Health inspection·October 20, 2025

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Based on interviews and record review, the facility did not ensure grievances were documented and/or resolved for the Resident Council for five months in 2025 (June, July, August, September and October 2025) out of five months reviewed.Findings included: A review of resident council minutes revealed there were multiple discussions related to residents wanting more ice water and snacks to be offered from June 2025-October 2025. An interview was conducted on 10/13/25 at 4:25 p.m. with Resident #2. The resident said she goes to the resident council meeting, and they had discussed needing water refills and wanting snacks several times, but nothing changed. Resident #2 said she occasionally had heard staff refilling water in the hall, but they didn't come to her side of the hall. Review of Resident #2's Brief Interview for Mental Status (BIMS), conducted 5/29/25, revealed a score of 15, indicating she was cognitively intact. An interview was conducted on 10/13/25 at 4:30 p.m. with Resident #3. The resident said she attended resident council meetings. She said they still did not get more water refills and snacks even though it had been requested multiple times. Resident #3 said she had to get up occasionally at night to go find water because she didn't get her water refilled. Review of Resident #3's Minimum Data Set (MDS), Section C, Cognitive pattern, revealed a BIMS score of 13, indicating she was cognitively intact. Review of Resident Council Meetings showed:6/11/15 11:00 a.m. 20 residents attending.New Business included: Wanting extra snacks and ice water to be offered during the day.7/9/25 11:00 a.m. 22 residents attending.Old Business included: Wanting extra snacks and ice water to be offered throughout the day.8/13/25 11:00 a.m. 25 residents attending.Old Business included: Wanting extra snacks and hydration to be offered throughout the day.10/8/25 11:00 a.m. 19 residents attending.New Business included: Requested that additional snacks and hydration be offered throughout the day. A review of grievance log from June 2025 through October 2025 revealed there were no documented grievances from the resident council related to residents wanting more ice water and snacks or any other resident council concerns. An interview was conducted on 10/13/25 at 3:45 p.m. with the facilities Activities Director. She said they had resident council meeting once a month and she took minutes for the meetings. The activities director said about the concerns that are discussed; if it is one person that had a concern, she would put it in as a grievance, but if it was a group concern it was not entered as a grievance. She said group concerns were talked about in the Interdisciplinary Team (IDT) meeting and addressed. The activities director said for example there was a group concern related to staff customer service, so it was discussed at the IDT meeting and education was done even though a grievance wasn't filed. The Activities Director recalled hydration and snacks being discussed at resident council. She said when it first came up, she told IDT members staff need to pass extra hydration and snacks. She agreed the concern was not being tracked or followed up on. The activities director said if the resident council concern was entered as a grievance, it would be tracked. An interview was conducted on 10/13/25 at 4:58 p.m. with the Nursing Home Administrator (NHA). The NHA Page 1 of 2 105037 105037 10/20/2025 Palms at Sebring Nursing and Rehabilitation The 725 S Pine St Sebring, FL 33870

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many said for grievances, anyone can fill them out either by paper or by scanning the barcode on their phone. She said grievances are turned into social services and logged. The grievance was then given to the appropriate person to follow up. She said social services tracks the logs ensuring paper and electronic grievances are followed-up on. The NHA said she remembered discussing resident's hydration concerns in the management meetings. She said she knew education was a part of what they did. She said she thought the hydration and snack concern was being tracked. The NHA was not aware resident council concerns were not being entered as grievances. Review of a facility policy titled Complaint/Grievance, effective date 9/7/23, showed:Policy: - The Center will support each resident's right to voice a complaint/grievance without fear of discrimination or reprisal. The center will make prompt efforts to resolve the complaint/grievance and inform the resident of progress towards resolution. Grievances will be reviewed by the Quality Assurance Performance Improvement Committee. Grievances discovered to meet the definition of Abuse, Neglect, Exploitation or Misappropriation will be handled per the facility's Abuse Policy. The resident should have reasonable expectations of care and services and the center should address those expectations in a timely, reasonable, and consistent manner. The Center will inform residents of the right to file a grievance orally and in writing, the right to file grievances anonymously, the contact information of the Grievance Officer, a reasonable time frame for completing the review of the grievance, the right to obtain a written decision regarding the grievance, and contact information of independent entities with whom grievances may be file (State agency, Ombudsman, Quality Improvement Organizations) The Executive Director will designate a Grievance Officer at the facility.Procedure:1. An employee receiving a complaint/grievance from a resident, family member and/or visitor will initiate a Complaint/Grievance Form. Complaint/Grievance forms will be available 24 hours per days 7 days a week in an unsecured common area. Accommodations will be made to ensure residents have the opportunity regardless of their physical abilities or limitations.2. Original grievance forms are then submitted to the Grievance Officer /designee for further action.3. The Grievance Officer /designee shall act on the grievance and begin follow-up of the concern or submit it to the appropriate department director for follow-up.4. The grievance follow-up should be completed in a reasonable time frame; this should not exceed 14 days.5. The findings of the grievance shall be recorded on the Complaint/Grievance Form.6. The results will be forwarded to the Executive Director for review and filing.7. The Grievance Official will log complaints/grievances on a Monthly Grievance Log. 105037 Page 2 of 2