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TheVardellReport
Kensington Gardens Rehab and Nursing Center
Skilled nursing facility and nursing facility
2055 Palmetto St
Clearwater, FL 33758
Report
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The Vardell Report.Kensington Gardens Rehab and Nursing Center
The deeper story, beautifully organized. Available records, historical context, and questions worth asking.
- Provider Category
- Nursing home
- Location
- Clearwater, FL
- Record Period
- 2021–2026
- Source Documents
- 11
This report is free. Vardell does not certify, grade or endorse; it shows what the record documents.
The Essentials
Summary
Across 9 inspections from February 2021 to August 2026, state surveyors documented 43 findings at Kensington Gardens Rehab and Nursing Center; 43 have a recorded correction; CMS lists 2 enforcement actions in the window.
- Inspections
- 9
- 2021–2026, complaint and standard
- Findings
- 43
- Deficiencies cited by state inspectors
- Corrected
- 43
- Of 43 findings, with a recorded correction date
- Penalties
- 2
- 2 fines; payment not published
Findings by Year
- Findings
- Of which, actual harm (level G or above)
* Partial year, through October 1, 2026.
| Year | Inspections | Findings | Of which, actual harm (level G or above) |
|---|---|---|---|
| 2021 | 1 | 0 | 0 |
| 2022 | 1 | 9 | 0 |
| 2023 | 1 | 3 | 0 |
| 2024 | 1 | 10 | 0 |
| 2025 | 2 | 7 | 0 |
| 2026 | 3 | 14 | 0 |
What the Record Shows
- 43 of 43 findings have a recorded correction date.
- CMS lists 2 enforcement actions in the window: 2 fines totaling $18,070, their payment not published.
- 7 visits in this window included a complaint investigation. CMS publishes what a complaint investigation cited, not what the complaint alleged.
- The latest standard inspection, February 1, 2024, recorded 10 findings (most serious: Level F).
What to Ask About
- A Clean, Homelike Setting, Cited in Four Inspections
- Grievances, Cited in Three Inspections
- Reporting Suspected Abuse, Cited in Three Inspections
- Accident Hazards and Supervision, Cited in Three Inspections
- Infection Control, Cited in Three Inspections
- Care Plans, Cited in Two Inspections
- Quality of Care, Cited in Two Inspections
- Respiratory Care, Cited in Two Inspections
- Post nurse staffing information every day, Cited in Two Inspections
- Medication Error Rate, Cited in Two Inspections
- Citation F867, Cited in Two Inspections
- Citation F925, Cited in Two Inspections
Report at a Glance
- Facility
- Kensington Gardens Rehab and Nursing Center
- Address
- 2055 Palmetto St, Clearwater, FL 33758
- CMS Certification Number
- 105453
- Provider Type
- Skilled nursing facility and nursing facility
- Certified Beds
- 150
- Ownership
- For profit - Individual
- Record Window
- February 5, 2021 to October 1, 2026
Chronology
Inspection History
Every inspection in the record window, newest first. A finding is a deficiency an inspector cited. CMS publishes what a complaint investigation cited, not what the complaint alleged.
- 2026
Complaint investigation
2 findings
- F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level ENo actual harm, potential for moreCorrected Sep 27, 2026
- F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Sep 27, 2026
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2026
Complaint investigation
2 findings
- F881Implement a program that monitors antibiotic use.Level ENo actual harm, potential for moreCorrected Mar 18, 2026
- F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Mar 18, 2026
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2026
Complaint investigation
10 findings
- F585Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.Level ENo actual harm, potential for moreCorrected Feb 15, 2026
- F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level ENo actual harm, potential for moreCorrected Feb 15, 2026
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level ENo actual harm, potential for moreCorrected Mar 18, 2026
- F867Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.Level ENo actual harm, potential for moreCorrected Mar 18, 2026
- F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Level DNo actual harm, potential for moreCorrected Feb 15, 2026
- F584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.Level DNo actual harm, potential for moreCorrected Feb 15, 2026
- F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Level DNo actual harm, potential for moreCorrected Feb 15, 2026
- F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Feb 15, 2026
- F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level DNo actual harm, potential for moreCorrected Feb 15, 2026
- F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected Feb 15, 2026
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2025
Complaint investigation
4 findings
- F584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.Level ENo actual harm, potential for moreCorrected Jul 12, 2025
- F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Jul 12, 2025
- F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected Jul 12, 2025
- F925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.Level DNo actual harm, potential for moreCorrected Jul 12, 2025
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2025
Complaint investigation
3 findings
- F867Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.Level ENo actual harm, potential for moreCorrected Jul 12, 2025
- F908Keep all essential equipment working safely.Level DNo actual harm, potential for moreCorrected Jul 12, 2025
- F921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.Level DNo actual harm, potential for moreCorrected Jul 12, 2025
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2024
Standard health inspection
10 findings
The same visit included a complaint investigation.
- F732Post nurse staffing information every day.Level FNo actual harm, potential for moreCorrected Feb 29, 2024
- F644Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.Level ENo actual harm, potential for moreCorrected Feb 29, 2024
- F585Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.Level DNo actual harm, potential for moreCorrected Feb 29, 2024
- F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Level DNo actual harm, potential for moreCorrected Feb 29, 2024
- F695Provide safe and appropriate respiratory care for a resident when needed.Level DNo actual harm, potential for moreCorrected Feb 29, 2024
- F584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.Level ENo actual harm, potential for moreCorrected Feb 29, 2024
- F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Level ENo actual harm, potential for moreCorrected Feb 29, 2024
- F759Ensure medication error rates are not 5 percent or greater.Level ENo actual harm, potential for moreCorrected Feb 29, 2024
- F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Feb 29, 2024
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected Feb 29, 2024
Enforcement Action
Civil money penalty, $8,490 imposed May 13, 2025. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of February 1, 2024, the nearest before the penalty date.
Enforcement Action
Civil money penalty, $9,580 imposed May 13, 2025. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of February 1, 2024, the nearest before the penalty date.
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2023
Complaint investigation
3 findings
- F569Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.Level ENo actual harm, potential for moreCorrected Jan 14, 2024
- F568Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.Level DNo actual harm, potential for moreCorrected Jan 14, 2024
- F585Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.Level DNo actual harm, potential for moreCorrected Jan 14, 2024
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2022
Standard health inspection
9 findings
- F584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.Level ENo actual harm, potential for moreCorrected May 14, 2022
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level ENo actual harm, potential for moreCorrected May 14, 2022
- F761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.Level ENo actual harm, potential for moreCorrected May 14, 2022
- F925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.Level ENo actual harm, potential for moreCorrected May 14, 2022
- F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level DNo actual harm, potential for moreCorrected May 14, 2022
- F695Provide safe and appropriate respiratory care for a resident when needed.Level DNo actual harm, potential for moreCorrected May 14, 2022
- F732Post nurse staffing information every day.Level DNo actual harm, potential for moreCorrected May 14, 2022
- F759Ensure medication error rates are not 5 percent or greater.Level DNo actual harm, potential for moreCorrected May 14, 2022
- F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected May 14, 2022
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2021
Standard health inspection
No findings
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Severity levels follow the CMS scope and severity grid. A–C: potential for minimal harm. D–F: no actual harm, potential for more than minimal harm. G–I: actual harm. J–L: immediate jeopardy.
Context
Patterns Worth Examining
A repeated citation can merit attention, but context and corrective action must be reviewed before drawing a conclusion.
- 1
A Clean, Homelike Setting, Cited in Four Inspections
Inspectors cited F584 in April 2022, February 2024, June 2025 and January 2026. This citation covers whether rooms and shared spaces are kept safe, clean, comfortable and homelike. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
212223242525262626F584 across all 9 inspections, oldest to newest - 2
Grievances, Cited in Three Inspections
Inspectors cited F585 in December 2023, February 2024 and January 2026. This citation covers residents’ right to voice grievances without reprisal, and the home’s process for resolving them. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
212223242525262626F585 across all 9 inspections, oldest to newest - 3
Reporting Suspected Abuse, Cited in Three Inspections
Inspectors cited F609 in February 2024, June 2025 and January 2026. This citation covers whether suspected abuse, neglect or theft is reported to the authorities on time, with the results of the home’s investigation. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
212223242525262626F609 across all 9 inspections, oldest to newest - 4
Accident Hazards and Supervision, Cited in Three Inspections
Inspectors cited F689 in April 2022, February 2024 and January 2026. This citation covers whether residents are protected from accident hazards and supervised closely enough to prevent accidents, including falls. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
212223242525262626F689 across all 9 inspections, oldest to newest - 5
Infection Control, Cited in Three Inspections
Inspectors cited F880 in April 2022, February 2026 and August 2026. This citation covers hand hygiene, isolation practice and the home’s infection-prevention program. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
212223242525262626F880 across all 9 inspections, oldest to newest - 6
Care Plans, Cited in Two Inspections
Inspectors cited F656 in April 2022 and January 2026. This citation covers whether each resident has a written care plan that meets their needs, with goals that can be measured. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
212223242525262626F656 across all 9 inspections, oldest to newest - 7
Quality of Care, Cited in Two Inspections
Inspectors cited F684 in January 2026 and August 2026. This citation covers whether residents receive the treatment their orders, preferences and goals call for. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
212223242525262626F684 across all 9 inspections, oldest to newest - 8
Respiratory Care, Cited in Two Inspections
Inspectors cited F695 in April 2022 and February 2024. This citation covers oxygen, breathing treatments and other respiratory care. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
212223242525262626F695 across all 9 inspections, oldest to newest - 9
Post nurse staffing information every day, Cited in Two Inspections
Inspectors cited F732 in April 2022 and February 2024. The agency describes it this way: Post nurse staffing information every day. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
212223242525262626F732 across all 9 inspections, oldest to newest - 10
Medication Error Rate, Cited in Two Inspections
Inspectors cited F759 in April 2022 and February 2024. This citation covers whether medication errors stayed under 5 percent when inspectors watched medications being given. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
212223242525262626F759 across all 9 inspections, oldest to newest - 11
Citation F867, Cited in Two Inspections
Inspectors cited F867 in May 2025 and January 2026. The agency describes it this way: Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
212223242525262626F867 across all 9 inspections, oldest to newest - 12
Citation F925, Cited in Two Inspections
Inspectors cited F925 in April 2022 and June 2025. The agency describes it this way: Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
212223242525262626F925 across all 9 inspections, oldest to newest
For Your Next Visit
Questions to Ask on Your Visit
Bring these to the tour. Each one comes from something in the record; the reason is under the question.
- 01
What was done about the cleanliness citation, and how are rooms and shared spaces checked now?
A Clean, Homelike Setting: cited in four inspections, most seriously at level E.
- 02
How do we file a grievance, who answers it, and how quickly?
Grievances: cited in three inspections, most seriously at level E.
- 03
How are staff trained to report suspected abuse or neglect, and who reports it to the state?
Reporting Suspected Abuse: cited in three inspections, most seriously at level D.
- 04
What changed in fall prevention and supervision after the last citation, and how do you check that it is still working?
Accident Hazards and Supervision: cited in three inspections, most seriously at level E.
- 05
Who leads infection control here, and how often are hand-hygiene and isolation practices audited?
Infection Control: cited in three inspections, most seriously at level D.
- 06
How is a care plan written and reviewed here, and how do families take part in it?
Care Plans: cited in two inspections, most seriously at level D.
- 07
How do nurses make sure a doctor’s orders are carried out, and how are families told when something is missed?
Quality of Care: cited in two inspections, most seriously at level E.
- 08
Who manages oxygen and breathing treatments on each shift, and how is the equipment checked?
Respiratory Care: cited in two inspections, most seriously at level D.
- 09
What changed after F732 was cited, and how do you check it now?
Post nurse staffing information every day: cited in two inspections, most seriously at level F.
- 10
How are medication passes checked, and what happens when an error is found?
Medication Error Rate: cited in two inspections, most seriously at level E.
- 11
What changed after F867 was cited, and how do you check it now?
Citation F867: cited in two inspections, most seriously at level E.
- 12
What changed after F925 was cited, and how do you check it now?
Citation F925: cited in two inspections, most seriously at level E.
- 13
How many nurses and aides are on each shift, including nights and weekends, for the unit we are considering?
No staffing citation appears in this window. Staffing levels are published separately by CMS and are worth asking about directly.
- 14
What led to the 2025 fine, and has it been paid?
An $8,490 civil money penalty was imposed May 13, 2025. CMS publishes the fine, not whether it has been paid. The record holds two enforcement actions in the window.
The Evidence
Sources and Coverage
Inspection results and penalties are published by the Centers for Medicare & Medicaid Services from surveys conducted by the Florida state survey agency.
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Florida state survey agency
Inspection Feb 5, 2021 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Florida state survey agency
Inspection Apr 14, 2022 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Florida state survey agency
Inspection Dec 14, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Florida state survey agency
Inspection Feb 1, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Florida state survey agency
Inspection May 13, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Florida state survey agency
Inspection Jun 12, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Florida state survey agency
Inspection Jan 16, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Florida state survey agency
Inspection Feb 18, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Florida state survey agency
Inspection Aug 27, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Penalties, Provider Data CatalogView Dataset ↗
Centers for Medicare & Medicaid Services
Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Provider Information, Provider Data CatalogView Dataset ↗
Centers for Medicare & Medicaid Services · 105453
Published Oct 1, 2026 · Retrieved Nov 1, 2026
Coverage
Record windowFebruary 5, 2021 – October 1, 2026
- CMS publishes about three inspection cycles; inspections before February 2021 are not in this release.
- CMS refreshes these files monthly, after statements of deficiencies are processed, so an inspection from the last two months may not appear yet.
What This Report Cannot Tell You
- Complaints not investigated onsite
- Allegations screened out by the state before an onsite visit are not published.
- Complaint allegations
- CMS publishes the deficiencies a complaint survey cited, not the allegation itself.
- Facility-reported incidents
- Self-reported incidents appear only if they led to an inspection.
- Follow-up visits
- CMS's files list standard, complaint and infection control surveys, not revisits; a correction date is the one CMS records.
- Fire safety inspections
- Published by CMS separately and not included in this record yet.
- Staffing levels and ownership history
- Published by CMS separately and not included in this record.
- Whether fines were paid
- CMS publishes the fines imposed, not whether or when they were paid.
Historical coverage varies by agency and location. Missing records do not mean that no complaint or violation occurred.
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