Inspection·April 14, 2022

F 0584 Level of Harm - Minimal harm or potential for actual harm On 04/11/22 at 12:30 p.m. Resident #56 was observed in bed. Her overhead wall light fixture did not have a cover which resulted in the lightbulbs being exposed. Additionally, Resident #56's pull cord was observed to be about an inch in length and out of the resident's reach. Resident #56 stated she had anxiety when the staff turned her light off. She stated the light stayed on all day/night because she could not turn it on/off herself. Residents Affected - Some Additional observations were made of Resident #56's room on 04/12/22 and 04/13/22. Both observations revealed the overhead wall light had not been covered and the pull cord remained out of reach. On 04/14/22 at 9:28 a.m. Resident #56 was observed in bed. Her overhead wall light fixture did not have a cover which resulted in the lightbulbs being exposed. Additionally, Resident #56's pull cord was observed to be about an inch in length and out of the resident's reach. (Photographic Evidence Obtained) A review of Resident #56's most recent care plan revealed a focus area for the use of anti-anxiety medication related to anxiety disorder. Goals to be free from discomfort or adverse reactions related to anti-anxiety therapy. Interventions included but were not limited to monitor for effectiveness each shift. Further review revealed a focus area for the use of melatonin related to insomnia. Goals were to be free from any discomfort or adverse side effects of melatonin. Interventions included but were not limited to evaluate factors potentially causing insomnia such as environment or lighting. On 04/14/22 at 12:18 p.m. an interview was conducted with Staff A, Certified Nursing Assistant (CNA). She stated if a resident did not have a cover on their overhead wall light fixture, she would have notified the Maintenance Director immediately. She confirmed the CNAs could have entered the information into the electronic notification system used to input issues. Staff A stated she did not know how long it would have taken before the request was reviewed by the Maintenance Director. Staff A stated, additionally she would have notified the Maintenance Director verbally. On 04/14/22 at 12:35 p.m. an interview was conducted with the Nursing Home Administrator (NHA) and the Maintenance Director. They stated the facility had a program called Angel Rounds which required all members of the management team to visit resident rooms. They confirmed the overhead wall light fixture and the pull cord concerns should have been caught by the member of management assigned to the room. Based on observations, interviews and record review, the facility failed to provide a safe, clean, comfortable and homelike environment by not ensuring 1. resident closet room doors in three rooms (228, 231 and 328) were functioning, 2. HVAC (Heating, Ventilation, and Air Conditioning) system filters in 12 resident rooms (303, 304, 306, 307, 309, 311, 319, 320, 323, 324, 325, and 326) were free of dust and debris, 3. walls, floors, closet ceiling (resident room [ROOM NUMBER]), handrail, an electrical outlet, resident room furniture and trim molding were maintained in two units (300 and 200) of three units to include nine resident rooms (317, 309A and 217P, 326, 328, 330, 332, 333, and 334), and 4. An overhead wall light and cover worked and had a light pull cord for use for one resident (#56) for a total of four days (4/11/2022 to 04/14/2022) four days observed. Findings included: 1. An observation was conducted of resident room [ROOM NUMBER] on 4/11/2022 at 12:37 p.m. The observation revealed sliding doors to the closet broken and being supported by the resident's clothing. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105453 If continuation sheet Page 2 of 28 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 105453 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kensington Gardens Rehab and Nursing Center 2055 Palmetto St Clearwater, FL 33758 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 0584 (Photographic Evidence Obtained) Level of Harm - Minimal harm or potential for actual harm On 4/14/2022 at 10:00 a.m., an observation was conducted of resident room [ROOM NUMBER] and the closet doors did not move on the track to open the closet doors fully. Residents Affected - Some On 4/14/2022 at 12:48 p.m., an interview was conducted with the Maintenance Director who was informed of the observations made of resident rooms [ROOM NUMBERS]. The Maintenance Director stated, They (closet doors) are easy; to pop those doors into place, and the handle of the dresser draw is an easy fix. On 4/11/2022 at 10:19 a.m. resident room [ROOM NUMBER]-A was observed to not have furniture handle hardware on the top right drawer of the dresser. On 4/12/2022 at 1:00 p.m., a second observation was made from the hall of resident room [ROOM NUMBER]-A and revealed the handle hardware was missing on the top right drawer of the dresser. (Photographic Evidence Obtained) 3. On 4/11/22 at 9:50 a.m., an observation of the 300-high hallway revealed reddish-brown splatter across the door of resident room [ROOM NUMBER], and between resident rooms [ROOM NUMBERS] there were two unfinished areas of white colored plaster. The areas of plaster were dented and cracked. (Photographic Evidence Obtained). The observation of the 300-high hallway continued, on 4/11/22 at 10:06 a.m., which revealed a red-colored, uncovered electrical outlet in the hallway outside of room [ROOM NUMBER]. The red outlet cover was lying on the molding next to the outlet. (Photographic Evidence Obtained) An additional observation of the area outside room [ROOM NUMBER] on 4/12/22 at 9:27 a.m., revealed the same red-colored electrical outlet continued to be uncovered with a corresponding outlet cover sitting on the molding next to the outlet. The observation also revealed a couple of tiles were broken with a piece lying on the floor next to an emergency door leading to a courtyard. The area of broken tile revealed patches of cement. A continued observation of the 300-hallway on 4/12/22 that began at 9:27 a.m., revealed the handrail outside of resident room [ROOM NUMBER] was broken and the edges were sharp, and an unfinished area of plaster, which was cracked, was above the baseboard between resident rooms [ROOM NUMBERS]. (Photographic Evidence Obtained) On 4/11/22 at 12:44 p.m., an observation of resident room [ROOM NUMBER], where three residents resided, revealed inside the closet was a ceiling tile missing and the void above the ceiling tile was an assortment of wires. (Photographic Evidence Obtained) An observation was conducted on 4/11/22 at 2:43 p.m., of resident room [ROOM NUMBER] with Resident #33. The legs of the over-bed table for Resident #33 were rusty and had an assortment of residue on it, as very little of the silver (chrome) was visible. (Photographic Evidence Obtained) On 4/12/22 at 9:13 a.m., an observation was made of Resident #22's private room (217P). In the bathroom of the resident was a ceiling air vent with gray dust hanging from it, a hole in the wall directly behind the bathroom call light, and an individual serving container of a brand name macaroni and cheese which inside the container was a paper towel and a plastic utensil. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105453 If continuation sheet Page 3 of 28 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 105453 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kensington Gardens Rehab and Nursing Center 2055 Palmetto St Clearwater, FL 33758 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 0584 Another observation on 4/12/22 at 12:21 p.m., revealed the same findings in Resident #22's bathroom. Level of Harm - Minimal harm or potential for actual harm An additional observation of Resident #22's bathroom at 9:33 a.m. on 4/13/22 identified the macaroni and cheese container continued to be sitting in the same location on a shelf in the bathroom. Residents Affected - Some Review of the admission Record revealed Resident #22 was admitted on [DATE]. The medical record identified the resident did not receive any oral intake (NPO) and received 51% or more of intake via an artificial route. The resident's medical record indicated the resident was totally dependent upon two-persons for transfers. An interview and observation was conducted on 4/13/22 at 9:48 a.m., with Staff P, Housekeeping. The staff member stated if garbage was on the floor it would be swept up. If garbage was on the resident's over-bed table the employee would ask before throwing it away. The housekeeper reported Resident #22's room had not received its daily cleaning. The Staff P was shown the container of macaroni and cheese in the bathroom and the staff member stated it must have been missed. On 4/12/22 at 9:22 a.m., an observation was conducted of the bathroom of resident room [ROOM NUMBER]. The corner in front of the toilet was rounded off with synthetic baseboard and the area between the baseboard and the squared corner was filled with white plaster. The wall above the baseboard was coated with unfinished white plaster. (Photographic Evidence Obtained) The Nursing Home Administrator (NHA) reported on 4/12/22 at 12:00 p.m. the facility had a remodeling plan that had not started yet. He stated the facility was going to start by enlarging the therapy gym, redoing the lobby and the business offices. The NHA did not report the timeline for remodeling or maintenance of the resident rooms. The Regional of Plant Services, on 4/13/21 at 1:21 p.m., stated the facility was going to start remodeling soon and the corporation had bought the building two years ago. She stated, We don't believe in doing things twice, so everything would be fixed and she believed the remodeling was going to start in the lobby, and due to COVID-19 the facility could not even get paint. During an interview on 4/14/22 at 12:50 p.m., the Maintenance Director stated someone had moved assist bars (in resident rooms), had patched walls, but did not paint. The new guy the facility just hired was going to be fixing the areas. The NHA stated the facility's Angel Rounds and housekeeping should have seen the macaroni and cheese container. The Maintenance Director stated Resident 33's over-bed table should have been cleaned by housekeeping but the chemicals used for COVID-19 caused a lot of rust. After reviewing the photo that had been obtained, he stated it should just be taken out to the dumpster. The Maintenance Director stated he would immediately take care of the ceiling tile in room [ROOM NUMBER] and staff should have told him about the electrical outlet cover outside of resident room [ROOM NUMBER]. The NHA and Maintenance Director reported they would evaluate the missing floor tiles. 2. On 4/11/2022 at 10:00 a.m., 4/12/2022 at 1:00 p.m., 4/13/2022 at 8:15 a.m., and on 4/14/2022 at 10:45 a.m. the building was toured to include resident rooms. During the above listed tour times, the following was observed: Resident Rooms 303, 304, 306, 307, 309, 311, 319, 320, 323, 324, 325, and 326: wall unit HVAC systems were observed with two sliding filters. Once the filters were pulled up from the unit housing, they were observed heavily caked with dust and debris. The units were observed on and operating while residents were in the room. (Photographic Evidence Obtained) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105453 If continuation sheet Page 4 of 28 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 105453 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kensington Gardens Rehab and Nursing Center 2055 Palmetto St Clearwater, FL 33758 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 0584 Level of Harm - Minimal harm or potential for actual harm On 4/11/2022 at 10:22 a.m. an interview with the Unit Manager for the 300 Unit revealed nursing staff are not responsible for the maintenance of the HVAC units in each room. She revealed nursing staff are allowed and able to change the temperatures per resident request, but do not touch or look at the filters. The Unit Manager revealed all maintenance for the HVAC systems are under the responsibility of the Maintenance Department. Residents Affected - Some On 4/11/2022 at 12:30 p.m. an interview was obtained with the Maintenance Director. He indicated that he has a Electronic Work Order system that indicates HVAC unit air filters are to be changed and or replaced on a monthly basis. He did not have documentation to support the timeframes of when the filters needed to be changed. He revealed that staff should notify maintenance as a part of the Angel program. He revealed staff should be entering rooms every day and looking out for cleanliness and maintenance of equipment. He revealed that should they (staff) see something that needs attention or fixing, they notify him through the work order process. He confirmed the soiled filters and revealed he is trying to hire on more maintenance staff so these things can be tended to in a timely manner. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105453 If continuation sheet Page 5 of 28 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 105453 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kensington Gardens Rehab and Nursing Center 2055 Palmetto St Clearwater, FL 33758 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations and interviews, the facility failed to implement care plan interventions with relation to bed rail use and bed rail monitoring for seven of sixty-one sampled residents (#64, #43, #40, #62, #38 and #56, and #55), during four of four days observed (4/11/2022, 4/12/2022, 4/13/2022, and 4/14/2022). Findings included: 1. On 4/11/2022 at 10:15 a.m. Resident #64 was observed in his room and in bed. He was observed lying in low bed, flat and under the covers with his feet hanging off the right side of the bed. There were ½ bed rails/enablers up and in position. Both side rails appeared not secured and loose fitting. Once the bed rails/enablers were handled, it was found they swayed approximately two to three inches from side to side. It was determined that they were not tightened enough next to the bed frame to ensure resident positioning safety. On 4/12/2022 at 10:00 a.m., 1:10 p.m. and 4/12/2022 at 7:40 a.m. and 11:10 a.m. Resident #64's room was observed, and he was noted in low bed and with both side rails up and in place. The call light was placed within his reach, and he was awake with eyes open. He was positioned on his side with his legs and knees pulled up to his stomach. Both side rails/enablers were again observed up and in position but still loose and not secured enough for the resident to use safely. On 4/13/2022 at 7:40 a.m. and 10:00 a.m. Resident #64's room was approached and entered. Upon entering the room, the resident was observed lying in bed, flat and under the covers and not presenting with any behaviors, pain, or discomfort. However, observations of both bed rails/enablers still loose fitted and were not secured in a manner where the resident could utilize them safely. Resident #63 has been observed to grab at them during several observed visits dated from 4/11/2022 through 4/14/2022. Review of Resident #64's medical revealed he was admitted to the facility on [DATE]. Review of the advance directives revealed he had a Power of Attorney in place. Review of the Minimum Data Set (MDS) Quarterly assessment, dated 2/24/2022 revealed: (Cognition/Brief Interview Mental Status or BIMS score Not scored but indicated resident has Long Term/Short Term memory problems with severely impaired decision-making skills); (Activities of Daily Living ADL to include extensive assist to total dependent with most to all ADLs. Review of the current Physician's Order Sheet dated for month 4/2022 revealed an order to include: Half side rails when in bed as enabler for bed mobility, with an original order date of 11/22/2021. Review of the current care plans with next review date 5/26/2022 revealed care plan problem areas to include but not limited to: a. Resident #64 is using 2 half side rails and is at risk for entrapment and injury with interventions in place to include but not limited to: Ensure proper positioning, Explain risks and benefits, Frequent check while resident is in bed, Have maintenance check the side rails if found loose or found with any issues, Have side rails consent form signed by the resident or responsible party. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105453 If continuation sheet Page 6 of 28 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 105453 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kensington Gardens Rehab and Nursing Center 2055 Palmetto St Clearwater, FL 33758 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 4/14/2022 at 9:00 a.m. an interview with two Certified Nursing Assistants (CNA), to include Employees A, and C. both were able to confirm the bed rails in Resident #64's room were loose. They were not aware of the loose side rails and indicated that this should be reported to the Maintenance department immediately. 2. On 4/11/2022 at 10:00 a.m., 4/12/2022 at 7:40 a.m., 4/13/2022 at 7:20 a.m., and on 4/14/2022 at 8:00 a.m. and 11:40 a.m. Resident #43 was observed in her bed and lying flat under the covers with the call light placed within her reach. Resident #43 was not presenting with any behaviors, pain, or discomfort. However, further observations revealed both half side rails/enablers were not tightly secured to the bed frame and when handled, the rails swayed to the side with approximately two to three inches. The resident had been observed to grab at the bars during times she was visited. The side rails were not secured enough for the resident to safely position herself. Review of Resident #43's medical record revealed she was admitted to the facility on [DATE]. Review of the advance directives revealed she was her own responsible party. Review of the 4/2022 Physician's Order Sheet revealed an order to include: Half side rails as enabler for positioning every shift, with an original order date of 11/4/2021. Review of the most current care plans with a next review date 5/9/2022 revealed a problem area to include but not limited to: Resident is using two half side rails and is at risk for entrapment injury, with interventions to include, but not limited to: Have maintenance check the side rails if found loose or found with any issues, and to have frequent checks while the resident is in bed. 3. On 4/11/2022 at 10:00 a.m., 4/12/2022 at 7:40 a.m., 4/13/2022 at 7:20 a.m., and on 4/14/2022 at 8:00 a.m. and 11:40 a.m. Resident #40's room was observed. Both half bed rails/enablers were observed loose fitting and not secured tightly to the bed frame. When handled, the rails swayed back and forth with approximately two to three inches of play. Resident #40 was observed at times while in bed and trying to position herself while using the bed rails/enablers. Interview with Resident #40 confirmed the rails were loose and it was sometimes hard to use them. She revealed she had not told anyone about them as she just thought that was the way they were. Review of Resident #40's medical record revealed she was admitted to the facility on [DATE]. Review of the Advance Directives revealed the resident was her own decision maker. Review of the 4/2022 Physician's Order Sheet revealed an order to include: Half side rails when in bed as enabler for bed mobility, with an original order date of 5/21/2021. Review of the current care plans with a next review date 5/11/2022, revealed a problem area to include but not limited to: Resident using half rails and is at risk for entrapment and injury with interventions to include but not limited to: Have maintenance check the side rails if found loose or found with any issues and check frequently while the resident is in bed. 4. On 4/11/2022 at 10:00 a.m., 4/12/2022 at 7:40 a.m., 4/13/2022 at 7:20 a.m., and on 4/14/2022 at 8:00 a.m. and 11:40 a.m. Resident #62 was observed in his room and lying flat in bed. It was also observed both half side rails/enablers were not tightly secured to the bed frame and when handled, the rails swayed to the side with approximately two to three inches. Review of Resident #62's medical record revealed he was admitted to the facility on [DATE]. Review (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105453 If continuation sheet Page 7 of 28 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 105453 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kensington Gardens Rehab and Nursing Center 2055 Palmetto St Clearwater, FL 33758 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few of the advance directives revealed Resident #62 had a responsible party to make his medical decisions. Review of the Physician's Order Sheet dated for the month of 4/2022 revealed an order to include but not limited to: Half side rails when in bed as enabler for bed mobility, with an original order date of 2/24/2022. Review of the current care plans with a next review date 5/24/2022 revealed a problem area to include but not limited to: Resident is using two half side rails and is at risk for entrapment and injury with interventions to include but not limited to: Frequent checks while the resident is in bed and Have maintenance check the side rails if found loose or found with any issues. 5. On 4/11/2022 at 10:00 a.m., 4/12/2022 at 7:40 a.m., 4/13/2022 at 7:20 a.m., and on 4/14/2022 at 8:00 a.m. and 11:40 a.m. Resident #38 was observed in his room and was lying in bed most of the day. His bed was observed with half side rails/enablers that were not tightly secured to the bed frame and when handled, the rails swayed to the side with approximately two to three inches. Review of Resident #38's medical record revealed he was admitted to the facility on [DATE]. Review of the advance directives revealed he had a Power of Attorney to make his medical decisions. Review of the current Physician's Order Sheet dated for the month 4/2022 revealed an order to include but not limited to: Quarter side rails when in bed as enabler for bed mobility with an original order date of 2/2/2022. Review of the current care plans with a next review date of 5/11/2022 revealed problem areas to include but not limited to: Using 2 quarter side rails and is at risk for entrapment and injury, with interventions to include but not limited to: Frequent checks while in bed, have maintenance check the side rails if found loose or found with any issues. 6. On 4/11/2022 at 10:00 a.m., 4/12/2022 at 7:40 a.m., 4/13/2022 at 7:20 a.m., and on 4/14/2022 at 8:00 a.m. and 11:40 a.m. Resident #56 was observed in her room and was lying in bed most of the day. Her bed was observed with half side rails/enablers that were not tightly secured to the bed frame and when handled, the rails swayed to the side with approximately two to three inches. It was determined that the bed rails/enablers were not secured tightly in a manner to promote safe enabling/positioning. Review of Resident #56's medical record revealed she was admitted to the facility on [DATE]. Review of the advance directives revealed the resident had a Power of Attorney in place to make her medical decisions. Review of the current care plans revealed problem areas to include but not limited to: Resident using 2 quarter side rails and is at risk for entrapment and injury, with interventions to include but not limited to: Frequent checks when resident is in bed, and Have maintenance check the side rails if found loose or found with any issues. 7. On 4/11/2022 at 10:00 a.m., 4/12/2022 at 7:40 a.m., 4/13/2022 at 7:20 a.m., and on 4/14/2022 at 8:00 a.m. and 11:40 a.m. Resident #55 was observed in her room and was lying in bed most of the day. Her bed was observed with half side rails/enablers that were not tightly secured to the bed frame and when handled, the rails swayed to the side with approximately two to three inches. Review of Resident #55's medical record revealed she was admitted to the facility on [DATE]. Review of the advance directives revealed the resident had a Power of Attorney to make her medical decisions. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105453 If continuation sheet Page 8 of 28 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 105453 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kensington Gardens Rehab and Nursing Center 2055 Palmetto St Clearwater, FL 33758 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the current Physician's Order Sheet dated for the month of 4/2022 revealed orders to include but not limited to: Half side rails when in bed as enabler for bed mobility, with an original order date 12/7/2021. Review of the care plans revealed problem areas to include but not limited to: Resident using 2 quarter side rails and is at risk for entrapment and injury with interventions to include but not limited to: Frequent checks while resident is in bed, and Have maintenance check the side rails if found loose or found with any issues. On 4/14/2022 at 9:15 a.m. Certified Nursing Assistants (CNA) Employees A., B., and C. all revealed they were not aware of the bed rail enablers loose fitting and shaky when used. They revealed if they had known, they would report to the Unit Manager and the Maintenance Department though a work order. Employees A., B., and C. further revealed if they observe loose fitting bed rail enablers, they are to report it immediately as the loose fitted rails could become an accident hazard for the residents. Interview with the 300 floor Nurse, Employee E. revealed she was not aware of loose fitted bed side rail/enablers and would look into it and report it to the Maintenance Department. She did not know who was responsible for assessing the rails nor was she aware of how often the rails are looked at for maintenance. On 4/14/2022 at 12:30 p.m. an interview with the Maintenance Director revealed he was not aware of any ill fitted or loose bed rails/enablers. He revealed there should be an Angel program where staff go into rooms and look out for the maintenance of furniture and equipment. He revealed that maintenance should be doing their own assessment, but he has been short maintenance staff and is in the process of trying to hire on new personnel. The Maintenance Director did confirm the loose fitted bed rails/enablers related to residents #64, #43, #40, #62, #38 and #56, and #55. On 4/14/2022 at 1:00 p.m. an interview with the care plan coordinator confirmed residents #64, #43, #40, #62, #38 and #56, and #55 all had orders to utilize bed rails as enablers and were also followed up with care planning with relation to bed rails/enabler use. She revealed all residents who are ordered for use of bed rails/enablers, are care planned and with specific interventions to include: Staff to report loose fitting rails/enablers to maintenance. On 4/14/2022 at 3:00 p.m. the Director of Nursing provided the following policies for review: 1. Using the Care Pan, dated 2001, revealed that the care plan shall be used in developing the resident's daily care routines and will be available to staff personnel who have responsibility for providing care or services to the resident. #3 of implementation revealed; CNAs are responsible for reporting to the Nurse Supervisor any change in the resident's condition and care plan goals and objectives that have not been met or expected outcomes that have not been achieved. 2. Problem Identification List, dated 2001, revealed; Prior to care planning conference, a problem identification list shall be developed to assist the Care Planning/Interdisciplinary Team in developing and revising comprehensive care plans. #2 of Implementation revealed; Each discipline will provide a written or oral report of the resident's problems, strengths, goals, and approaches as outlined below; (d.) Approach The specific action(s) or intervention(s) that the staff will take to assist the resident in meeting/achieving the short-term goal(s). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105453 If continuation sheet Page 9 of 28 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 105453 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kensington Gardens Rehab and Nursing Center 2055 Palmetto St Clearwater, FL 33758 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 Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure resident smoking supplies were secured and residents adhered to designated smoking times for seven residents (#40, #9, #57, #4, #68, #78, and #81), on four (4/11/2022, 4/12/2022, 4/13/2022, and 4/14/2022) of four days observed Findings included: During an observation of Resident #40's room on 4/12/2022 at 11:20 AM. a full pack of cigarettes was noted on the resident's bedside tray table. (Photographic evidence obtained.) According to admission records, Resident #40 was admitted on [DATE] with diagnoses including alcohol abuse, anxiety, adult failure to thrive, emphysema, and personal history of adult neglect. Review of Resident #40's Minimum Data Set (MDS) Section C (Cognitive Patterns) indicated her Brief Interview for Mental Status (BIMS) score is 15, indicating resident is cognitively intact. Review of Resident #40's care plans indicated a care plan in place for smoking, potential for injury. Interventions included monitor for compliance with smoking policy, explain facility's smoking policy, and notify charge nurse immediately if resident is suspected to violate facility smoking policy. An observation was made of the smoking patio on 4/13/2022 at 9:34 AM. According to the facility smoking schedule, the smoking patio is closed from 9:00 AM to 10:00 AM. Two residents (#40 and #9) were observed sitting on the patio smoking. No smoking aide was present at the time. An interview was conducted with Staff W, Registered Nurse (RN), Unit Manager (UM) on 4/13/2022 at 10:16 AM. The UM stated no one should have cigarettes or lighters in their possession. She said the smoking aide keeps all smoking supplies locked in the smoking cart on the patio, and confirmed residents should only be smoking during posted smoking times with the smoking aide in attendance. The UM stated if staff see cigarettes or lighters, they should ask the resident for them. She stated, if the resident says no, we can't take it from them. The UM was able to name several residents, including Resident #40, she believes had smoking supplies in their room. An interview was conducted on 4/13/2022 at 11:30 AM. with the Staff Q, Certified Nursing Assistant (CNA) who confirmed she was the assigned smoking aide, Staff Q demonstrated how smoking cart is set up with smoking supplies labeled with resident name and locked in a drawer. The aide stated there is a book to document who smokes, the date, time and how many cigarettes they ask for. She stated no one should be smoking during times the patio is closed. She stated there should always be an aide present for safety when residents are smoking. The CNA said all smoking supplies should be locked in the cart, and none should be in resident rooms. Staff Q stated if a resident comes out to the patio and has their own supplies, she would take them and put in the cart and educate the resident. An observation was made of the smoking patio on 4/14/2022 at 9:50 AM.; the smoking patio was closed. Five residents (#57, #4, #68, #78, and #81) were on the patio smoking. While observing, Staff Z walked through the courtyard, near the smoking area. Staff Z stated no one should be outside smoking at that time. She stated she did not know where the residents got the smoking supplies. She confirmed no smoking aide was present, and the smoking patio was closed. An interview was conducted with the Director of Nursing (DON) on 4/14/2022 at 10:02 AM. The DON (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105453 If continuation sheet Page 10 of 28 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 105453 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kensington Gardens Rehab and Nursing Center 2055 Palmetto St Clearwater, FL 33758 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 Residents Affected - Some confirmed there was only one smoking area. He stated an aide should be present when the smoking patio is open, and no resident should be smoking during closed times. The DON confirmed that no one should have been smoking at 9:50 AM. He stated many residents buy smoking supplies when they leave the building. The DON stated if staff see residents with smoking supplies, they should ask the resident for the supplies and educate them on the rules and risks. He stated he has never had a resident tell him no when he asked for their smoking supplies. The DON stated if the resident did not comply with having their smoking supplies locked up, social services would work on an alternate placement and the resident would be given a 30-day notice. The resident would then be one-on-one care. The DON stated that all residents review and sign the smoking policy and are given a copy of the policy and smoking times. An interview was conducted with Staff R, admissions coordinator. Staff R confirmed all residents are given the smoking policy with their facility admission packet and they must sign a copy. Residents #40, #9, #57, #4, #68, #78, and #81 all have signed Tobacco-Restrictive Policy Agreements. An observation was made of Resident #40 at 4/14/2022 at 10:55 AM. Resident was sitting in her bed with a lighter sitting on her bedside table. An interview was conducted with Resident #40 on 4/14/2022 at 10:59 AM. Resident #40 stated there are smoking times and residents can only smoke during those times. She stated the smoking aide keeps all supplies in the locked cart outside. Resident #40 stated residents are not allowed to have cigarettes or lighters because people have oxygen, and it could be dangerous. She stated some people get cigarettes when they go to the store on a leave of absence. An interview was conducted with Staff A, CNA at 4/14/2022 at 11:04 AM. Staff A stated residents are not allowed to have any smoking supplies personally. The CNA said if she sees any supplies, she will remove them and talk to the resident. She stated if the resident does not give the smoking supplies to her, she would go to her supervisor. She stated the facility has educated staff and everyone is aware residents cannot have smoking supplies. An interview was conducted with Staff S, Social Services Director on 4/14/2022 at 2:00 PM. Staff S stated if there are issues with residents having smoking supplies and not being compliant, they would be referred to her. She stated she has only had one referral recently. She stated she did not think there was much of a problem lately with residents having smoking supplies personally. A facility policy titled Citadel Safe Smoking Policy & Procedure, undated was provided by the DON. The policy revealed: Residents who smoke are to smoke with direct staff monitoring. A staff member will be assigned to the smoking area for resident safety & supervision. 4. Residents are not to retain lighters, matches, cigarettes, ignitable tobacco products or other smoking materials in their personal possession. 5. Residents will have their cigarette lit for them. The assigned staff member will hold the lighter while the resident lights the cigarette. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105453 If continuation sheet Page 11 of 28 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 105453 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kensington Gardens Rehab and Nursing Center 2055 Palmetto St Clearwater, FL 33758 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. According to the clinical record, Resident #22 was admitted on [DATE] and included diagnoses of hypertension and pneumonia. Residents Affected - Few An observation was conducted at 9:25 a.m. on 4/11/22 of Resident #22's nebulizer equipment. The observation indicated a nebulizer mask with an attached medication cup was lying on top of electronic equipment on the resident's bedside dresser, uncovered. The medication cup had droplets of residual liquid in it. On 4/12/22 at 9:17 a.m., an observation of Resident #22 identified nebulizer equipment lying on top of the resident's bedside dresser. The nebulizer mask was not in a protective bag and had liquid residual in the attached medication cup. Resident #22 was observed, on 4/13/22 at 9:35 a.m., lying in bed. A nebulizer mask was lying on the bedside dresser with liquid residue in the medication cup. During an interview with Staff Member W, Unit Manager/Registered Nurse on 4/13/22 at 10:40 a.m. she viewed Resident #22's nebulizer equipment lying on the bedside dresser and said it should be stored in this bag, identifying an opaque bag attached to the nebulizer machine. She stated that the nebulizer equipment should be washed after use and air dried before putting in the bag. A review of Resident #22's physician orders indicated the resident was to be administered Albuterol Sulfate Neb Solution: 2.5 milligram/milliliter - inhale orally via nebulizer three times a day for pneumonia. The schedule of administration was 6 a.m., 2 p.m., and 10 p.m. The policy - Departmental (Respiratory Therapy) Prevention of Infection, revised November 2011, identified the purpose was to guide prevention of infection associated with respiratory therapy tasks and equipment, including ventilators, among residents and staff. The procedure instructed as Infection Control Consideration Related to Medication Nebulizers/Continuous Aerosol: - 1. Obtain equipment (i.e., administration set-up, plastic bag, gauze sponges). - 2. Wash hands. - 3. After completion of therapy; -- a. Remove the nebulizer container; -- b. Rinse the container with fresh tap water; -- c. Dry on a clean paper towel of gauze sponge. - 4. Reconnect to the administration set-up when air dried. - 5. Take care not to contaminate internal nebulizer tubes. - 6. Wipe the mouthpiece with damp paper towel or gauze sponge. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105453 If continuation sheet Page 12 of 28 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 105453 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kensington Gardens Rehab and Nursing Center 2055 Palmetto St Clearwater, FL 33758 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 - 7. Store the circuit in plastic bag, marked with date and resident's name, between uses. Level of Harm - Minimal harm or potential for actual harm - 8. Wash hands. - 9. Discard the administration set-up every seven (7) days. Residents Affected - Few Based on observation, interview and policy review the facility failed to ensure 1.) oxygen tubing was appropriately stored for one (Resident #33) of twenty-five residents sampled for oxygen; 2.) Physician's Orders were obtained for two (Residents #33 and #56) of twenty-five residents sampled for oxygen; and 3.) nebulizer equipment and tubing was appropriately stored for two (Residents #22 and #85) of thirty-six residents sampled for respiratory treatments Findings included: 1. A review of facility policy titled Departmental (Respiratory Therapy) Prevention of Infection, with revision date of November 2011, under Steps in Procedure, revealed: 8. Keep oxygen cannula and tubing PRN [as needed] in a plastic bag when not in use. On 04/12/12022 at 03:30 p.m. Resident #33's room was observed to have Oxygen Nasal Cannula (NC) and tubing hanging over the oxygen concentrator and not stored appropriately. Resident #33 was observed to be self-propelling in the hallway, oxygen was set at 2 Liters per minute (L/min) and wearing bilateral NC. During interview with the resident, he revealed he wears oxygen continuously. On 04/13/2022 at 02:00 p.m. Resident #33 was observed to be seated on the side of the bed wearing oxygen. The resident indicated once again that he needed to wear oxygen all the time. A record review of Physician Order's for Resident #33 revealed no active order for oxygen. The last Physician Order to wear oxygen at 3L/NC, as needed, was discontinued on 08/18/2021. The resident's Care-Plan revealed an intervention to provide oxygen as ordered. On 04/14/2022 at 11:11 a.m., an interview was conducted with the Director of Nursing (DON), who confirmed that Resident #33 did not have an active order for oxygen. He further indicated Staff D, Registered Nurse (RN) put an active order into the resident's Electronic Medical Record (EMR). A subsequent review of the clinical record revealed a new physician order which read O2 at 2L/min via NC as needed for SOB [shortness of breath], dated 04/14/2022. A review of facility policy titled Oxygen Administration, with revision date of October 2010, Page 01 of 03, under Purpose revealed The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation: 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. 2. Review of Resident #56's admission Record revealed she was admitted to the facility on [DATE] with diagnoses of but not limited to acute respiratory failure with hypoxia and chronic obstructive pulmonary disease. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105453 If continuation sheet Page 13 of 28 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 105453 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kensington Gardens Rehab and Nursing Center 2055 Palmetto St Clearwater, FL 33758 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 Residents Affected - Few A review of the Minimum Data Set (MDS) assessment dated [DATE], Section C: Cognitive Patterns revealed Brief Interview for Mental Status (BIMS) score of 11, which indicated Resident #56 had moderately impaired cognition. Section O: Special Treatments, Procedures and Programs revealed Resident #56 used oxygen therapy while a resident. A review of Resident #56's most recent Care Plan revealed a focus area for altered respiratory status related to a diagnosis of chronic obstructive pulmonary disease and respiratory failure. Goals included Resident #56 would display optimal breathing patterns daily. Interventions included oxygen per order. A review of Resident #56's most recent Physician's Orders revealed no orders for the use of oxygen therapy. Further review revealed orders dated 12/13/21 to change oxygen cannula/tubing and clean oxygen concentrator filter once weekly on Sunday and as needed. On 04/11/22 at 12:30 p.m. Resident #56 was observed in bed wearing a nasal cannula with the oxygen concentrator set at 5 liters per minute. On 04/12/22 at 12:37 p.m. Resident #56 was observed in bed wearing a nasal cannula with the oxygen concentrator set at 5 liters per minute (photographic evidence obtained). On 04/13/22 at 12:55 p.m. an interview was conducted with Staff N, Licensed Practical Nurse (LPN). Staff N stated Resident #56 should have had an order for the use of oxygen therapy. Staff N checked the electronic health record and confirmed that Resident #56 did not have an order. Staff N confirmed that Resident #56 used oxygen continuously. Staff N confirmed there were current orders related to the cleaning and changing of oxygen equipment but did not understand why there was no current order for the use of oxygen. Staff N stated she was going to contact the physician to obtain an order for Resident #56's use of oxygen. Staff N stated the admitting nurse or manager was responsible to put in the order. On 04/13/22 at 03:59 p.m. an interview was conducted with the Director of Nursing (DON). He confirmed that there should have been an order for the use of oxygen for Resident #56. The DON stated that he was going to address the issue immediately. On 04/14/22 at 09:30 a.m. Resident #56 was observed in bed wearing a nasal cannula with her oxygen concentrator set on 2 liters per minute (photographic evidence obtained). Resident #56 stated the nurse came into her room on 04/13/22 and said she had obtained an order from her physician to change her oxygen from 5 liters to 2 liters per minute. 4. An observation was made for Resident #85 on 4/11/2022 at 12:35 PM. Resident's nebulizer mask was sitting on the bedside tray table uncovered. Resident #85 stated his masks always sits there when it is not being used. A second observation on was made on 4/13/2022 at 9:57 AM of Resident #85's nebulizer mask sitting uncovered on his bedside tray table. An observation was made for Resident #85 on 4/13/2022 at 11:20 AM. Resident #85's nebulizer tubing was placed in the top drawer of her bedside table, not bagged, or labeled. The drawer contained many personal items, including a hairbrush, papers, jelly, and gum. The resident stated her nebulizer is usually there. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105453 If continuation sheet Page 14 of 28 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 105453 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kensington Gardens Rehab and Nursing Center 2055 Palmetto St Clearwater, FL 33758 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 Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete An interview was conducted with Staff T, Registered Nurse (RN) on 4/13/2022 at 1:15 PM. Staff T stated respiratory equipment is supposed to be stored in a bag. She stated the bag should have the date the equipment was opened. Staff T confirmed that respiratory equipment should not be lying out uncovered. An interview was conducted with Staff W, RN, Unit manager on 4/13/2022 at 10:20 AM. Staff W stated all respiratory tubing and equipment should be store in a bag. She stated no equipment, including face masks or tubing, should be on a bedside table or in a drawer without being in a dated bag. Staff W stated tubing should be changed once weekly, on Saturday night shift. She stated all nurses are responsible for cleaning equipment and making sure it is stored properly. Event ID: Facility ID: 105453 If continuation sheet Page 15 of 28 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 105453 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kensington Gardens Rehab and Nursing Center 2055 Palmetto St Clearwater, FL 33758 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and policy review the facility failed to ensure Nursing Staffing Information was posted for three days (04/08/22, 04/09/22 and 04/10/22). Residents Affected - Few Findings included: Upon entrance to the facility on [DATE] at 9:00 a.m. the required Nursing Staff Posting was observed on the wall in front of the Nursing Home Administrator's (NHA) office titled, Daily Staffing Levels, with a date of 04/07/22 (Photographic Evidence Obtained). On 04/14/22 at 11:30 a.m. an interview was conducted with Staff Y, Staffing Coordinator. He confirmed he was responsible for posting the Nursing Staff, daily. He stated he worked on 04/08/22 but forgot to post the required daily staffing sheet. He confirmed the weekend supervisor was responsible to post the daily staffing sheet on 04/09/22 and 04/10/22. Review of a facility policy titled, Posting Direct Care Daily Staffing Numbers, with a revision date of 07/2016, revealed the following policy statement: Our facility will post daily for each shift, the number of nursing personnel responsible for providing direct care to residents. 1. Within two (2) hours of the beginning of each shift, the number of Licensed Nurses; Registered Nurses (RN), Licensed Practical Nurses (LPN) and Licensed Vocational Nurses (LVN) and the number of unlicensed nursing personnel Certified Nursing Assistants (CNAs) directly responsible for resident care will be posted in a prominent location (accessible to residents and visitors) and in a clear readable format. 3. Shift staffing information shall be recorded on the Nursing Staff Directly Responsible for Resident Care form each shift. The information recorded on the form shall include: a. The name of the facility. b. The date for which the information is posted. c. The resident census at the beginning of the shift for which the information is posted. d. Twenty-four (24) hour shift schedule operated by the facility. e. The shift for which the information is posted. f. Type (RN, LPN, LVN, or CNA) and the category (licensed or non- licensed) of nursing staff working during that shift. g. The actual time worked during that shift for each category and type of nursing staff. h. Total number of licensed and non- licensed nursing staff working for the posted shift. 5. Within two (2) hours of the beginning of each shift, the shift supervisor shall compute the number of direct care staff and complete the Nursing Staff Directly Responsible for Resident Care form. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105453 If continuation sheet Page 16 of 28 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 105453 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kensington Gardens Rehab and Nursing Center 2055 Palmetto St Clearwater, FL 33758 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 The shift supervisor shall date the form, record the census, and post the staffing information in the location(s) designated by the Administrator. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105453 If continuation sheet Page 17 of 28 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 105453 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kensington Gardens Rehab and Nursing Center 2055 Palmetto St Clearwater, FL 33758 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record review, the facility failed to ensure the medication error rate was less than 5.00%. Twenty-five medication administration opportunities were observed, and two medication errors were identified for two (Residents #98, and #275) of seven residents observed. These errors constituted an 8.00% medication error rate. Residents Affected - Few Findings included: Facility-provided policy titled Specific Medication Administration Procedures, revised January 2018, Page 125, under Metered Dose and Dry-Powder Inhalers revealed: Q. For Steroid inhalers, provide resident with cup of water and instruct him/her to rinse mouth and spit water back into cup. On 04/12/2022 at 09:48 a.m., an observation of medication administration with Staff G, Licensed Practical Nurse (LPN), was conducted with Resident #98. Staff G, LPN was observed administering Advair Diskus 100-80 microgram (MCG)/Dose Aerosol Powder 1 puff by mouth. Once the medication was completely administered by Staff G, LPN, she did not ensure the resident rinsed her mouth, and spit out the contents afterwards. An immediate interview was conducted with Staff G, LPN who confirmed she did not have the resident rinse her mouth and spit the contents out afterwards. On 04/12/2022 at 10:17 a.m., an observation of medication administration with Staff G, LPN, was conducted with Resident #275. Staff G, LPN was observed administering Acetylcysteine Solution 20% 2 Millimeter (MM), Inhalation through the resident's tracheostomy. The East Hall Staff M, Registered Nurse (RN), Unit Manager (UM) was in the resident's room at the time assisting Staff G, LPN with the medication administration. During an immediate interview with Staff G, LPN, she confirmed the medication for Resident #275 was administered late and it was due at 8:00 a.m. A record review of Resident #275's active physician orders dated 3/31/2022, with revision 04/1/2022, revealed Acetylcysteine Solution 20%, 2 MM Inhale every 12 Hours, for Shortness of Breath (SOB) was due to be given at 08:00 a.m. In an interview with the Director of Nursing (DON) on 4/13/2022 at 09:59 a.m., he stated My expectation is the nurse would say something to the Resident so she could swish and rinse remainder medication out of her mouth. [Staff G, LPN] should have said something as a nurse and stated that she needed help with medication administration. During a telephone interview with the Consultant Pharmacist on 04/14/2022 at 04:41 p.m., he was informed of the observations made during medication administration and stated, Sounds like an excellent teaching moment for the DON. A review of facility policy titled Preparation and General Guidelines, with revision date of January 2018, Page 87, and Page 88, under Preparation read as follows: B. Administration 2. Medications are administered in accordance with written orders of the prescriber (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105453 If continuation sheet Page 18 of 28 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 105453 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kensington Gardens Rehab and Nursing Center 2055 Palmetto St Clearwater, FL 33758 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 0759 Level of Harm - Minimal harm or potential for actual harm 12. Medications are administered within (60 minutes) of scheduled time, except before, with or after meal orders, which are administered (based on mealtimes). Unless otherwise specified by the prescriber, routine medications are administered according to the established medication administration schedule of the facility. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105453 If continuation sheet Page 19 of 28 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 105453 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kensington Gardens Rehab and Nursing Center 2055 Palmetto St Clearwater, FL 33758 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. An observation was conducted with Staff W, RN/UM on 4/13/22 at 10:44 a.m. of the South Medication Cart #2. The medication cart was parked behind the open nursing station and was unattended by authorized staff. Staff W confirmed the cart should have been locked. On 4/14/22 at 10:00 a.m., one of one treatment carts on the South Unit was observed unlocked, parked across from the nursing station, and unattended. The Unit Manager was in a meeting in her office behind the nursing station and the two nurses assigned to the unit were on the hallways administering medications. On 4/14/22 at 10:02 a.m., Staff T, LPN identified the treatment cart was the only one on the unit and it should be locked. Staff T locked the treatment cart. Based on observations, interviews and record review, the facility 1. failed to store medications securely and appropriately in five medication carts (East Hall Medication Cart #1, North Hall Medication Cart #2, East Hall Medication Cart #3, South Hall Medication Cart #1, and South Hall Medication Cart #2 ) of seven medication carts and one of one treatment cart on the South Hall, and 2. failed to ensure controlled substances were stored in a permanently attached container in two refrigerators (East Hall and North Hall) of three refrigerators used for storage of medications; and 3. failed to appropriately secure medications for four residents (#98, #85, #46 and #40) of 61 sampled residents. Findings included: 1. A facility policy titled, Medication Storage In The Facility, with a revision date of January 2018, was reviewed and revealed the policy for Storage of Medications as: Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. The Procedures included: A. The provider pharmacy dispenses medications in containers that meet regulatory requirements, including standards set forth by the United States Pharmacopeia (USP). Medications are kept in these containers. A continued review of the Medication Storage In The Facility, policy revealed the policy for Controlled Substance Storage policy as: Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and recordkeeping in the facility in accordance with federal, state, and other applicable laws and regulations. The Procedures included: B: Schedule (II-V) medications and other medications subject to abuse or diversion are stored in a permanently affixed, (double locked) compartment separate from all other medications or per state regulation. On 04/12/2022 at 9:38 a.m., the East Hall Medication Cart #1 was observed unlocked and no staff were in the vicinity of the medication cart. The Director of Nursing (DON) at the time confirmed the medication cart was unlocked and told Staff M, Registered Nurse/Unit Manager (RN/UM) to lock the cart. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105453 If continuation sheet Page 20 of 28 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 105453 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kensington Gardens Rehab and Nursing Center 2055 Palmetto St Clearwater, FL 33758 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 On 04/12/2022 at 9:48 a.m. an observation was conducted of Staff G, Licensed Practical Nurse (LPN), walking out of Resident #98's room, and leaving medication of Advair Diskus 100-80 MCG(microgram)/Dose Aerosol Powder, on the resident's bedside table. Staff G, LPN confirmed she left the medication in the room unattended, and she went down the hall to her medication cart. On 04/12/2022 at 3:45 p.m., an observation of the East Hall Medication Cart #1 revealed thirty-two loose pills in the second drawer, and twelve loose pills in third drawer from the top of the medication cart. Staff H, LPN confirmed the presence of the unsecured pills. (Photographic Evidence Obtained.) On 4/12/2022 at 4:15 p.m. an observation of the North Hall Medication Cart #2 included one loose tablet in the third drawer from the top of the medication cart. Staff J, Registered Nurse (RN) confirmed the presence of the unsecured white tablet. On 4/12/2022 at 4:31 p.m. an observation of the North Hall Medication Cart #2 included one loose tablet in the second drawer. Staff I, RN confirmed the presence of the unsecured white tablet. On 04/12/2022 at 4:47 p.m. an observation of the East Hall Medication Cart #3 included one loose tablet in the second drawer from the top of the medication cart. Staff L, LPN confirmed the presence of the unsecured white tablet. On 04/12/12022 at 5:06 p.m. an observation of the South Hall Medication Cart #1 included one loose tablet in the second drawer. Staff K, RN confirmed the presence of the unsecured gray pill. On 4/12/2022 at 3:00 p.m. an observation was conducted of the North Hall medication room with Staff J, RN. The refrigerator contained a tan lock box observed to not be permanently attached to the refrigerator. Staff J, RN opened the box and the EDK (Emergency Drug Kit) of insulin, also included two unopened vials of Lorazepam 1ml/2MG/ML (milliliter and milligram). On 4/12/2022 at 5:20 p.m. an observation was conducted of the East Hall medication room with Staff M, RN Unit Manager (UM). During the observation, the tan lock box was not permanently affixed to the refrigerator. The box was taken out of the refrigerator and opened. The box contained an unopened EDK with insulin, and two unopened vials of Lorazepam 1ml/2MG/ML inside the EDK. There were two punch cards of Dronabinol Capsules an one was observed with 10 capsules and the other had two capsules. On 04/13/2022 at 5:49 p.m., an interview with the Director of Nursing (DON) was conducted. He was informed of all the observations and indicated staff had brought him unsecured tablets. He stated, I expect if pills pop out of the punch cards, staff put it in the drug buster to dispose of them. The medication carts should be closed and locked once the nurse leaves the cart and walks away into resident rooms. I did not know the Lorazepam was in the EDK in with insulin, and that is how they (pharmacy) are sending the medication to use. The DON further indicated the medications are in locked boxes but did not know they were not permanently affixed to the refrigerator. On 4/13/2022 at 4:41 p.m. a telephone interview was conducted with Pharmacy Consultant. He stated, No medications should be left at bedside unless there is a physician order to do so, and an order to self-administer those medications; as for loose pills in the medications carts, the staff need to look out for that, and they need to make sure they look out for locking their medication carts. Schedule IV medications should be permanently affixed to the refrigerator, and the policy is currently under review with the facility. We are looking to move the Lorazepam medication into the Pyxis unit. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105453 If continuation sheet Page 21 of 28 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 105453 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kensington Gardens Rehab and Nursing Center 2055 Palmetto St Clearwater, FL 33758 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 3. An observation was made on 4/11/2022 at 2:36 p.m. of Resident #85's bedside tray table. Resident #85 had Visine Eye Drops and Deep-Sea Nasal Moisturizing Spay at his bedside. Neither medication was labeled with the resident's name, room number or opening date. (Photographic Evidence Obtained) A second observation was made of Resident #85 on 4/14/2022 at 3:14 p.m. The eye drops and nasal spray remained on the bedside tray table. An observation was made on 4/12/2022 at 9:55 a.m. of Resident #46. Resident #46 had Neosporin cream sitting on their bedside tray table. The cream was not labeled and dated. Resident #46 was sitting in bed and no staff were present. (Photographic Evidence Obtained) An observation was made of Resident #40 on 4/12/2022 at 9:55 a.m. The resident had a bottle of isopropyl alcohol on their bedside tray table. The bottle was not labeled or dated. Resident #40 or staff were not in the resident's room at the time. (Photographic Evidence Obtained) A second observation was made of the bottle of isopropyl alcohol on the bedside tray table in Resident #40's room on 04/13/2022 at 12:26 p.m. A review of the admission Record revealed Resident #40 was admitted on [DATE] with diagnoses including alcohol abuse, adult failure to thrive, and alcoholic liver disease. A review of Resident 40's electronic medical record indicated physician orders dated 5/21/2021 stating, May not have alcohol and May not self administer meds (medications). (Photographic Evidence Obtained) An interview was conducted with Staff T, RN on 4/13/2022 at 10:15 a.m. Staff T stated no medications should be kept in a resident's room, including eye drops or nasal spray. She stated some residents sneak things in, but when staff sees it, it should be removed. An interview was conducted with Staff W, RN/UM on 4/13/2022 at 10:20 a.m. Staff W stated she checks each week for medication in residents' rooms. She confirmed those checks would look for items such as eye drops, nasal spray, creams, isopropyl alcohol. She stated some residents get medications from friends/family or ordering online. Staff W stated they are not allowed to open a resident's package or go through resident's belonging to search for items. However, if staff see a medication of any kind in a resident's room, they should let the nurse know and it should be removed. She stated she would then educate the resident on the risk of having medications in their room. She stated staff are aware they should keep an eye out for medications in resident rooms. Staff W stated a resident could only have medication in their room if they have an order to keep it there. In that case, it would be dated by night shift with an opening date. Staff W confirmed that no resident on the unit currently has a self-administration of medication order, and no medication should be out. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105453 If continuation sheet Page 22 of 28 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 105453 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kensington Gardens Rehab and Nursing Center 2055 Palmetto St Clearwater, FL 33758 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews the facility failed to ensure the wound care for one (#44) of twelve residents with wounds was completed in a sanitary manner to promoted healing. Residents Affected - Few Findings included: Resident #44 was admitted on [DATE]. The admission Record included diagnoses not limited to Parkinson's Disease, Type 2 Diabetes Mellitus without complications, and End Stage Renal Disease. A Weekly Wound Evaluation, dated 4/7/22, identified a Diabetic Right Heel ulcer that measured 1.5 x 2.5 x 0 centimeter (cm). The evaluation indicated a small/minimal serous exudate with a wound bed of 26-50% granulation and 26-50% necrotic tissue. The physician's order, dated 4/4/22, for treatment identified the following regarding the dressing of the right heel: Silver alginate packed Right (R) heel, Abdominal (ABD) roll gauze three (3x) times a week (wk). Cleanser of choice, Return to Clinic (RTC) 2 weeks, and offload Right heel. The Treatment Administration Record (TAR) instructed staff to Cleanse Right Plantar Heel with Normal Saline (NS), apply silver alginate, abd and wrap with kerlix, every day shift every Monday, Wednesday, and Friday for wound. An observation was conducted with Staff O, Licensed Practical Nurse (LPN) on 4/13/22 at 1:46pm, of the right heel wound treatment for Resident #44. The staff member had parked the treatment cart inside the resident's room. Staff O removed a pair of scissors from a cloth pouch, laid them on top of the treatment cart, then applied gloves. Staff O cut the previously applied rolled gauze from the right heel, which was stained reddish-brown at the heel, then laid the scissors back on top of the cart. Staff O ungloved, removed wound cleanser from the cart, gloved (she did not perform hand hygiene), and sprayed a portion of the previous dressing loose. She held the dressing below the wound, sprayed the wound cleanser into the wound and then pressed the old dressing into the wound. The staff member searched the cart for a biohazard bag and then removed the trash liner from the room's trash can and placed it on the floor in front of the cart. Staff O removed a stack of 4x4 gauze pads from an open sleeve and patted the wound. She pushed Resident #44's over-bed table and wheelchair out of the way and retrieved a package of dressing from the resident's bedside dresser. The staff member unwrapped the foam optifoam and alginate, and then picked up the alginate from the package. She did not perform hand hygiene or replace gloves. An interview was conducted, during the observation of wound care, with Staff O in the hallway outside of Resident #44's room. The staff member ungloved and the concerns of lack of glove changing between clean and dirty, lack of hand hygiene when changing gloves, and the contamination of the dressings by the gloves worn after touching the resident's environment were discussed. She stated This is my second pair of gloves then returned to the residents' room. The staff member applied gloves (without hand hygiene), sprayed wound cleanser onto the wound, patted the wound with a 4x4 gauze, ungloved, re-gloved, and placed alginate then optifoam on the wound. She then ungloved and asked resident for hand sanitizer. The resident's roommate pointed to a bottle of hand sanitizer on the dresser, which the Staff member used. Staff O used the scissors, previously used to cut old dressing, to cut a strip of woven tape, placed scissors back on cart, then removed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105453 If continuation sheet Page 23 of 28 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 105453 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kensington Gardens Rehab and Nursing Center 2055 Palmetto St Clearwater, FL 33758 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few a package of rolled gauze from the cart. The Staff member applied gloves, without hand hygiene, and asked the resident if anything else was placed on the wound. Staff O wrapped the heel with rolled gauze, and then applied the woven tape. She removed the wound cart from the room and parked it across from the nursing station. After throwing the trash into the soiled utility room, then going into the pantry, she returned to the cart, placed the scissors back into the cloth pouch (without cleaning), and used a disinfecting wipe to clean the top of the wound cart. On 4/13/22 at 2:10 p.m., the Director of Nursing (DON) was interviewed regarding the observation of Resident #44's wound care. The DON confirmed Staff O was agency staff; he shook his head and notified the Staffing Coordinator that Staff O was a DNR, do not return. He reported he would have the Unit Managers redo all wound treatment on the hallway as he could not trust that they were done properly. The policy - Handwashing/Hand Hygiene, revised August 2015, indicated: This facility considers hand hygiene the primary means to prevent the spread of infections. The policy indicated that the use of alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: - k. After handling used dressings, contaminated equipment, etc.; - l. After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident; - m. After removing gloves. The policy - Wound Care, revised October 2010, included the following: 1. Use disposable cloth to establish clean field on resident's overbed table. Place items to be used during procedure on the clean field. Arrange the supplies so they can be easily reached. 2. Wash and dry your hands thoroughly. 3. Position resident. Place disposable cloth next to resident (under the wound) to serve as a barrier to protect the bed linen and other body sites. 4. Put on exam glove. Loosen tape and remove dressing. 5. Pull glove over dressing and discard into appropriate receptacle. Wash and dry your hands thoroughly. 6. Put on gloves. Gowns will only be necessary if soiling of your skin or clothing with blood, urine, feces, or other body fluids is likely. 7. Use no-touch technique. Use sterile tongue blades and applicators to remove ointments and creams from their containers. 8. Pour liquid solutions directly on gauze sponges on their papers. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105453 If continuation sheet Page 24 of 28 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 105453 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kensington Gardens Rehab and Nursing Center 2055 Palmetto St Clearwater, FL 33758 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 9. Wear exam gloves for holding gauze to catch irrigation solutions that are poured directly over the wound. Level of Harm - Minimal harm or potential for actual harm 10. Wear sterile gloves when physically touching the wound or holding as moist surface over the wound, Residents Affected - Few 11. Place one (1) gauze to cover all broken skin. Wash tissue around the wound that is usually covered by the dressing, tape or gauze with antiseptic or soap and water. 12. Remove dry gauze. Apply treatments as indicated. 13. Dress wound. Pick up sponge with paper and apply directly to area. [NAME] tape with initials, time, date, and apply to dressing. Be certain all clean items are on clean field. 21. Wipe reusable supplies with alcohol as indicated. 22. Take only the disposable supplies that are necessary for the treatment into the room. Disposable supplies cannot be returned to the cart. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105453 If continuation sheet Page 25 of 28 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 105453 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kensington Gardens Rehab and Nursing Center 2055 Palmetto St Clearwater, FL 33758 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review the facility failed to maintain an effective pest control program for two units (300 and 200) of three units related to small flying insects, ants, and wasp like insects for four days (4/11/2022, 4/12/2022, 4/13/2022, and 4/14/2022) of four days observed. Residents Affected - Some Findings included: 1. On 4/11/2022 at 11:30 a.m. and 1:40 p.m. the restorative dining/activity room on the 300 Unit was observed. There were four tables with chairs, which have been used at times by residents for various activities. The windowsill at the back of the room and in between the two large sliding glass doors was observed with over ten small ants crawling on the windowsill, the window and wall. In addition, ants were observed to crawl on the table that was placed under the windowsill. (Photographic Evidence Obtained) On 4/12/2022 at 7:55 a.m. the restorative dining/activity room on the 300 Unit was again observed with many small ants at and near the windowsill in between both sliding glass doors. Ants were observed crawling on the wall and table as well. Further observation revealed another table on the side of the room with a lunch meal tray on it. A meal ticket on the tray was observed and reviewed, and it indicated the meal tray was from the previous night's dinner meal service (4/11/22). There were approximately ten small insects flying at and around the meal tray. When the lid was lifted, the plate was observed with an uneaten sandwich and there were five small ants on the plate and more small insects flying around. There were no residents and or staff in this room when observed. (Photographic Evidence Obtained) On 4/12/2022 at 7:45 a.m. and 10:40 a.m. over five small flying insects were observed around the 300 unit nurses' station the insects were flying and landing on residents, who were self- propelling by the station. Residents were observed to swat at the insects. On 4/13/2022 at 7:40 a.m. the restorative/activity room on the 300 Unit was observed with over ten ants crawling on the windowsill and table, located between both of the sliding glass doors. Further observation revealed over ten small insects flying around the window area and the four tables in the room. Also, the 300 Unit nurses' station was observed with over five small flying insects flying around the counter space. On 4/13/2022 at 12:58 p.m. the 300 Unit station nurses' desk was observed with over ten small flying insects flying around the nurses' station and landing on various residents that were passing by. Residents were observed swatting at the insects. The 300 Unit restorative/activities room was observed with over ten small flying insects flying around the room next too and on tables near the sliding glass doors. Also, the table near the window and in between the two glass doors was observed with over ten small ants crawling on the table and windowsill. On 4/14/2022 at 7:30 a.m. the 300 Unit station nurse desk was observed with small flying insects landing on the desk. There were approximately five to six of these insects flying around. There were two residents seated in wheelchairs positioned at the nurses' station desk and they were observed to attempt to swat at some of these flying insects. The restorative dining/activity room on the 300 Unit was observed with over ten small flying insects at the window and windowsill between the two glass sliding doors. Further observation revealed approximately ten to fifteen small ants crawling on the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105453 If continuation sheet Page 26 of 28 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 105453 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kensington Gardens Rehab and Nursing Center 2055 Palmetto St Clearwater, FL 33758 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0925 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some walls and table positioned below and at the window and in between the two glass sliding doors. Residents had been observed in this room and the room was used for resident activities, family visitation and some dining. On 4/14/2022 at 9:15 a.m. Staff A, Certified Nursing Assistant (CNA), Staff B, CNA and Staff C, CNA all confirmed the 300 hall/unit has been observed with small flying insects at times. They all indicated they report any insect sightings by two ways. One way was to document in their electronic record, which turns into a maintenance work order, and the other way was to physically speak to the Unit Manager and the Maintenance Director. Staff A, B, and C further confirmed the pest control company treats the facility about once a month. They stated they felt the small flying insects and the ants always come back. An interview at this time with Staff D, Registered Nurse (RN) revealed she does notice little flying insects while seated at the nurses' station and has seen some out in the hallways as well. She had not spoken with maintenance about it and did not know when the last time pest control was out to treat the inside of the building. On 4/14/2022 at 7:30 a.m. to 8:30 a.m. interviews with random residents (#24, #41, #85, #4, #96, and #27) all revealed they routinely see various types of bugs in the hallways and other spaces. They also confirmed they see bugs in their rooms as well. They continually report this to nursing staff and see pest control come out to treat. However, they felt the pest control company does not fix the problem, because they see the bugs after the pest control company treats the building. On 4/14/2022 at 12:30 p.m. the Nursing Home Administrator (NHA) and Maintenance Director were interviewed related to the facility's pest control program. The Maintenance Director revealed the facility has a contract with a pest control company and they come out routinely; about once a month. However, he explained they have additional calls for them to come out and treat outbreaks of various pests, more than monthly. The Maintenance Director confirmed the building was older and with the placement of the building within a wooded area, they are always fighting to keep bugs, pests and insects out from the inside of the building. The Maintenance Director revealed floor staff are to do Angel rounds in rooms and spaces on a daily basis and if they see any pests, they are to report it to him through a work order system, and then he can work on treating himself or calling the pest company to make visits to treat. The Maintenance Director also revealed he is short on maintenance workers and he is currently trying to hire staff for his department. The Maintenance Director and NHA both confirmed they were not aware of the ants and small flying insects on the 300 unit. Review of the pest control log revealed the pest control company visited the facility to treat for ants, cockroaches, and flies and touch up. The dates of the visits included 4/12/2022, 3/28/2022, 3/15/2022, 2/28/2022, 2/18/2022, 2/14/2022, 1/26/2022, 1/17/2022, and 1/7/2022. 3. On 4/11/22 at 12:00 p.m., a spray bottle labeled (Bleach Cleaner Brand Name) was observed sitting on a resident dresser in room [ROOM NUMBER], next to the television. Resident #33 stated that it was killing the cucaracha's (cockroaches) that came out at night. The south-wing Unit Manager (UM) observed this at 10:04 a.m. on 4/14/22. She opened the bottle up and stated she did not know what it was, the liquid in the bottle did have a slight chlorine smell. The UM removed it stated, Absolutely not the bottle should be in the resident room. 2. During an interview on 04/11/22 at 12:37 p.m. Resident #57 indicated there are ants and roaches in the facility, and stated, Everyone knows, I tell everyone, no one does anything about it, I cover everything and still ants, and roaches. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105453 If continuation sheet Page 27 of 28 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 105453 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kensington Gardens Rehab and Nursing Center 2055 Palmetto St Clearwater, FL 33758 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0925 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 4. On 4/14/22 at 12:08 p.m. an observation of the skylight on the 200 hall revealed two flying insects that resembled wasps and a nest on the skylight. The wasps were flying around landing and crawling down the walls. At this time there was one visitor, four residents and five staff members walking under the wasps. In addition four resident rooms (204, 205, 206, and 207) were adjacent to the location of the wasp nest. The hallway was observed from 4/11/22 to 4/14/22 to be a high traffic area with many people coming and going at various hours throughout the day. A facility policy titled, Pest Control, dated 2001, revealed: Our facility shall maintain an effective pest control program. The Policy Interpretation and Implementation revealed: 1. This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents . 6. Maintenance services assist, when appropriate and necessary, in providing pest control services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105453 If continuation sheet Page 28 of 28