Health inspection·June 5, 2025

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 interview, and record review, the facility failed to act promptly upon the grievances and recommendations of the resident council; and failed to demonstrate an active response for resolution of their complaints in a timely manner. Findings: On 6/02/25 during the initial resident screening, concerns about repeated complaints made to the facility without resolution were found. Multiple residents expressed they had previously complained at the resident council meetings, but nothing had changed and they felt the facility had never addressed their grievances. Review of the resident council meeting minutes for the prior six months from December 2024 to May 2025, revealed complaints about temperatures inside the facility being too cold were brought up by members during both the December 2024 and January 2025 meetings. The response from the facility revealed minutes from the January meeting indicated maintenance staff were aware to check the room thermostats. Complaints regarding food/nutrition services were brought up during the March 2025 meeting, but review of the April 2025 and May 2025 minutes revealed the facility did not address any resolutions for these grievances initiated during the resident council meeting. On 6/03/25 at 1:04 PM, the Activities Director stated about 12-15 residents regularly attended the monthly resident council meeting. She explained the major issues the council had complained of included issues with food/dietary services and call lights not being answered timely. The Activities Director stated she had informed the Maintenance Director and the Dietary Manager of the issues brought up in the resident council meetings, and they had been working on them. She expressed staff offered blankets and jackets to the residents when they were in other areas of the facility other than their room, and added, when they had 15-25 people in the dining room she didn't think it was cold. The Activities Director explained she invited the department managers to the resident council meetings in order to address issues when they arose. On 6/03/25 at 2:30 PM, the Certified Dietary Manager (CDM) and the Assistant Dietary Manager stated they were not aware of residents having issues with the food at the facility. The CDM stated she was invited to the resident council meeting when she first started at the facility eight months ago in order to introduce herself to residents. The Assistant Dietary Manager stated she had been to one of the meetings a few weeks ago. They acknowledged neither of them regularly attended the resident council's monthly meeting, and had not been aware of the issues resident council members had brought forward. Page 1 of 2 105783 105783 06/05/2025 Solaris Healthcare East Orlando 250 South Chickasaw Trail Orlando, FL 32825

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 6/04/25 at 12:45 PM, the Activities Director explained she took notes and talked to the department managers for the areas where issues were brought up by the resident council. She said if not, she would bring the issues to the facility's morning meeting. The Activities Director conveyed that she learned about the resident council meetings when she was trained to become an Activities Director. She confirmed she had not filed any grievances on behalf of the resident council's concerns and had only filed a grievance for an individual resident once, last year. The Activities Director acknowledged that filing a grievance would leave a paper trail that indicated what the action and resolution was to an issue but said she had never considered writing a grievance for resident council concerns. She confirmed she had invited the dietary department to the resident council meeting twice to discuss food issues, but acknowledged they did not regularly attend. On 6/04/25 at 3:33 PM, the Grievance Officer stated she had not received any grievances from resident council since she was started working at the facility, so she figured they did not have any complaints, and the facility was doing a good job. She recalled, the Activities Director brought up a resident's issue at the morning meeting a couple of weeks previous but could not recall any other issues/concerns from the resident council being brought to the morning meetings. The Grievance Officer confirmed she trained staff regularly to file a grievance if there were any issues that could not be resolved immediately, but she had not received any grievances from the resident council group. On 6/05/25 at 9:34 AM, the Activities Director stated she responded to resident council issues in person by telling them what was done about their concerns. She acknowledged she didn't file an actual grievance for them nor did she always document any action taken. The Activities Director confirmed that repeated issues brought up by residents at the monthly meeting did not have documentation to indicate the issues were addressed or resolved. She acknowledged she should have detailed meeting notes and documentation of grievances for any issues brought up by the resident council meeting in order for the department managers to respond timely and appropriately to the residents' concerns. The facility's policy entitled Filing Grievances and Complaints dated January 2024, indicated the facility would help residents, their representatives and advocates file a grievance; a written summary of the investigation would be provided to the resident; and a copy would be maintained in the grievance log. The facility's policy entitled Resident Council dated January 2024, indicated the facility supported residents' desire to be involved and have input in the operation of the facility. The policy added, grievance/concern forms would be utilized to track issues, their resolution and the facility department related to the issues would be responsible to address the items of concern. The policy indicated minutes from the meetings would include follow-up on prior issues with responses being presented at the next meeting, or sooner if indicated. 105783 Page 2 of 2