Inspection·June 12, 2025

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some #11 stated her overhead bed light does not work. Staff P, CNA arrived in the room and stated her light works, She said, you don't have the switch. Staff P, CNA turned the light switch on by the doorway of Resident #11's room, then went to the bedside to pull the cord to turn on the overhead light. The light did not go on, and Staff P, CNA pulled the cord multiple times until the light flickered, and stated, see it works. Staff P, CNA had to pull the cord aggressively again to turn off the light. Resident #11 stated she did not think she could pull the cord the same way Staff P, CNA pulled the cord. On 6/11/2025 at 1:20 p.m., an observation was made of the pantry room in the east hallway. The refrigerator for the residents in the east hall had a temperature log on the outside door. A documented entry for 6/11/2025 showed a reading for the refrigerator at 50 degrees Fahrenheit and the freezer was documented at 28 degrees Fahrenheit. No documented entries were entered for 6/10/2025. The current refrigerator temperature reading was 58-60 degrees Fahrenheit, and the freezer temperature reading was 36-40 degrees Fahrenheit. Staff J, CNA was witness to the current temperatures for the refrigerator. Inside the refrigerator there were four quarts of milk with a resident's name on them. The milk was lukewarm to touch. In the freezer, there were three half gallons of orange sherbert ice cream, a box of ice cream sandwiches and a box of popsicles. All of the freezer items were observed to be thawed. Staff J, CNA agreed the items were soft to touch and not frozen. Staff D, Licensed Practical Nurse/Unit Manager (LPN/UM) for the east hallway was made aware of the refrigerator temperature readings. Staff D, LPN/UM stated according to the temperature log on the refrigerator, the temperature for the refrigerator had been adjusted but agreed the temperature reading were out of normal range. An observation was made of the inside of the cupboard under the sink of the east pantry room. Under the sink there was a large collection of dark brown/black bio growth matter throughout the underside inside the pantry cabinet. An observation was made of the ceiling tile directly above the door partially hanging down. Directly across the entry doorway, was a fan in the wall with a collection of leaves and debris and an opening to the outside environment approximately one inch wide. Staff D, LPN/UM acknowledged these findings. On 6/11/2025 at 3:15 p.m., an observation was made of room [ROOM NUMBER] with open areas of flooring visualized from the hallway. The resident in the room allowed further observation revealing the flooring could be lifted with a slide of the foot. On 6/11/2025 at 3:20 p.m., an observation was made in Residents #12 and #13. The room was designed for a three-resident occupancy. The room was noticeably warmer. Resident #12 stated his roommate #13's AC does not work but his works. Resident #12 had his headboard directly next to his AC unit with his privacy curtain over his headboard where he could receive a direct flow of air from his AC personal unit. Resident #12 stated he moved the curtain because he gets better direct airflow from his AC unit. Resident #12 stated, they know about his AC unit not working. Resident #13's AC unit was powered on, set at 61 degrees Fahrenheit. No air flow was noted. AC filters were observed with a heavy black bio growth. Resident #13 stated he felt his room was hot. A hygrometer reading of 80 degrees Fahrenheit was obtained. Photographic evidence obtained On 6/11/25 at 3:36 p.m., observation was conducted of the bathroom for Resident's #12 and #13. A ceiling tile was observed to be missing with exposed pipes present. On 6/11/2025 at 3:40 p.m., an observation was made of loose flooring on the east hallway. An unidentified resident was walking the hallway with her walker and stated, be careful, you can trip over the loose floor. during this tour, numerous observations were made of loose flooring. The flooring easily would come up when sliding foot over the areas. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105453 If continuation sheet Page 2 of 14 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 06/12/2025 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 Residents Affected - Some On 6/11/2025 at 4:46 p.m., a walking tour was conducted with the NHA, DON, maintenance assistant, maintenance director from another facility and Staff D, LPN/UM. The NHA became aware of the loose flooring, especially in the 200 hallways. The team acknowledged the refrigerator was removed in the east hallway pantry. The team acknowledged the ceiling tile directly above the entry door, the heavy dark brown/black bio growth under the sink cabinet, and the exposed area to the outside environment along the wall fan/vent. The team toured Resident #13's room to witness a non-functioning A/C (Air Conditioning) unit, with dark black bio growth substance on the A/C filter. The administration team confirmed the observations and the missing bathroom ceiling tile with exposed pipes. During the tour on 6/11/2025 at 5:20 p.m., the NHA, DON, maintenance assistant, maintenance director from another facility and Staff D, LPN/UM confirmed these areas of concerns and stated they would be addressed immediately. Review of a facility policy titled, Standards and Guidelines: General cleaning dated 01/2024 showed a standard: It is the policy of this facility to provide a clean, safe, orderly, comfortable and attractive home like environment as outlined below: 1. Accepted practices and procedures are used to keep the facility free from odors, accumulations of dirt, dust and safety hazards. 2. Floors and horizonal surfaces are cleaned routinely. Finishes on floors provide an appropriate finish and disinfectants are used where required. 3. Walls and ceilings are maintained free from dirt or other matters. 4. Entrances, exits, walkways, driveways and other outside or entry areas are kept free from debris and dirt. 5. Beds, bedside tables, chairs overbed tables, nightstands and dressers should be cleaned with a germicidal and allowed to air dry. 6. Dry dusting is used on items such as pictures, plaques, mirrors, bulletin boards, tops of partitions, vents, tops of cabinets, coat racks and window/door frames. Damp dusting may be used as needed. (Photographic Evidence Obtained.) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105453 If continuation sheet Page 3 of 14 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 06/12/2025 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to develop and implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act for one resident (#3) out of four residents sampled. Findings included: Review of Resident #3's admission Record revealed she was admitted to the facility on [DATE] with medical diagnoses of displaced fracture of upper end of right humerus, with routine healing, asthma, dysphagia, unsteadiness on feet, lack of coordination, abnormalities of gait and mobility, muscle weakness, major depressive disorder, post traumatic stress disorder (PTSD), and generalized anxiety disorder. An interview was conducted on 6/11/25 at 11:03AM with Resident #3. She said it was a Saturday around the last week of May 2025; she came out of the bathroom and was in a towel. She said Staff C, Occupational Therapist Assistant (OTA) knocked, came into her room, and she realized it was a male, so she said, I'm not dressed get out! She said Staff C, OTA said to her I can walk in anytime I want to I'm with physical therapy. She said she told him again to get out of her room, and he left. She said he tried to come into her room the next day for therapy, but she refused therapy because she did not want to work with Staff C, OTA. Resident #3 said she did not have any problems with him leaving her room that day. She said she felt sexually harassed and abused. She said on the Monday after it happened, she told a female supervisor what happened and she told the Director of Nursing (DON) she did not want Staff C, OTA in her room anymore and told her what happened over the weekend as well. Review of Resident #3's admission Minimum Data Set (MDS) dated [DATE], Section C, Cognitive Patterns, revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15 indicating she is cognitively intact. Review of the facility's state agency reportable log did not reveal evidence a report was filed to stage agencies, or an investigation was conducted related to Resident #3. An interview was conducted on 6/12/25 at 9:56AM with the Director of Rehabilitation. She said it was around Memorial Day (the last Monday in May) Resident #3 came to her and said Staff C, OTA came into her room and she was in the bathroom and he knocked on the door and she said enter, she saw it was a man and she said oh my god I'm naked get out! The Director of Rehabilitation said Resident #3 told her Staff C, OTA said something back to her but the Director of Rehabilitation could not remember what Resident #3 told her Staff C, OTA said But then he left the room. The Rehabilitation Director said Resident #3 told her Staff C, OTA came back on Sunday to work with her, but she kicked him out of her room. However, he did not come back on Sunday because no one was on the schedule on Sunday. The Director of Rehabilitation said she went to talk to Staff C, OTA the same day Resident #3 told her what happened. The Director of Rehabilitation said Staff C, OTA told her he knocked on the door heard enter, he poked his head in the bathroom, and she said, oh my god I'm naked get out! and he said, no you're dressed and she said, no I'm not get out. The Director of Rehabilitation said Resident #3 had also told her Therapy was sexually harassing her but she changed the story, it wasn't about Staff C, OTA anymore. The Director of Rehabilitation said after Resident #3 told her what happened, and she interviewed Staff C, OTA, she told the DON what Resident #3 had said and what Staff C, OTA had (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105453 If continuation sheet Page 4 of 14 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 06/12/2025 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few said. The Director of Rehabilitation said she could not remember what the DON told her, but she thinks she said she'd look into it. I'm sure they took action. The Director of Rehabilitation said she reported it to the DON because the DON was the abuse coordinator and Resident #3 reported a serious allegation of Sexual Harassment. An interview was conducted on 6/12/25 at 11:07 AM with the DON and the Nursing Home Administrator (NHA). The DON said the Director of Rehabilitation did not come to her with sexual harassment concerns related to Resident #3 and Staff C, OTA. The DON said Resident #3 came to her and said when the therapist went into her room she said she was not ready for therapy, so he left. The DON said to Resident #3 well maybe we can come up with a schedule, so she was ready for therapy, and she said well who is going to be my therapist, and she said she didn't want it to be this person and that person. The DON said she does not recall Resident #3 saying any specific therapist names. So, the DON went to the Director of Rehabilitation and asked if Resident #3 could have a therapy schedule so she could be ready for therapy. The Director of Rehabilitation said, okay I'll take care it. The DON said the Director of Rehabilitation never came to her and told her there was a sexual harassment allegation against Staff C, OTA. If there was, she would have suspended the staff member, reported the allegation and carried out an investigation. The DON said if a resident tells any staff member of an allegation of abuse or sexual harassment, they are to report the allegation to her immediately so it could be reported and investigated. The DON reviewed the reportable events log and confirmed there was not a report, or an investigation conducted related to Resident #3's allegation. A phone interview was conduncted on 6/12/25 at 11:24PM with Staff C, He said Resident #3 is hard to forget because she confabulates a lot, you have to redirect her into what is actually going on. He said about three weeks ago, he knocked on Resident #3's door, someone said come in, so he walked in, Resident #3 said get out of here I'm not dressed, and he said you're dressed and she said no I'm not, and he said you are fully dressed, shirt, pants, and she no I'm not, get out of here and so he left the room. Staff C, OTA said no one talked to him or asked him what happened except for another therapist told him Resident #3 was very mad at him and all he said was okay sorry. He said he went to the Director of Rehabilitation and asked not to be assigned to Resident #3 anymore and the Director of Rehabilitation said she wouldn't assign her to him anymore. Review of the facility's policy Abuse, Neglect, Exploitation, Misappropriation, Mistreatment, and Injury of Unknown Origin (ANEMMI) revised on 3/2025 revealed Standard: The resident has the right to be free from abuse, neglect, exploitation, misappropriation of resident property, mistreatment, and exploitation as defined in this subpart . Definitions: 1. Abuse, is defined .as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish .Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. 4. Willful, . in the definition of abuse, and means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Reporting: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105453 If continuation sheet Page 5 of 14 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 06/12/2025 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 0609 The facility must develop and implement written policies and procedures that: Level of Harm - Minimal harm or potential for actual harm 1. §483.12(b)(5) Ensure reporting of crimes occurring in federally-funded long-term care facilities in accordance with section 1150B of the Act. Residents Affected - Few 3. Staff are required to report any allegation of NEMMI to the facility risk manager, direct supervisor, and/or abuse coordinator immediately upon knowledge of the allegation. 4. Allegations of possible ANEMMI will be reported to state agencies per the federal regulation timeframe. State agencies may include (but are not limited to): - Abuse Hotline (Department of Children and Families) - State Agencies (Agency for Health Care Administration) - Local Law Enforcement . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105453 If continuation sheet Page 6 of 14 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 06/12/2025 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 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to thoroughly investigate a resident-to-resident allegation of abuse involving two residents (#14 and #15) out of four reportable events sampled. Residents Affected - Few Findings included: Review of the facility's state agency reportable log revealed on 5/22/25 a resident to resident report was made involving Resident #14 and Resident #15. An interview was conducted on 6/11/25 at 1:21 PM with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) on 6/11/25 at 1:21PM. The DON said she was the one who reported and investigated the event and the NHA said she was not working at the facility at the time the event occurred. The DON said the event occurred on 5/22/25 around 6:00 PM and she reported the event the state agencies on 5/22/25 at 6:00 PM. The DON said staff reported to Staff D, Eat Wing Unit Manager (UM) that Resident #14 made contact with Resident #15 to the back of his head. Staff were noted to be within close immediate proximity with both residents and intervened immediately and placed Resident #14 on one-to-one supervision monitoring. Resident #15 was immedieitly assessed by nursing, vitals were within normal limits, they notified the physician and out of the abundance of caution Resident #15 was sent to the emergency department where a computed tomography (CT) scan was conducted, and the results were negative. Resident #14 did not say what caused the interaction to happen and he was unable to state what he was attempting to do. The DON said from staff interviews Resident #14 grazed the back of Resident #15's head with a white plastic tube (The DON clarified the white plastic tube was a polyvinyl chloride (PVC) pipe). The DON said Resident #15 returned to the facility the same day. The DON said Resident #14 was sent to the hospital for increased agitation. The DON said at the time of the incident both residents were under adequate supervision on the smoking patio. And staff responded immediately to the residents change in behavior. Other alert and oriented residents were interviewed without concerns for care, safety, or supervision. The DON said, after a thorough investigation the allegation of abuse was not substantiated. The DON said she obtained statements as part of her investigation and said Staff B, Licensed Practical Nurse (LPN) statement was collected and said, she was sitting at the nurse's station when she heard yelling coming from one of the CNA's. Resident #14 had made contact with the CNA. After making contact with the CNA the resident was placed on one-on-one supervision. Resident #14 had increased agitation after being placed on one-on-one supervision, so the resident was then placed on 15-minute checks and within the first 15 minutes, he was noted outside in the smoking area pacing but not showing aggressive behaviors at that time. The DON said Staff D, East wing UM statement said on 5/22/25 I was notified that [Resident #14] was outside on the smoking area and made contact with [Resident #15's] head. The residents were immedieitly separated Resident #15 was assessed and he had a reddened raised area which was observed on Resident #15's posterior scalp. He denied pain. He notified DON. [Physician] was notified, and new orders were received to send the resident to the ER [emergency room] for further eval [evaluation]. Resident #14 was assisted to his room and [Physician] was notified to send the resident to the ER for further eval [evaluation] and treatment. The DON said the facility's Psychologist initiated an involuntary hospitalization for Resident #14. They attempted medication to manage his behaviors, but his behaviors continued to escalate. The DON said Resident #14 was emergently transferred related to the incident because they could not redirect him. The DON said Staff T, CNA was the CNA who was out on the smoking patio at the time of the event and his statement was, he was sitting in the smoking patio when he saw Resident #14 behind Resident #15. He said Resident #14 had his hand behind his back and he kept walking closer to Resident #15. He said Resident #14 pulled his hand out from behind his back and he had a PVC (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105453 If continuation sheet Page 7 of 14 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 06/12/2025 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few pipe in his hand, the CNA said he yelled at Resident #14 to drop it, and Staff T, CNA said he got closer to Resident #14 and when he got closer to Resident #14, he swung at Resident #15 with it. The DON said there are no cameras on the smoking patio therefore there was no video footage to review. An interview was conducted on 6/11/25 at 11:03AM with Resident #3. Resident #3 said she has not seen Resident #14 since he left when he hit another resident over the head with a pipe. 1. Review of Resident #14's admission Record revealed he was admitted to the facility on [DATE] and discharged on 5/22/25. His medical diagnoses included Major depressive disorder, Post Traumatic Stress Disorder (PTSD), generalized anxiety disorder, insomnia, Parkinsons disease, and dementia without behavioral disturbances, psychotic disturbances, mood disturbance, and anxiety. Review of Resident #14's care plan with an initiated date of 12/13/25 and a revision date of 5/22/25 revealed a focus of [Resident #14] has a history of exhibiting the following behaviors: Confabulation, verbally aggressive. Pacing. removing wander guard, combative at times. The goal revealed [Resident #14] will have fewer episodes of the identified behavior through the next review date. The intervention dated 12/13/2023 revealed Acknowledge/commend the resident's progress/improvement in behavior. Administer medications as ordered. Monitor/document for side effects and effectiveness. Encourage and assist the resident to develop more appropriate methods of coping and interacting as able. Encourage the resident to express feelings as needed. Encourage resident to interact with staff members as tolerated. Explain procedures to the resident before starting and allow the resident time to adjust to changes as needed. If reasonable/appropriate, discuss the behavior with the resident. Explain/reinforce why behavior is inappropriate and/or unacceptable. Intervene and/or redirect resident behavior as necessary. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Minimize potential for the resident's disruptive behaviors by offering tasks which divert attention/redirect behavior as indicated. Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. Offer Psychology/Psychiatry services as needed. Provide a program of activities that is of interest and accommodates residents status. Social Services will offer education for the resident/family member on successful coping and interaction strategies specific to individual resident needs. Review of the intervention with an initiated date of 5/22/25 revealed Intervene and/or redirect resident behavior as necessary. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Review of Resident #14's Crisis Intervention Note with a service date of 5/22/25 at 6:49PM revealed Summary Narrative of Session: Staff reported that the patient has unpredictable episodes of aggression towards others. Another provider attempted medication earlier today to manage aggressive behaviors after the patient hit a CNA with his hands, pushing her face and later hitting her arms. This afternoon, the patient managed to remover [sic] forcefully a PVC pipe from the courtyard area of the facility and hit another patient with the pipe on their head. Attempts to use behavioral redirection and psychotropic medication failed. [involuntary hospitalization] initiated. 2. Review of Resident #15 admission Record revealed he was admitted on [DATE] with medical diagnoses of Dementia with mild agitation, spinal stenosis, lumber region without neurogenic claudication, muscle wasting and atrophy. An interview was conducted on 6/11/25 at 4:07pm with Resident #15. He said about two weeks ago a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105453 If continuation sheet Page 8 of 14 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 06/12/2025 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 0610 guy hit him on my head, [explicit] yes it hurt. Level of Harm - Minimal harm or potential for actual harm Review of Resident #15's Annual, Minimum Data Set (MDS) dated [DATE] revealed a brief interview for mental status (BIMS) score of 11 out of 15 indicating moderate cognitive impairment. Residents Affected - Few Review of Resident #15's change in condition dated 5/22/25 at 9:57PM revealed the change in condition, symptoms or signs was: .head injury. This started on 5/22/25 in the afternoon. Is a skin assessment relevant to the change in condition been reported? Not clinically applicable to the change in condition being reported. Were the change in condition and notifications reported to the primary care clinical? No . Review of Resident #15's Progress notes revealed on 5/22/25 at 9:57PM a Situation Background Assessment Recomendation (SBAR) summary for providers revealed a change in condition other change in condition outcome of physical assessment: Positive findings reported on the residents evaluation for this change in condition were: no changes in mental status observed, no changes in functional status observed, no documentation for a skin status evaluation, no documentation for a pain status evaluation and there was no documentation the physician was notified of the change in condition. Review of Resident #15's medical record did not reveal documentation of a skin assessment from the time of the event. Review of Resident #15's transfer form dated 5/22/25 revealed he was being transferred to a hospital for an unplanned CT of the head. Review of Resident #15's progress note dated 5/22/25 at 10:00PM, written by the DON, revealed Resident returned from [Hospital] after being sent out in the abundance of caution for ED [Emergency Department] evaluation. CT of head completed with no acute findings, no intracranial hemorrhage. Skin assessment completed skin remains intact, resident denies pain at this time. MD [Medical Doctor] made aware of return, NNO [no new orders.] An interview was conducted on 6/11/25 at 3:46pm with Staff D, East Wing Unit Manager (UM). He said Staff T, CNA came to him and told him Resident #14 hit Resident #15 in the back of the head with a PVC pipe. Staff D, UM said Resident #15 did not have any injures but he was sent out to the hospital to get evaluated. He said Resident #14 definitely got hit by the PVC pipe on his head. An interview was conducted on 6/12/205 at 1:17PM with Staff B, Licensed Practical Nurse (LPN) she confirmed she was familiar with Resident #14, and she was his nurse on 5/22/25. Staff B, LPN said shortly after the start of the 3:00 PM to 11:00PM shift Resident #14 started to sundown. She said when it comes to sundowning time Resident #14 is a whole different person. On 5/22/25 around the start of the 3:00PM-11:00PM shift we heard his CNA yelling and when we went in there, he was hitting her, and she was covering her face. So, she separated him from the CNA and placed Resident #14 on one-to-one supervision. Staff B, LPN said they called his physician and his psychiatrist to get as needed medications to calm him down they ordered an extra dose of Rexulti and Vistaril and labs for the next day. Staff B, LPN said she gave him his as needed Ativan and the other medications, but nothing worked. So, they put him on one-to-one supervision. Staff B, LPN said Resident #14 wasn't too comfortable with the one-to-one supervision and he was very annoyed with someone being close by him. Staff B, LPN said either Staff D, UM or The DON gave her directive to place Resident #14 on 15-minute checks because he was getting agitated with the one-to-one supervision and we didn't want to make things worse. She said she was the one who completed the 15-minutes checks, and he was observed to be outside (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105453 If continuation sheet Page 9 of 14 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 06/12/2025 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few on the smoking patio pacing with his hands behind his back but that's just how he walks. Staff B, LPN said Staff T, CNA was the smoking aide that day and he brought Resident #14 to her and Staff T, CNA told her he just hit a resident in the back of his head with some kind of pole. Staff B, LPN said she escorted Resident #14 to his room, he was agitated because it had just happened. Staff B, LPN said she sat with him for a little bit and started to talk to him he calmed down a little bit but you could tell he was still a little agitated because he started to run down the hall so we ran down the hall with him and then he ran back down the hall and into his room. Staff B, LPN said she continued to sit with him and shortly after, the Emergency Medical Technicians (EMT) came and got him. She said from the CNA got hit by Resident #14 to the time Resident #14 hit Resident #15 with the PVC pipe was about two hours. She confirmed she was told by Staff T, CNA Resident #14 hit Resident #15 with the PVC pipe on his head. An interview was conducted on 6/12/25 at 9:03AM with the DON she stated she reported to the State Agency Resident #14 attempted to make contact with Resident #15 with a white tube which she clarified was a PVC pipe. She said she reported Resident #14 attempted to hit Resident #15 because since Resident #15 did not have any injuries to his head and the CT scan results did not show any injuries she could not prove he was actually hit by the PVC pipe therefore she did not substantiate the allegation of abuse. Review of the facility's policy Abuse, Neglect, Exploitation, Misappropriation, Mistreatment, and Injury of Unknown Origin (ANEMMI) revised on 3/2025 revealed Standard: The resident has the right to be free from abuse, neglect, exploitation, misappropriation of resident property, mistreatment, and exploitation as defined in this subpart . Definitions: 1. Abuse, is defined .as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish .Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. .4. Willful, . in the definition of abuse, and means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Follow-up investigation Report 1. Within 5 working days of the incident, the facility must provide in its report sufficient information to describe the results of the investigation, and indicate any corrective actions taken, if the allegation was verified. It is important that the facility provide as much information as possible, to the best of its knowledge at the time of the submission of the report, so that State agencies can initiate action necessary to oversee the protection of the nursing home residents . The facility should include any updates to information provided in the initial report. .Investigation: 1.In response to allegations of abuse, neglect, exploitation, misappropriation, mistreatment, or injury of unknown origin the facility must: . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105453 If continuation sheet Page 10 of 14 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 06/12/2025 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 0610 a. Have evidence that all alleged violations are thoroughly investigated . Level of Harm - Minimal harm or potential for actual harm b. Prevent further potential abuse, neglect, exploitation, misappropriation, mistreatment, or injury of unknown origin while the investigation is in progress . Residents Affected - Few c. Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. d. Conduct observations of the alleged victim, including identification of any injuries as appropriate, the location where the alleged situation occurred, interactions and relationships between staff and the alleged victim and/or other residents, and interactions/relationships between resident to the other residents; e. Conduct interviews with, as appropriate, the alleged victim and representative, alleged perpetrator, witness, practitioner, interviews with personnel from outside agencies such as other investigatory agencies, and hospital or emergency room personnel. f. Conduct record review for pertinent information related to the alleged violation, as appropriate, such as progress notes (Nurse, social services, physician, therapist, consultants as appropriate, etc.), financial records incident reports (if used), reports from hospital/emergency room records, laboratory or x-ray reports, medication administration records, photographic evidence, and reports from other investigatory agencies. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105453 If continuation sheet Page 11 of 14 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 06/12/2025 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 observations, interviews and record review, the facility did maintain an effective pest control program related to roaches for their residents. Residents Affected - Few Findings include: On [DATE] at 10:11 a.m., an observation was made in front of Resident #4's room of a large moving roach on its back swept up in a pile of debris from Staff A, housekeeping. An interview was conducted with Resident #4 in his room. Resident #4 stated roaches are a problem and he sees them all the time in his room. Upon observation, live roaches were seen on the windowsill, walls and dressers. An observation was made behind Resident #4's dresser of a heavy growth of dark brown/black dusty-like debris on the floor by the baseboards behind his dresser. Staff A, housekeeping, returned to the room and was witnessed moving the dresser to sweep the debris on the floor. Staff A, housekeeping through an interpreter's phone, stated she sees roaches all the time. Photographic evidence obtained. On [DATE] at 10:52 a.m., an interview was conducted with Resident #7. Resident #7. Resident #7 stated, roaches are definitely a problem here. Resident #7 stated, I don't think they come in my room to spray for bugs. On [DATE] at 11:03 a.m., an interview was conducted with Resident #3. Resident #3 said she sees roaches in her room all the time and pointed to a roach located under her dresser. She said the roach was dead but it had been there for longer than she can remember. She said she had told staff about the roaches in her room. She said she had never seen a pest control company come into her room to treat the roaches. (Picture evidence obtained) On [DATE] at 11:03 a.m., an interview was conducted with Resident #11 in her room. Resident #11 stated she sees roaches all the time but has not witnessed anyone coming into her room to spray for them. On [DATE] at 11:20 a.m., an interview was conducted with Resident #8 in his room. Resident #8 stated he sees roaches all the time and stated, I saw two big one's last night. Resident #8 allowed observations to be made of his dresser drawers and a large live roach moving quickly was witnessed in one of the drawers. Resident #8 stated he has never seen anyone come in his room to spray for bugs. On [DATE] at 2:40 p.m., an observation was made of the pantry room in the north hallway. On the right side of the refrigerator were various dead body parts of roaches on the ground. An interview was conducted with the nursing staff at the nurses' station related to roaches. An unidentified staff member stated, they have taken residency here. All staff were aware of the pest control log. Photographic evidence obtained. On [DATE] at 3:17 p.m., an observation and interview were conducted with two residents in a room designed for three residents. Residents #12 and #13 stated they see roaches in their room all the time. Resident #12 stated he can walk to his bathroom and stated he sees live roaches on a frequent bases especially at nighttime. Resident #13 pointed to his overhead fluorescent light fixture over his bed and stated, I watched that roach for a while until he flipped over and died. An observation was made of a large dead roach on its back in the overhead fluorescent light. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105453 If continuation sheet Page 12 of 14 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 06/12/2025 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 - Few On [DATE] at 9:42 a.m., an interview was conducted with Staff E, Certified Nurse Assistant (CNA). Staff E, CNA stated she sees numerous roaches, dead and alive, in residents' rooms and will place concerns in the pest control log book. On [DATE] at 9:55 a.m., an interview was conducted with Staff F, Licensed Practical Nurse (LPN). Staff F, LPN stated roaches are a concern but stated it was worse two months ago. On [DATE] at 10:09 a. m., an interview was conducted with Staff H, housekeeping, with Staff I, CNA, utilized for interpretation. Staff H, housekeeping, stated she sees lots of roaches dead and alive. Staff H, housekeeping, stated she just kills the live ones when she can. On [DATE] at 10:16 a.m., an interview was conducted with Staff I, CNA. Staff I, CNA stated sees roaches all the time and they are worse on the east hallway. Staff I, CNA stated she just kills the roaches herself. On [DATE] at 10:33 a.m., an interview was conducted with Staff J, CNA. Staff J, CNA stated he sees alive roaches every other day during his shift. On [DATE] at 10:30 a.m., an interview was conducted with Staff K, CNA and Staff L, CNA. Both staff members stated they see roaches. Staff K, CNA stated she sees all kinds of roaches, big, small, dead and alive. Staff K, CNA stated there are lots of holes in the building, that's how they are getting in. Staff K, CNA stated she just kills them when she sees them and cleans up the mess. Staff L, CNA stated she has put pest concerns in the pest control log. On [DATE] at 11:09 a.m., an observation and interview were conducted with Staff M, housekeeping. An observation was made by Staff M, housekeeping, servicing Residents #12 and #13's room. Staff M, housekeeping, was in the room mopping the floor and, in the doorway entrance, was a swept-up pile of dead roaches. An interview was conducted with Staff M through her phone utilized for interpretation. Staff M, housekeeping, stated she sees lots of roaches, dead and alive. She said she tries to kill the lives one as best as she can. On [DATE] at 11:13 a.m., an interview was conducted with Staff N, LPN. Staff N, LPN stated she sees roaches dead and alive, and she will use the pest control log and added, we make morning rounds every morning and they will take care of it. On [DATE] at 11:20 a.m., an interview was conducted with the representative servicemen for the facility contracted commercial pest control service company(pest control serviceman). The pest control serviceman stated he has been servicing the facility on and off for the past 8-9 years but more on a continually basis for the past one and one-half years. The pest control serviceman stated his point of contact for the facility has always been Staff O, maintenance assistant. The pest control serviceman stated he will contact Staff O upon arrival and they will review the pest logs from each nurses' station and other concerns Staff O would bring to his attention. The pest control serviceman stated he comes every Thursday. The pest control serviceman stated he will make his rounds and then provide a verbal and written report to Staff O, maintenance assistant, of his findings. The pest control serviceman stated he would make suggestions in his report such as fixing holes in the facility to minimize entrance of pests. The pest control serviceman stated, Staff O has too much on his plate. The pest control serviceman stated points of entry include such places as air conditioning units, pipes and dead foliage around the facility The pest control serviceman stated the pest log is not utilized appropriately and added sometimes he will come in for service and there would be very little rooms (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105453 If continuation sheet Page 13 of 14 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 06/12/2025 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 - Few on the pest control ledger and then next week the ledger will be a full page. The pest control serviceman stated he sees American roaches and German roaches. He stated German roaches are not good to have in a facility and are difficult to maintain once you have an outbreak. The pest control serviceman stated another job duty while in the facility is to maintain the numerous ultraviolet pest control lights. The pest control serviceman stated he cleans and changes out the filters monthly but stated two are in need of new bulbs with one located in the east nurses' stations, out for four months, and the other in the kitchen, out for two months. The pest control serviceman stated Staff O, maintenance assistant was aware. On [DATE] at 12:26 p.m., an interview was conducted with Staff O, maintenance assistant, a maintenance director from another facility and the Nursing Home Administrator (NHA). Staff O, maintenance assistant, stated he will meet up with the pest control serviceman every Thursday to review the pest logs at each nurses' station. Staff O stated he does not get the emailed written reports. The maintenance director from another facility stated she thinks the former Maintenance Director was getting them. The maintenance director from another facility stated she printed the emails yesterday to be viewed during the survey. The NHA stated she has not received any emails but will rectify the issue. Staff O, maintenance assistant, stated he was aware of the holes outside in need of repair to minimize entry but the NHA, newly hired, stated she was not aware. Staff O stated the facility has a lawn service but it would need approval to have the perimeter cleared from the facility. The NHA stated Staff O, maintenance assistant, is doing the work of three at this time and attempts have been made to hire more staff for maintenance. A review of the facility's policy titled, Pest Control, revised on 7/2024 stated the following standard statement: Our facility shall maintain an effective pest control program. . 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 14 of 14