Health inspection·February 18, 2026

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 implement an effective infection control program related to staff performing hand hygiene between providing care for two (#27 and #28) resident's and failed to ensure an enhanced barrier precaution sign was posted for one (#29) of thirteen residents diagnosed with a infectious disease.Findings included: On 2/17/26 at 9:40 a.m. Staff J, Restorative Aide (RA) was observed standing next to Resident #27s bed. The staff member was observed removing a pair of gloves, leaving the room, crossing the hallway, and entering Resident #28s room. The staff member came out of room holding a pair of disposable gloves going to the laundry cart parked further down the hallway. Staff J returned to Resident #28s room and was heard informing the resident that a splint would be put on Resident #28. The staff member exited the room and stated hand hygiene should have been performed after removing gloves and had not completed the task in between the two resident's. Review of the facility's December and January infection line listings was completed on 2/18/26 at 10:51 a.m. The line listings did not reveal any resident had been diagnosed with the fungal infection of Candida auris (C. auris). The listing did reveal skin and soft tissue infections. The review of January listing showed multiple incomplete areas regarding symptoms exhibited, if culture or testing had been done, and/or results of the culture or testing. The December listing included generalized symptoms such as pain, acute functional decline, and urinary tract symptoms. An interview was conducted with the Infection Preventionist (IP) on 2/18/26 at 10:59 a.m. The IP reported not tracking or having a list of residents diagnosed with C. auris. The IP stated resident's with C. Auris should be on Enhanced Barrier Precautions (EBP) forever and did track EBPs. On 2/18/26 at 12:44 p.m. the IP provided a list of resident's who had been diagnosed with C. Auris and stated they do not add them to the line listing as those residents are not receiving antibiotics. The IP reported tracking C. Auris based on the EBPs. The IP reported having failed job as life had been hectic and recently quit smoking and had been working from home. Review of the list showing names of residents currently diagnosed with C. Auris included Resident #29. An observation was made on 2/18/26 as staff were removing lunch trays from resident rooms. The door and surrounding area outside of Resident #29s room did not show a precaution sign was posted. The [NAME] was hung on the door. During the observation multiple Certified Nursing Assistants (CNAs) were seen at the meal cart. Staff L, CNA was observed leaving Resident #29s room and reported being assigned to Resident #29. The staff member reported there was no precautions for the resident and two other unknown staff members also reported Resident #29 did not have precautions as the resident only had a wound. Review of Resident #29s admission Record showed the resident was admitted on [DATE], 1/17/26, and 2/12/26. The record included diagnoses not limited to acute and chronic respiratory failure with hypoxia and unspecified severe protein-calorie malnutrition. The diagnoses did not include C. Auris. Review of Resident #29s active physician orders included an order dated 2/12/26 at 6:36 p.m. for Enhanced Barrier: Encourage and assist resident to maintain enhanced barrier Residents Affected - Few Page 1 of 5 105453 105453 02/18/2026 Kensington Gardens Rehab and Nursing Center 2055 Palmetto St Clearwater, FL 33758

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few precautions for C. Auris, intravenous (IV), and wound every shift. Review of the Center of Disease Control and Prevention (CDC) website revealed Candida auris (C. auris) was an emerging fungus, spread in hospitals, and could cause severe multidrug-resistant illness, (https://www.cdc.gov/candida-auris/index.html). The CDC Infection Control Guidance for C. auris, dated April 24, 2024, revealed the fungus spreads easily in healthcare settings and can cause outbreaks, environmental disinfection, staff training, and hand hygiene can prevent outbreaks. C. auris can colonize patients and persist on surfaces for many months and is not killed by some common disinfectants. The guidance showed However, facilities may assign rooms based on single (or a limited number of) high-concern multi-drug resistant organisms (MDROs) (e.g. C. auris or carbapenemase-producing Enterobacterales) without regard to co-colonizing organisms. Ensuring that all healthcare personnel adhere to infection control recommendations is critical to preventing transmission of C. auris, other MDROs, and communicable diseases. Ensure that an appropriate sign is present on the patient's door to alert healthcare personnel and visitors of recommended precautions. An interview was conducted with the Infection Preventionist (IP) on 2/18/26 at 2:00 p.m. The IP stated all the residents on the C. auris list should have a sign posted, usually checks on Mondays but this week hadn't been usual, and Resident #29 was just readmitted . The IP reviewed the resident's record and stated the resident had been readmitted on the twelfth (2/12/26) and should have been on precautions at that time. The IP confirmed making the list of residents with C. auris today, usually pulled an order listing report for EBPs on Mondays, and walks the halls to ensure signs are posted. The IP stated staff should be aware of precautions and hand hygiene should be done before during and after care, absolutely should be done in between patients and before putting gloves on. Review of the policy - Hand Hygiene Infection Control, revised 6/2023, revealed Hand hygiene is the single most important measure for preventing the spread of infection. This facility shall require facility personnel use accepted hand hygiene after each direct resident contact for which hand hygiene is indicated. The procedure included but not limited to situations that require hand hygiene: before and after direct resident contact (for which hand hygiene is indicated by acceptable professional practice), and after removing gloves or aprons. Review of the policy - Infection Control - Infection Prevention and Control Program, revised 1/2024, An infection prevention and control program (IPCP) are established and maintained provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The program is based on accepted national infection prevention and control standards in accordance with local, state, and federal regulations and guidelines. The elements of the infection prevention and control program consist of coordination/ oversight, policies/ procedures, surveillance, data analyst, antibiotic stewardship, outbreak management, prevention of infection, and employee health and safety. The important facets of infection prevention included but not limited to: a. Identifying possible infections or potential complications of existing infections; b. Instituting measures to avoid complications or dissemination;c. Educating staff and ensuring that they adhere to proper techniques and procedures;g. Implementing appropriate isolation precautions when necessary; andh. Following established general and disease-specific guidelines such as those of the CDC. Review of the policy - Transmission Based Precautions, revised 2/2024, revealed All staff receive training on transmission-based precautions upon hire and at least annually.The procedure revealed Initiation of Transmission-based Precautions:a. In order for isolation will be obtained for residents who are known or suspected to be infected with infectious agents that require additional controls to prevent transmission effectively.b. The order of for isolation will specify the type of isolation and reason for isolation. The duration will depend upon the infection in physician recommendations.5. Enhanced Barrier 105453 Page 2 of 5 105453 02/18/2026 Kensington Gardens Rehab and Nursing Center 2055 Palmetto St Clearwater, FL 33758

F 0880 Level of Harm - Minimal harm or potential for actual harm Precautions: a. Enhanced Barrier Precautions can be applied (when Contact Precautions do not otherwise apply) to residents with any of the following: i. Wounds or indwelling medical devices when colonization is present ii. Infection or colonization with an MDRO and/or C. auris (CAURIS).The policy showed the recommended transmission-based precautions for C. auris was enhanced barrier if colonized with no duration time. Residents Affected - Few 105453 Page 3 of 5 105453 02/18/2026 Kensington Gardens Rehab and Nursing Center 2055 Palmetto St Clearwater, FL 33758

F 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews the facility failed to implement an effective Antibiotic Stewardship program as evidence by the lack of tracking of infections and not ensuring antibiotic use met infection criteria. Findings included: Review of the facility December 2025 Infection and Antibiotic Tracking Tool showed symptoms related to antibiotic use as urinary tract symptoms. The tool revealed Resident #42 was diagnosed with an urinary tract infection (UTI) with symptoms of urinary tract symptoms and leukocytosis, an urine test was obtained with no documentation of white blood cell count (WBC), colony count, or culture results. The documentation showed the resident was treated with Ceftriaxone for 7 days (12/20-12/27/25) and the urinalysis (UA) was negative (neg). Review of the facility January 2026 Infection and Antibiotic Tracking Tool revealed the tool was incomplete, symptoms were not listed and did not show if a culture or test had been obtained for five of nineteen facility acquired conditions treated with antibiotics. Review of Resident #30s tracking tool documentation showed the resident was treated with Nitrofurantoin from 1/8 to 1/18/26 for a facility-acquired urinary tract infection (UTI). The tool did not reveal the resident had symptoms, if a test had been obtained, or the results of the testing. Review of Resident #30s progress note dated 1/5/26 at 9:32 p.m. showed the resident complained of not feeling like herself. The staff received orders for testing including an urinalysis. Review of the note showed on 1/8/26 the physician was notified of the urinalysis culture and sensitivity results. The urine culture showed a colony count of >100,000 of Escherichia coli with many bacteria. Review of Resident #30s record did not show an infection surveillance criteria had not been completed to determine the necessity of the residents antibiotic use. Review of Resident #31s tracking tool documentation showed the resident was treated for a facility-acquired skin and soft tissue infection. The tool did not reveal the resident had any symptoms, did not show results of a test or culture or if any had been obtained. The tool revealed the resident was treated with doxycycline from 1/3 to 1/17/26 for a lower extremity ([NAME]) wound. A Situation, Background, Appearance, and Review showed the resident had a skin wound or ulcer which started on 12/29/25 and had not occurred before. The SBAR showed no changes in skin had been observed and pain was not applicable to the change in condition. Review of Resident #31s infection surveillance criteria showed cellulitis was suspected, the resident had a left [NAME] with open wound/cellulitis. The surveillance tool showed to meet infection criteria either pus or four other signs/symptoms (s/s) were required. The documentation showed no pus, and three of the four required s/s were met. The conclusion was the condition did not meet criteria for infection. During an interview on 2/18/26 at 2:00 p.m. the Infection Preventionist (IP) reported normally does the line listing every week, runs an antibiotic report sometimes during the week and does the line listing from that, I try to do it every week. The IP reported checking antibiotics by using the order listing and the electronic dashboard, checks the dashboard every day, and does the surveillance criteria probably every week when order listing report is ran. The IP stated urinary tract symptoms are burning with urination, frequency, new incontinency, feeling urgency, and needing to pee'. The IP stated when someone has an UTI not all of the reported symptoms are exhibited. The IP reviewed the line listing and confirmed the listing should identify what type of urinary tract symptoms were exhibited and would have to look at the resident record to see what had been exhibited. The IP stated they don't check antibiotic when coming from the hospital assumes the hospital has done it. The IP stated the January line listing was not complete and corporate expectation was for it to be done by the sixth of the month. An interview was conducted with the Director of Nursing (DON) on 2/18/26 at 3:14 p.m. The DON stated the expectation for (infection) line listings was they should be completed. The [NAME] revealed the Residents Affected - Some 105453 Page 4 of 5 105453 02/18/2026 Kensington Gardens Rehab and Nursing Center 2055 Palmetto St Clearwater, FL 33758

F 0881 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some line listing, usually updates (it) continuously, it's an ongoing document, continuously is needed. The DON confirmed the listing should be updated when a new antibiotic was ordered, with culture/(test) results, and #31s line listing and stated it should be completed entirely. The DON reviewed Resident #30s line listing documentation, stating the listing should show symptoms, test results, and be completed entirely. The DON confirmed Resident #30 did not have a surveillance criteria completed. The DON stated C. auris was in the building, there should be tracking, where they (resident) had been, and should have EBP if colonized. She stated the IP should have a list of current C. auris residents not just a list of persons on EBP and there should be signage on (resident) door. Review of the policy - Nursing - Infection Control - Antibiotic Stewardship, revised 2/2023, revealed Antibiotic Stewardship is the effort to measure and improve how antibiotics use with residents. It is a commitment of education, action, and response to effectively treat infections, protect residents from harm caused by unnecessary antibiotic use, and combat antibiotic resistance. Antibiotics will be prescribed and administered to residents under the guidance of the facilities antibiotic stewardship program.1. The purpose of our antibiotic stewardship program is to monitor the use of antibiotics in our residents.The policy did not address the completion of tracking and surveillance tools. Review of the policy - Infection Control - Infection Prevention and Control Program, revised 1/2024, revealed An infection prevention and control program (IPCP) our established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.2. The elements of the infection prevention and control program consist of coordination/ oversight, policies/ procedures, surveillance, data analysts, antibiotic stewardship, outbreak management, prevention of infection, and employee health and safety.4. The infection prevention the control committee is responsible for reviewing and providing feedback on the overall program. Surveillance data and reporting information is used to inform the committee of potential issues and trends.The Antibiotic Stewardship portion revealed:1. Culture reports, sensitivity data, and antibiotic usage reviews are included in the surveillance activities.2. Medical criteria and standardized definitions of infections are used to help recognize and manage infections. 105453 Page 5 of 5