Inspection·February 1, 2024

F 0585 Level of Harm - Minimal harm or potential for actual harm An interview was conducted with Resident #16 on 1/30/24 at 11:41 AM. Resident #16 stated,Every morning when they come to give my roommate her meds, they turn on the lights. When they turn on her lights, [NAME] come on too. There's no way to turn it off. The switch isn't working correctly. It's annoying as hell. Every morning it wakes me up and I have to fight myself back to sleep. It's [expletive]me off. I've told them over and over. They haven't done anything about it. Residents Affected - Few An observation of Resident #16's room revealed the light switch that controls her overhead light was not working as designed. A follow-up interview was conducted with Resident #16 on 1/31/24 at 10:24 AM. Resident #16 stated, Yes, I told them again right after you left yesterday. I even told the previous Administrator about this. We were going back and forth about this for months. He kept telling me and telling me that he would get it fixed, but nothing has happened. He is gone now. They just not going to do anything about it. It's really [expletive] me off. An interview was conducted on 1/31/24 at 2:27 PM with the Director of Maintenance (DOM). The DOM confirmed the light switch was not working as designed and stated, .This looks like there's two hot wires on that fixture. Basically, it's just wired incorrectly, an easy fix will get that rectified. A follow up observation of Resident #16's room on 2/01/24 at 1:38 PM revealed that the resident light switch/fixture was not working as designed. A review of the facility's Grievance log on 2/01/24 at 1:41 PM revealed no entries or resolutions related to voiced concerns for Resident #56 and Resident #16. A review of the facility's policy titled Grievances- Resident Rights last revised 6/2023 revealed the following: 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. Guideline: The Administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and/or representative. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105453 If continuation sheet Page 2 of 9 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 02/01/2024 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Review of Resident #45's medical record revealed admission to the facility on [DATE] and with a readmission date of 1/11/2024. Review of the advance directives revealed Resident #45 was her own responsible party. Review of the admission diagnosis sheet revealed diagnoses to include but not limited to: Morbid obesity, Major Depression (as of 12/23/2023), Need for assistance with personal care, Adult Failure to thrive, Psychosis (as of 12/21/2023), Post Traumatic Stress Disorder (PTSD), unspecified (as of 12/21/2023). Review of the Level 1 Preadmission Screening and Resident Review (PASRR) screen dated 1/11/2024 revealed on page 2 and to include Section I: PASRR Screen Decision-Making, part (A) did not have any specific diagnoses checked. No diagnoses were checked in section I part (A), mental illness or suspected mental illness. Review of the current Minimum Data Set (MDS) admission 5 day assessment, dated 1/14/2024 for Resident #45 revealed; (Cognition/Brief Interview Mental Status or BIMS score - 15 of 15, which indicated the resident had no cognitive deficits and was able to make her decisions); (Behaviors - None checked as exhibited during the assessment period); (Active Diagnosis - Checked Yes for Trauma/PTSD). On 1/30/2024 at 10:30 a.m. Resident #45 was observed in her room and was lying in bed under the covers. She was briefly interviewed and confirmed she felt comfortable and safe at the facility and also confirmed she has had a history of PTSD, but did not want to specify what trauma she experienced. She did confirm she does have depression as well and has had depression prior to her nursing center admission. On 1/30/2024 at 10:00 a.m. an interview with the South Unit Manager confirmed social services and admission handles the intake of the Level 1 PASRR screen and she believed that it was the responsibility of either the Social Services Director or the Nursing Home Administrator. The South Unit Manager reviewed Resident #45's Level 1 PASRR screen dated 1/11/2024. She confirmed section I part (A) on page 2 did not identify any MI diagnoses to include Depression and Psychosis. She also confirmed Resident #45 was admitted with these diagnoses. Review of Resident #100'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 admission diagnosis sheet revealed diagnoses to include but not limited to: Major Depression (as of 3/21/2023), and Psychosis (as of 3/21/2023). Review of the Level 1 Preadmission Screening and Resident Review (PASRR) screen, dated 3/3/2023, revealed on page 2 and under section I (A), MI or Suspected MI to include Other: Unspecified Psychosis. This section did not identify Resident #100 as having depression. Section II #3, asks; Is there an indication that the individual has receive recent treatment for a mental illness with an indication that the individual has experienced at least one of the following? Part (a) was checked, Yes indicating Psychiatric treatment more intensive than outpatient care. (e.g. partial hospitalization or inpatient hospitalization). Part (b) was checked, Yes indicating Due to the mental illness, the individual has experienced an episode of significant disruption to the normal living situation, for which supportive services were required to maintain functioning at home, or in a residential treatment environment, or which resulted in intervention by housing or law enforcement officials. The Level 1 PASRR screen instructed; A level II PASRR evaluation must be completed prior to admission if any box in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105453 If continuation sheet Page 3 of 9 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 02/01/2024 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 0644 Level of Harm - Minimal harm or potential for actual harm Section I, (A). or I (B). is checked and there is a Yes checked in Section II.1, II.2, or II.3, unless the individual meets the definition of a provisional admission or a hospital discharge exemption. Per review of this Level I PASRR screen, it was confirmed that Section I (A) had a diagnoses, as well as Section II (A) and Section II (B) were checked Yes. There was no evidence Resident #100 had a provisional admission or exemption. Residents Affected - Some Review of the most current Quarterly MDS assessment, dated 12/11/2023 reveled; (Cognition/BIMS score 14 of 15, which indicated Resident #100 was able to make her own decisions); (Behaviors - None exhibited during the assessment timeframe). On 2/1/2024 at 11:00 a.m. the South Unit Manager reviewed and confirmed Resident #100's Level I PASRR screen dated 3/3/2023 appeared to have been assessed and to obtain a Level II PASRR screen. She understood the criteria for the need for a Level II PASRR and felt one should have been completed. She revealed that the Social Service Director and or the Nursing Home Administrator are the staff that usually reviews the Level I and Level II PASRR screens. The South Unit Manager did not know why Resident #100 did not have a Level II PASRR completed. Based on interview and record review, the facility failed to ensure the accuracy of the Preadmission Screening and Resident Review (PASARR) Level I for six (#61, #43, #5, #342, #48, and #45) of fifty-seven residents reviewed; and failed to ensure a PASARR Level II was completed for one (#100) of fifty-seven residents reviewed. Findings included: Review of the clinical record for Resident #61 revealed admission to the facility on [DATE], with admission diagnosis that included, but not limited to, major depressive disorder, anxiety, and adjustment disorder with anxiety as per the face sheet. Review of the PASARR dated 12/05/2023 for Resident #61 revealed no diagnosis checked in Section I A (mental illness or suspected mental illness). Review of the clinical record for Resident #43 revealed admission to the facility on [DATE], with admission diagnosis that included, but not limited to, depression as per the face sheet. Review of the PASARR dated 12/15/2023 for Resident #43 revealed no diagnosis checked in Section I A (mental illness or suspected mental illness). Review of the clinical record for Resident #5 revealed admission to the facility on [DATE] and readmission on [DATE], with admission diagnosis that included, but not limited to, schizophrenia, depression, and antisocial personality disorder as per the face sheet. Review of the PASARR dated 10/30/2023 for Resident #5 revealed no diagnosis checked in Section I A (mental illness or suspected mental illness). Review of the clinical record for Resident #342 revealed admission to the facility on [DATE], with admission diagnosis that included, but not limited to, anxiety disorder as per the face sheet. Review of the PASARR dated 01/18/2024 for Resident #342 revealed no diagnosis checked in Section I A (mental illness or suspected mental illness). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105453 If continuation sheet Page 4 of 9 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 02/01/2024 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure one resident (#120) out of four residents reviewed for falls had the comprehensive care plan revised with additional interventions after a fall. Findings included: An observation on 01/29/24 at 10:13 a.m. showed Resident #120 had a bruised left eye. During an interview on 01/29/24 at 10:13 a.m., Resident # 120's Family Representative (FR) stated Resident #120 obtained her black eye from a fall roughly a week and half ago. Resident #120's FR stated the fall occurred in the bathroom. Resident #120's FR stated he asked staff about maybe bed rails or other interventions to be put in place so Resident #120 didn't fall again but the facility said Resident #120 could not have bed rails because that would be considered a restraint. Review of the facility's Incident Log for January 2024 showed Resident #120 had a fall on 01/19/24. Review of the admission Record showed Resident #120 was admitted to the facility on [DATE] with diagnoses included but not limited to Motor Neuron Disease, contusion of other part of the head, muscle weakness, and abnormal gait and mobility. Review of the care plan with focus area, dated 01/09/24, showed [Resident #120] is at risk for falls with history of falls, unsteady gait/poor balance, use of antihypertensive medications. The Goal revised on 01/22/24 showed [Resident #120] potential for sustaining a fall related injury will be minimized by utilizing fall precautions/interventions through next review date. The Interventions all dated 01/09/24 showed, -Encourage and assist resident to use bed in lowest position as tolerated - Encourage and assist the resident to increase activity participation - Encourage the resident to wear appropriate footwear such as rubber soled shoes, non-slip bedroom slippers etc. when ambulating, transferring and toileting as indicated. - Encourage and remind resident to use the call bell to wait for staff assistance with transfers, ambulation, toileting as indicted. - Physical and Occupational Therapy consulted as needed. Review of a progress note titled Nursing Note, dated 01/19/24 showed, Called to resident's bathroom by cna [Certified Nursing Assistant]. Resident was observed sitting on the bathroom floor in front of the toilet. Resident was assisted to the bathroom by resident's cna prior to fall. Resident's cna stated he was in resident room making resident's bed when he heard a noise and saw resident sitting on the floor. Resident was assessed for injuries. Sustained a hematoma to left eyebrow/eyelid. Sustained cut on left cheek bone and abrasion to right finger. First aid applied. No complaints of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105453 If continuation sheet Page 5 of 9 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 02/01/2024 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few headache or dizziness. Resident ROM [Range of Motion] was within normal limits. Resident was assisted back to her wheelchair. Resident was assessed by in house [provider] and ordered resident to be sent to ER [emergency room] for evaluation. Resident's physician and spouse was notified of above information. Paramedics was called and arrived. Resident transported to [local] Hospital. Review of a progress note titled Fall Evaluation, dated 01/19/24 showed, Resident is oriented X 2. Resident has the following safety awareness behaviors. Lack of understanding of physical limitations. Resident had one or more falls within the last 90 days. History of multiple falls. The following interventions and approaches have been implemented for the resident: call light orientation. The outcome of the education provided was verbalizes understanding. Review of facility's policy Standards and Guidelines: Falls- Managing, preventing and Documentation, revised date 01/2024, showed, Resident-Centered Approaches to managing Falls and Fall Risk 4. If falling recurs despite initial intervention, staff will implement additional or different interventions, or indicate why the current approach remains relevant. Documentation 3. The residents care plan should be updated with the new interventions determined by the interdisciplinary team. During an interview on 01/31/24 at 5:45 p.m., the Director of Nursing (DON) stated anytime a resident falls in the facility new and additional interventions will be discussed in the next Interdisciplinary team (IDT) meeting with any new interventions being updated and revised on that resident's care plan. Reviewed of the care plan with DON confirmed no additional interventions were revised on Resident #120's care plan after the fall on 01/19/24. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105453 If continuation sheet Page 6 of 9 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 02/01/2024 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** Based on observations, interviews, and record review, the facility failed to provide care and services related to accessible emergent tracheostomy supplies at the bedside and providing oxygen as ordered for one resident (#109) out of one resident reviewed for tracheostomy care. Residents Affected - Few Findings included: Review of Resident #109's admission Record revealed she was initially admitted to the facility on [DATE] and readmitted on [DATE]. Her medical diagnoses included Hemiplegia and Hemiparesis following cerebral infarction affecting the right dominant side, encounter for attention to tracheostomy, acute respiratory failure with hypoxia, dysphagia, and need for assistance with personal care. An observation was conducted on 01/29/24 at 11:05 AM. Resident #109 was observed to be in bed, looking around the room, with her head of bed elevated, breathing comfortably. Resident #109 was observed to have a tracheostomy tube in place. She was receiving 28% humidified oxygen with the oxygen concentrator set on two liters via trach collar. Four Shiley size six tracheostomy inner cannulas and one Shiley size six tracheostomy was observed to be in the bedside dresser drawer. Review of Resident #109's physician orders revealed a physician order with a start date of 11/28/23 for Extra Trach [tracheostomy] #8 at bedside. A physician's order with a revision date of 11/28/23 and no end date revealed Trach: Humidified Oxygen 30% on 8 Liters via trach collar. Review of Resident #109 clinical record did not contain a physician order related to the size and type of tracheostomy tube Resident #109 had. An observation and interview were conducted on 1/31/24 at 11:00 a.m. with Staff G, Licensed Practical Nurse (LPN). Resident #109 was observed to be in bed, eyes closed, with the head of her bed elevated, breathing comfortably. Staff G, LPN confirmed Resident #109 was on 28% humidified oxygen on two liters via trach collar. She confirmed there were four Shiley size six inner cannulas in her bedside drawer along with a Shiley size six tracheostomy in her bedside drawer. She said the resident used to have a Shiley size eight, but she pulled it out and went to the hospital and the hospital downsized her trach to a Shiley size six and stitched it to her neck. Staff G, LPN reviewed the physicians orders and confirmed the order said to keep an extra trach number 8 at the bedside. She said when the resident came back from the hospital they probably just reordered the same order and did not change it. An interview was conducted with the Director of Nursing (DON) on 2/1/24 at 12:50 p.m. she said Resident #109 had a size 8 tracheostomy and she pulled it out and was sent back to the hospital because they were unable to get a new tracheostomy back in. She said when Resident #109 returned from the hospital she had a size six tracheostomy. She said there should be a size 6 tracheostomy and a size four tracheostomy at the bedside. She said there should be a physician's order for the type and size tracheostomy each resident has. She also confirmed physician oxygen orders should be followed. A tracheostomy management and care policy was requested from the facility. The only policy provided was TRACHEOSTOMY-CARING FOR THE PATIENT. Administering Tracheostomy Care Procedure According to Tracheostomy Education dated 2021, revealed All clinical staff should be aware of the location of equipment for individuals with tracheostomy. Equipment should be kept at bedside in an (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105453 If continuation sheet Page 7 of 9 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 02/01/2024 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 easily accessible location for both routine and emergency use. At a minimum a replacement tracheostomy tube of the same size and one of a smaller size should be available at bedside. https://tracheostomyeducation.com/emergency-equipment/. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105453 If continuation sheet Page 8 of 9 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 02/01/2024 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 Based on observations and interviews, the facility failed to post the nurse staffing data to ensure the information was readily accessible to all residents and visitors during three of four days of survey. Residents Affected - Many Findings included: An observation on 01/29/24 at 9:00 a.m., revealed no nurse staffing data was posted in the facility. An observation on 01/30/24 at 6:00 p.m., revealed no nurse staffing data was posted in the facility. An observation on 01/31/24 at 3:00 p.m., revealed no nurse staffing data was posted in the facility. During an interview on 01/31/24 at 3:00 p.m., the Administrator stated normally the staffing coordinator would be responsible for posting the staffing numbers, however, the daily staff posting had not been getting posted with the absence of the staffing coordinator. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105453 If continuation sheet Page 9 of 9