Inspection·December 14, 2023

F 0568 -10/05/2023 of $1,254.00 Level of Harm - Minimal harm or potential for actual harm Further review of the Room and Board bill, printed on 12/13/2023, reflected the resident had a credit due to him of $2,959.05. Residents Affected - Few During the interview with the BOM, she confirmed the facility had withdrawn $1,254.00 for September and again $1,254.00 in October. When asked if the Care Cost should have been pro-rated due to Resident #2's hospital stay, she stated she was working on it. She stated, it comes out automatically.The BOM confirmed the Care Cost should have been prorated as follows: -For September, 30 days, the $1254.05 divided by 30= $41.80 per day multiplied by the number of days in the facility of 26, would equal a Care Cost of $1,086.84. -For October, 31 days, the resident was not in the facility, the Care Cost would be $0. -For November, 30 days, the $1254.05 divided by 30= $41.80 per day multiplied by the number of days in the facility of 16, would equal a Care Cost of $668.82, if the resident was not covered by Medicare totally, which he was because he was skilled, which would mean his Care Cost would be $0. -For December, review of Resident #2's Payor source census page documented he would revert to Medicaid on 12/15/2023, which would mean December bill, 31 days, the $1,254.05 divided by 31 equaled $40.45 per day multiplied by 17 days would equal $687.70 for Care Cost for December. During the interview, the BOM confirmed Resident #2 had a credit on the presented bill of $2,959.05, as of 12/01/2023 which did not include the adjustments to the monthly billing due to the inaccurate charges to the resident. The BOM stated, that was the money we were trying to determine what to do with. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105453 If continuation sheet Page 2 of 6 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105453 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2023 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 0569 Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to convey and provide a final accounting of personal funds within 30 days of discharge for three (#5, #7, and #8) of three residents reviewed. Residents Affected - Some Resident #5 was discharged from the facility on 10/29/2023, as of 12/13/2023, Resident #5's patient trust account had $4,442.73 in it and his room and board bill documented he was due a refund of $736.80. Resident #7 was discharged from the facility on 01/20/2023, as of 12/13/2023, Resident #7's patient trust account had $1249.69 in it. Resident #8 was discharged from the facility on 04/26/2023, as of 12/13/2023, Resident #8's patient trust account had $45.00 in it. Findings included: A review of Resident #5's clinical chart, the face sheet, documented an admission of 12/16/2022 and a discharge date of 10/29/2023. A review of Resident #5's profile, listed a Power of Attorney (POA) for care and financial, with home and cell phone number. A review of Resident #5's Discharge summary, dated [DATE], documented Resident #5 had been discharged to an Assisted Living facility in another state. A review of the facility's Resident Fund Management Service balance list, dated 12/13/2023, documented Resident #5 had a current balance in his patient trust account of $4442.73. A phone interview was conducted on 12/13/2023 at 1:10 p.m. with the POA listed on the Resident #5's profile. She confirmed she was the POA, she was a family member also. She stated she had received no communication from the facility about monies in Resident #5's patient trust account or any other monies. She confirmed Resident #5 was currently in a facility close to her home. An interview was conducted on 12/14/2023 at 10:00 a.m. with the Business Office Manager (BOM). She stated Resident #5 was a private pay resident for his entire stay. She stated the resident was alert and oriented. She confirmed Resident #5 had an appointed to be his Durable Power of Attorney. A review of Resident #5's Room and Board bill, print date of 12/13/2023 was conducted with the BOM. The BOM confirmed the bill documented a credit due to Resident #5 of $736.80. She stated she had requested a refund and would have to see if the refund had been issued. On 12/14/2023 at 10:19 a.m., during an interview the BOM stated, for the room and board credit, they are going to issue the check to Resident #5. I will call and get his address at the facility he is at. For the Patient Trust Account monies, the BOM confirmed the $4,442.73 was the current balance. She stated, I believe it is closed now and we will cut the check. A review of the facility's Resident Fund management service balance list, dated 12/13/2023, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105453 If continuation sheet Page 3 of 6 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105453 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2023 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 0569 documented Resident #7 had a patient trust balance of $1,249.69. Level of Harm - Minimal harm or potential for actual harm A review of resident #7's clinical chart, the face sheet, documented an admission of 06/01/2022; and subsequent discharge date of 01/20/2023. Residents Affected - Some A review of Resident #7's profile, listed her as the responsible party, in addition to three emergency contacts of which one was a financial agent'. A review of the facility's Resident Fund Management Service balance list, dated 12/13/2023, documented Resident #8 had a patient trust balance of $45.00. A review of resident #8's clinical chart documented an admission of 09/06/2023; and subsequent discharge date of 04/24/2023. The profile listed a friend as the resident's responsible party and POA, financial with phone number. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105453 If continuation sheet Page 4 of 6 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105453 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2023 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 0585 Level of Harm - Minimal harm or potential for actual harm Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Based on observation, record review and interview, the facility failed to implement the grievance policy and procedure for one (Resident #2) of ten sampled residents. Residents Affected - Few Findings included: A review of the facility's Standards and Guidelines: Grievances-Resident Rights, last revised 06/2023, documented the Standard: Residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances (e.g., the state Ombudsman). Guideline: The Administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and/or representative. The procedure included, Upon receipt of a grievance and/or complaint, the Grievance Officer will review and investigate the allegations and submit a report of such findings to the Administrator within five (5) working days of receiving the grievance and/or complaint. The resident, or person filing the grievance and /or complaint on behalf of the resident, will be informed (verbally and/or in writing as per request) of the findings of the investigation and the actions that will be taken to correct any identified problems. a. The Administrator, or his or her designee, will make such reports orally within ten (10) working days of the filing of the grievance or complaint with the facility. b. A written summary of the investigation will also be provided to the resident upon request, and a copy will be filed in the business office. On 12/14/2023 at 10:39 a.m. an interview was conducted with the Business Office Manager (BOM), regarding Resident #2. During the interview, the BOM stated one of Resident #2's Power of Attorney had presented a (lodging bill) for reimbursement out of Resident #2's Patient Trust Account. She stated when she talked to Resident #2, he does not know what he wants to do. The BOM stated the department team has started a discussion about the refund. The BOM provided a copy of a Durable Power of Attorney for Health Care, which appointed his sister, as his patient advocate, the alternate was his brother-in-law, and second alternate was a niece, dated 05/16/2017. The BOM provided a printout of General Note for Resident #2, which reflected an entry by the BOM on 10/17/2023, the niece had submitted a (lodging) bill for March 2023, and she had requested to be reimbursed for the lodging and air fare for the wellness check she and her mother had conducted in March 2023 for Resident #2. The facility did not provide evidence of a response to the request. A review of the facility Grievance log 09/01/2023 through the date of survey, 12/14/2023, reflected no listing of the concern by the family regarding the reimbursement, the conclusion the facility had made to whether the reimbursement was feasible or not, or a response by the facility to the concern. On 12/13/2023 at approximately 2:00 p.m., Staff A, Registered Nurse (RN) was interviewed. She confirmed she had Resident #2 on her assignment, and she was familiar with him. She stated the resident was able to be interviewed at times. She was unable to say if he was able to make medical decisions, but, if there was a change in condition, she would notify the resident's sister or niece. An attempt to interview Resident #2 was conducted with Staff A present. Resident #2 was observed in his bed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105453 If continuation sheet Page 5 of 6 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105453 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2023 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 0585 He stated he was hard of hearing. The attempt at an interview with Resident #2 was unsuccessful. Staff A stated he can hear better some days than others. 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 6 of 6