a 20 year veteran of the building. On the day in question I checked the line asking if everyone was ok or if they needed anything. The response was in affirmative that everyone was ok and all needed supplies were completed for tray line. I announced my departure to pick up supplies from [name of a local store] for the evening meal and exited the campus. Returning approximately 20 minutes later I was informed of the error in question.During an interview on 7/21/2025 at 10:23 AM, the Administrator stated, The dietary aid was doing the line his name is [Staff B's name] he was supposed to read the meal tickets out loud. A nurse came to the kitchen and asked [Staff B's name] for something he had just started calling the ticket for [Resident #1's name] and was interrupted. When he came back to calling the ticket he did not call the allergy and then the aid at the end of the line missed it [allergy] and placed the meal tray on the cart. The CNA delivered the tray, we didn't know she had fish served until the CNA went to pick up the tray and resident asked if it was fish. We suspended everyone involved. Ultimately, they are not here anymore. We didn't have a specific policy for the nurse to check the tray, so she is still working here. The CNA was supposed to check the tray. [Staff B's name] had an interruption from reading out the ticket, didn't get all the information out to the cook in the line. She [Resident #1] was sent out to the hospital and stayed overnight.During an interview on 7/21/2025 at 11:34 AM, the ARNP #1 stated, Staff called because [Resident #1's name] had a bite of fish and she [Resident #1] felt she had an allergy to it. I ordered a dose of Benadryl. The resident has had issues with her jaw in the past. The nursing staff came back saying she was still having issues, and I was worried the resident was having airway issues. They sent her to the ER and the ER gave her EPI and Benadryl. Depending, with her allergy [fish], it [the reaction] can be airway obstruction or hives. Everyone's allergy is different. It could be deadly if it's severe, it depends on the exposure the reaction you might have. I could not say if it was her chronic jaw issues or allergies. With the Benadryl administered she should have felt better but she was still feeling the same. I don't truly know if she had an airway obstruction as a provider, we would be more cautious and treat her. The staff verbalized she was feeling itchy. Our course of action would have been Benadryl, steroids also but as a diabetic patient it would flare right up. I feel everyone makes an error here and there. I feel she got exposed and the staff noticed and acted quickly. She verbalized symptoms in her mouth and her airway could be compromised so we sent her out for further testing and evaluation. I want to say it has not happened here before.During an interview on 7/21/2025 at 11:52 AM, the Director of Nursing stated, I was not here the day of the event. My Assistant Director of Nursing was here. They gave her [Resident #1] Benadryl and sent her out to the hospital. CNAs are supposed to check the tray. It is (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105397 If continuation sheet Page 4 of 8 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 07/22/2025 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 0806 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few in their competencies. They are to remove and report any inaccuracy to the nurse immediately. It was right on the ticket [the allergy] and the ticket was correct. Never happened before. The elderly taste buds decrease. In the emergency room she was there for two hours, and the staff didn't do anything and then the doctor came to talk to her in the ED and she started saying she could not talk and they gave her epi because she was saying she could not talk and they kept her just in case after she spoke to the doctor.During an interview on 7/21/2025 12:09 PM, Staff C, Dietary Aide, stated, It was my third day. I was a new hire. We were having all the CNA's coming in and out, left and right asking for things. I was doing my best to communicate. I am not sure what happened, we were all communicating and putting things on the trays. People had to get offline [the meal tray line] to grab things. I was putting drinks on trays along with desserts on the meal tray. I was at the end of the line. I don't recall looking at the tray it was a lot of trays being passed. I make sure the liquids and meals are correct. I don't know if I missed that one or not. The allergies are said out loud and it was listed on the meal ticket. I remember him saying fish allergy and then someone came out for something, and the tray was set up already on my side when I returned. I just placed the drink, and I don't recall if I looked to see the meal. I was put on suspension.During an interview on 7/21/2025 at 12:30 PM, Resident #1 stated, I was given fish, but I thought it was eggs. I ate some of the fish and my mouth started to swell up from inside. I told the nurse my jaw was swelling from the inside, and I could not get anything down. I am allergic to fish and lobster. In the past when I ate fish or lobster; I had a similar reaction.During an interview on 7/21/2025 at 12:35 PM, Staff D, CNA, stated, It was on a Friday we were all passing lunch trays all the CNAs work together and help each other. When I go to start collecting trays from my assignment, she [Resident #1] looks at me and tells me is this fish and gives me the ticket and the ticket said she was allergic to fish. I left and went to find the nurse and ADON. The ADON came to me, and I told her what happened, they suspended me. I was not the person who passed the tray, and they asked me to write a statement of what happened. I did not do it, I was not the one who passed it out to her, and I just picked up the tray and I did not pass it. I was responsible for her that day. When you pass trays one of first things you do is look at the tray ticket and meal. You have to check that before you pass it out to the resident, making sure no allergen is on the tray. She looked normal and did not verbalize any symptoms.During an interview on 7/21/2025 at 12:44 PM, Staff E, RN, stated, I came back from lunch to the floor the other nurse said resident [Resident #1's name] had gotten fish and she had a fish allergy. I took vital signs and gave her Benadryl and she said was itchy. I went to check on her 15 minutes or so later and she said she felt her tongue was swollen. I asked her to open her mouth or stick her tongue out. She said she could not do it, and the NP said to send her out because now she is complaining of her mouth. EMS came, she was talking normal, and EMS took her down the street to the hospital. She was talking to them like normal. Never has it happened before her [food allergy served]. [Before the incident occurred] CNAs were responsible to check the trays. The nurses didn't have to do that. The allergies were listed on the meal tickets. [After the incident occurred] Now, nurses check trays and sign off the slip and then give it to the CNA and the CNA double checks and everyone is on the floor. No one can go to lunch when trays are on the floor. Now they are highlighting [the allergies]. We received education on allergies. Allergies are on the resident records and dietary goes and ask allergies upon admission.During an interview on 7/21/2025 at 12:56 PM, the Medical Director stated, The facility communicated with me the incident with [Resident #1's name] and we decided to send her to the hospital even though she was asymptomatic but symptoms can happen at a later time. The problem is you never know the reaction they will have. In her case it was not anaphylactic, but we took steps and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105397 If continuation sheet Page 5 of 8 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 07/22/2025 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 0806 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few took it seriously. If an anaphylactic reaction had never happened it may happen, it is unpredictable. Some signs are hives, rash, swelling, anaphylactic reaction all depends how soon it's treated. If a patient is not around anyone they can die. During an interview on 7/21/2025 at 1:22 PM, the ADON stated, The Unit Manager came and told me what had happened. I went back and checked on the resident to see if she was okay. I contacted the provider and then started the investigation of what happened. I put out education immediately and then I was notified that we were going to send her out. I think it was 1 pm that we sent her out. I spoke to the CNA, and she had not checked the tray. At that point CNAs were responsible to check the tray. Things have changed. For one, we have either have Administration or nursing in the kitchen watching trays be done and the kitchen changed the policy as well. A nurse must check each tray and the CNA is checking each try also. The CNAs do their own hallways, but they are able to go help other halls. The expectation is to check the meal ticket before [the meal tray is delivered]. I put out education, a ticket, and showing them how to read a ticket. The new changes are no one is going into the kitchen at all they have a runner there now. If they need something the runner will help. No staff is allowed to go on break while trays are on the floor. That I know of, it has not happened before. I have been here three years. She [Resident #1] had no symptoms while I was there but with true allergies it can take a minute. A negative outcome could be rashes, swelling, and not being able to breathe. It could lead to death.During an interview on 7/21/2025 at 1:36 PM, the Food Service Manager stated, I had a three-year veteran on the line tasked with calling out the order to the cook, placing the ticket on the tray, and silver ware. He was pulling the plate off the line, placing them on hot plates, putting a lid on it, and passing it out to the second dietary aid, who was responsible for placing drinks and dessert. We had some order changes and requests. They [staff] were poking their heads [into the kitchen] making requests and order changes and he was trying to assist in putting a mechanical [soft diet] fish on the tray and send it down [the tray line] and he lost track of it [Resident #1's food tray]. He was really good just made a mistake. I was not in the kitchen at the time. The cook has been here for 20 years, and he [the dietary aid] had been here for three years. I had to get supplies, and they were well on their way [preparing the lunch trays] and I was back in 20 minutes and that is when I was told there was an error. Before the event, we had two aids and one cook. Now, one aid calls out the meal, the next aid places the food items on the tray, and then the tray is sent down the line, she [the aid], it was only her fifth shift [working at the facility]. She had experience prior before she came to us. She was capable of understanding drinks and desserts. I did not instruct her to check the plates [to verify the meal ticket to the tray]. We do that now. Now, after they send the tray, the aid who puts the lid on it [the meal] verifies the meal, now we have two sets of eyes on it. We have also an observer which is me or a registered nurse; usually it is me or the assistant director and a registered nurse. We are highlighting all allergies on the tickets now. Also, we talk about the items and the allergies everyday. Allergies are important because they [residents] can possibly die from it, and we are in charge of their health and to protect their wellbeing. Also, staff are not able to come in and out of the kitchen to interrupt. We have a staff standing by the [kitchen] door and aids are instructed not to stop the tray line. The designated person will get the request and between carts we can stop but during the line there is no distraction. We have a total of nine employees [in the kitchen]. All the staff were trained after the event.During an interview on 7/21/2025 at 2:57 PM, Staff F, Cook, stated, We were serving the food and one of the dietary aids made a mistake and did not call out the resident's food allergy. I don't know, I think he was busy with aids coming in and out. If a resident has an allergy, it should not be given to them because it can be harmful, and they will be sick. We (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105397 If continuation sheet Page 6 of 8 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 07/22/2025 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 0806 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few received training after that [the incident] as a group and individually. There is always a nurse in the kitchen now. We have to stop and review allergies. It was about four hours of training, and we don't stop for interruptions.During an interview on 7/22/2025 at 8:03 AM, Staff A, LPN, stated, CNAs were passing lunch trays and a CNA came to me and said she collected [Resident #1's name] tray and she ate the fish that was on the tray, and she [Resident #1] is allergic to fish. I removed the tray and assessed the resident. She looked fine, no distress. I contacted the provider, and the provider ordered Benadryl for her after her nurse [Staff E's name] came back and took over. Several things can happen if given an allergen to a resident from itchy to an anaphylactic shock.Review of the Allergy & Asthma Network at https://allergyasthmanetwork.org/anaphylaxis/what-is-epinephrine read, Epinephrine will treat a life-threatening allergic reaction immediately.Review of the Mayo Clinic website at https://www.mayoclinic.org/drugs-supplements/epinephrine-injection-route/description/drg-20072429 read, Epinephrine (injection route) Epinephrine injection is used for emergency treatment of severe allergic reactions (including anaphylaxis) to insect bites or stings, medicines, foods, or other substances.Review of the Mayo Clinic website at https://www.mayoclinic.org/diseases-conditions/food-allergy/symptoms-causes/syc-20355095 read, Food allergy - Symptoms and causes - Anaphylaxis: Constriction and tightening of the airways. A swollen throat or the sensation of a lump in your throat that makes it hard to breathe, shock with a severe drop in blood pressure, rapid pulse, and dizziness, lightheadedness or loss of consciousness.Review of the facility policy and procedure titled Food and Nutrition Services last reviewed on 1/1/2025 read, Policy: The facility strives to ensure excellence in nutritional services to residents through safe, nutritious, and balanced meals in a pleasant environment while maintaining individualized assessment of nutritional needs.Review of the facility policy and procedure titled Electronic Tray Card System last reviewed on 1/1/2025 read, Policy: To ensure the correct diet order, food preferences and food allergies are honored at meal delivery times. Procedure: 1. Complete/confirm a resident profile entry in the electronic tray card system for all residents upon admission and update as needed (e.g., physician diet order change, food preferences). 2. Record/verify the following on all resident profiles as obtained from nursing communication as applicable. E. Food allergies. 3. Print meal tickets and refer to these tray tickets during the service of each meal. 6. Print meal ticket report daily for posting in kitchen, dining locations, and/or activities department for additional staff reference to include but not limited to: b. Allergy Roster.Review of the policy and procedure titled Food Allergen Process. Recognizing, Auditing and Responding to Food Allergies last reviewed on 1/1/2025 read, Resident food allergies in the tray ticket system will print on the tray ticket. Allergens that are linked to food items in the tray ticket system will remove the food item from the tray. A premeal meeting should be held in order to review allergies, diet texture modifications, adaptive devices and any other necessary mealtime accommodations. When a meal tray is composed in which an allergen is present, this allergen should be called out by the staff member assembling the tray. This will notify the team of the allergen so that the meal items can be reviewed to ensure the allergen ingredient is not present prior to leaving the kitchen. Tray tickets must be inspected on the tray line to ensure compliance with listed allergies, diets, preferences, etc.The Immediate Jeopardy (IJ) was removed on 6/9/2025 by developing and implementing an IJ Removal Plan. On 6/6/2025, the facility conducted a root cause analysis, conducted a facility-wide audit for all residents for accuracy of food allergies, added a second check to the tray line for the verification of all meal tickets. Review of the QAPI agenda verified meetings were held on 6/7/2025 and 6/27/2025 to review the corrective actions related to the incident. Review of the in-service sign-in sheets dated 6/6/2025 through 6/9/2025 showed 91 of 91 LPNs, RNs, and CNAs, and 9 of 9 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105397 If continuation sheet Page 7 of 8 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 07/22/2025 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 0806 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete dietary staff received training on food safety, resident food allergies, meal tickets, checking trays for allergens, and on tray line procedures. Interviews were conducted with six LPNs, three RNs, thirteen CNAs, and seven dietary staff to verify education and training.The facility developed a plan of correction and corrected the non-compliance on 6/21/2025. The facility reviewed and updated the facility assessment on 6/20/2025. The survey team verified the facility had conducted observational audits of the kitchen, dining room, and floor meal service during breakfast, lunch and dinner from the period of 6/8/2025 to 6/21/2025. On 7/21/2025 at 12:20 PM, the survey team observed nurses and CNAs in 500 Hall verifying the meal items on trays before delivery to rooms. On 7/22/2025 starting at 6:55 AM through 7:20 AM, the survey team observed kitchen staff reading allergies out loud, with the last dietary aid placing the lid on the food plate after verifying meal items. Allergies list placed throughout the kitchen as well as in the main dining room and coffee carts. One cook, two dietary aides, the Food Service Manager, the Administrator and a registered nurse were present during the food preparation. On 7/22/2025 at 7:22 AM in the 100 Hall, and on 7/22/2025 at 7:25 AM, in the 400 Hall, the survey team observed nurses and CNAs verifying the meal trays before delivery of meal. Event ID: Facility ID: 105397 If continuation sheet Page 8 of 8