Pennsylvania Department of Health
WESLEY VILLAGE, THE
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

WESLEY VILLAGE, THE
Inspection Results For:

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WESLEY VILLAGE, THE - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure, and Civil Rights Compliance Survey completed on February 13, 2026, it was determined The Wesley Village was not in compliance with the following requirements of 42 CFR Part 483 Subpart B Requirements for Long Term Care and the 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations.\~

Plan of Correction:

483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:

This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.

§483.60(i) Food safety requirements.
The facility must -

§483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities.
(i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations.
(ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices.
(iii) This provision does not preclude residents from consuming foods not procured by the facility.

§483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.

Observations:

Based on observation and staff interview, it was determined the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of foodborne illness in the food and nutrition services department.

Findings include:

Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell, or taste harmful bacteria that may cause illness according to the USDA (The United States Department of Agriculture, also known as the Agriculture Department, is the U.S. federal executive department responsible for developing and executing federal laws related to food).

Observations during the initial tour of the kitchen conducted with the facility's Food and Nutrition Services Director on February 10, 2026, at 8:50 AM revealed the following unsanitary practices with the potential to introduce contaminants into food and increase the potential for foodborne illness:

The handwashing sink was visibly soiled and there were four small chunks of canned fruit cocktail in the basin of the sink.

There was a thick layer of dust on the fins of the hood vent panels located above the stove.

There were two broken wall tiles which created a two inch gap located above the floor molding in the food cart storage area.

The kitchen floor perimeter had an accumulation of dirt and debris, creating an unsanitary condition which could harbor pests and bacteria.

Interview with the Food Service Director at the time of observations confirmed the food and nutrition services department was to be maintained in a sanitary manner.

28 Pa. Code 201.18 (e) (2.1) Management.

28 Pa. Code 211.6 (f) Dietary Services.

Plan of Correction - To be completed: 03/31/2026

1. The handwashing sink, hood vent panels, wall tiles, and floor perimeter were cleaned/sanitized and in good repair within hours of identification.

2. Kitchen rounding with the NHA, DM, and Plant Operations Manager will be done weekly to prevent reoccurrence of these issues as well as prevention of other like issues weekly for 2 months and then monthly rounding will take place.

3. Dietary staff educated to immediately report any new damage to NHA, DM, and POM.
4. An additional walk through inspection audit will be done by a member of the IDT weekly x4 weeks and monthly x2 to ensure cleanliness and above items are in proper repair. The results of this audit will be discussed in facility QAPI meeting.

483.10(c)(1)(4)(5) REQUIREMENT Right to be Informed/Make Treatment Decisions:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

§483.10(c) Planning and Implementing Care.
The resident has the right to be informed of, and participate in, his or her treatment, including:

§483.10(c)(1) The right to be fully informed in language that he or she can understand of his or her total health status, including but not limited to, his or her medical condition.

§483.10(c)(4) The right to be informed, in advance, of the care to be furnished and the type of care giver or professional that will furnish care.

§483.10(c)(5) The right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers.

Observations:

Based on a review of clinical records, grievances filed with the facility, and resident and staff interviews, it was determined the facility failed to ensure residents are afforded the opportunity to make informed treatment decisions and choose preferred alternatives for one out of four residents sampled for a closed record review (Resident 128).

Findings include:

Clinical record review revealed Resident 128 was admitted to the facility on December 15, 2025 with diagnoses that included acute respiratory failure (a condition where the lungs fail to adequately oxygenate the blood or remove carbon dioxide, leading to insufficient oxygen to meet the body's needs).

A review of an admission Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated December 21, 2025, revealed Resident 128 was cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13 to 15 indicates cognition is intact).

A physician's order for Bisacodyl Laxative Suppository 10 mg with direction to insert one suppository rectally as needed for bowel management protocol was initiated on December 15, 2025. A medication administration record dated December 2025 revealed Resident 128 was administered Bisacodyl Laxative Suppository 10 mg on December 20, 2025, at 6:59 AM.

A progress note dated December 20, 2025, at 8:29 PM revealed Resident 128 was upset after she was administered a suppository even though she said "no." Resident 128 indicated she had the right to say no to something she did not want.

A review of a grievance filed with the facility dated December 20, 2025, at 5:30 PM revealed Resident 128 stated she was sleeping and the nurse supervisor came into her room and said, "Wake up, wake up," and proceeded to insert a suppository into her rectum, which she was not ready for nor awake enough to realize what was happening. The grievance indicated Resident 128 had a problem with not being given the opportunity to wake up and fully understand what they wanted to do because she was sleeping before they entered the room.

A witness statement provided by Employee 1, Registered Nurse (RN), revealed that Employee 1, RN, entered Resident 128's room on December 20, 2025, at 6:50 AM. Employee 1, RN, explained to the resident that they would be giving her a suppository. Employee 2, Nurse Aide, assisted in turning the resident, and the suppository was given, and the resident tolerated it well. Employee 1, RN, indicated at no time did the resident decline the suppository.

A witness statement provided by Employee 2, Nurse Aide, indicated that she remembered entering Resident 128's room with Employee 1, RN, on December 20, 2025. Employee 2, NA, indicated that she did not remember anything out of the normal. Employee 2, NA, indicated that she does not rush residents and is very gentle.

During a phone interview on February 13, 2025, at 9:24 AM, Resident 128 indicated she was upset because she was not afforded an opportunity to decline a suppository. She explained that she filed a grievance after nursing staff administered a suppository without providing her an opportunity to decline the medication.

During an interview on February 13, 2025, at 11:15 AM, the above information was reviewed with the nursing home administrator (NHA) and director of nursing (DON). The DON and NHA confirmed that residents are to be afforded the opportunity to choose, accept, or refuse care, including medication and treatments. The facility failed to ensure the resident's right to fully participate in care and treatment when Resident 128 was not afforded the opportunity to refuse a suppository on December 20, 2025.

28 Pa. Code 201.29 (a) Resident rights.

28 Pa. Code 211.2 (d)(7) Medical director.

28 Pa. Code 211.12 (d)(3)(5) Nursing services.

Plan of Correction - To be completed: 03/31/2026

Wesley Village submits that its policies, systems, and procedures related to resident care and comprehensive quality improvement program for monitoring of resident care are appropriate. Additionally, it is important to make clear that the submission of this plan of correction is not to be construed as an admission that the cited deficiencies are accurate or that at the time of the survey, Wesley Village did have policies, procedures and systems in place to maintain compliance with federal and state requirements; however, in an effort to enhance the care furnished to our residents, we have augmented some of our existing policies, procedures and systems.

1. This is a past event and Resident #128 is no longer a resident at Wesley.
2. Nursing will ensure they receive verbal approval from cognitively intact resident, before administering a suppository.
3. Nursing staff will be educated on resident rights with respect to the residents right to refuse care and inputting appropriate documentation.
4. An audit will be conducted randomly on residents who receive suppositories to ensure that appropriate consent was given prior to administration. The audit will be done weekly x 4 weeks and monthly x 2. Documentation in HER should reflect consent or declination. The results of this audit will be discussed in facility QAPI meeting.

483.60(d)(1)(2) REQUIREMENT Nutritive Value/Appear, Palatable/Prefer Temp:

§483.60(d) Food and drink
Each resident receives and the facility provides-

§483.60(d)(1) Food prepared by methods that conserve nutritive value, flavor, and appearance;

§483.60(d)(2) Food and drink that is palatable, attractive, and at a safe and appetizing temperature.

Observations:

Based on observations, review of clinical records, resident and staff interviews, and meal test tray results, it was determined the facility failed to serve meals that were palatable and at safe and appetizing temperatures for a test tray completed on the West Unit during the breakfast meal and for experiences of five of 25 residents sampled (Residents 82, 83, 20, 44, and 105).

Findings included:

According to the federal regulatory guidance at 483.60(i)-(2) Food safety requirements - the definition of "Danger Zone," found under the Definitions section, specifies that food temperatures between 41and 135allow rapid growth of pathogenic microorganisms that can cause foodborne illness. Hot foods must be maintained at or above 135and cold foods at or below 41review of a facility evaluation form titled "Resident Tray Assessment" revealed that hot food items were assessed based on being greater than or equal to 135 degrees Fahrenheit and on palatability. "Palatable" means acceptable to taste, including appropriate temperature, texture, and flavor.

A clinical record review revealed Resident 82 was admitted to the facility on November 12, 2019, with diagnoses that include chronic respiratory failure with hypoxia (a condition where the respiratory system is unable to remove carbon dioxide from or provide oxygen to the body).A review of a quarterly Minimum Data Set Assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated February 5, 2026, revealed that Resident 82 was cognitively intact with a BIMS (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information) score of 15 (a score of 13 to 15 indicates cognition is intact).

During an interview on February 10, 2026, at 10:42 AM, Resident 82 explained that the food temperatures are often cold because the meal trays sit for 30 to 45 minutes before staff are able to pass them on to residents.

A clinical record review revealed that Resident 83 was admitted to the facility on September 1, 2022, with diagnoses that include chronic heart failure (a condition that develops when the heart doesn't pump enough blood to meet the body's needs).A review of a quarterly MDS assessment dated February 2, 2026, revealed that Resident 83 was cognitively intact with a BIMS score of 15.

During an interview on February 10, 2026, at 11:05 AM, Resident 83 indicated that he was frustrated because the food is often cold. He explained that the soup is too cold for him to enjoy.

A clinical record review revealed Resident 20 was admitted to the facility on September 27, 2016, with diagnoses that include heart failure (a condition that develops when the heart doesn't pump enough blood to meet the body's needs).A review of a quarterly Minimum Data Set assessment dated February 10, 2026, revealed that Resident 20 was cognitively intact with a BIMS score of 15.

During an interview on February 10, 2026, at 11:24 AM, Resident 20 stated that he had concerns about food temperatures. He reported that staff frequently served his eggs cold and that he needed to request reheating.

During a resident group interview on February 11, 2026, at 10:00 AM, Residents 44 and 105 reported concerns regarding cold food temperatures. Resident 105 stated that staff frequently delivered her meals cold and that she needed to request reheating. Resident 44 stated that she felt upset because staff continued to deliver her meals cold and that she had reported this concern to staff multiple times over the previous weeks. Resident 44 reported that meal trays remain on carts for at least 20 minutes before staff deliver them to residents. She stated that breakfast presents the most frequent problem and that staff regularly serve her eggs cold.

Survey staff conducted a test tray evaluation on the West Unit on February 12, 2026, during the breakfast meal. Dietary staff placed the test tray in the meal delivery cart with resident trays at 7:50 AM. Unit staff began distributing trays from the cart at 8:20 AM, resulting in a 30-minute delay.

At 8:30 AM, after the last resident was served, food temperatures were recorded and revealed the following temperatures. The oatmeal was 121 degrees Fahrenheit, the omelet was 115 degrees Fahrenheit, the Canadian bacon was 110 degrees Fahrenheit, and the wheat toast cold and rubbery. The food tasted only lukewarm and was not palatable at the temperature served.

Interview with the Nursing Home Administrator (NHA) on February 12, 2026, at 11:00 AM confirmed that food served is to be palatable and served at safe and appetizing temperatures. The NHA confirmed that residents' food trays were to be timely served to residents upon arrival to each nursing unit to help ensure palatable temperatures.

28 Pa. Code 201.14(a)(b) Responsibility of licensee.

28 Pa. Code 201.18 (b)(1) Management.

Plan of Correction - To be completed: 03/31/2026

1. Residents 82,83,20,44,and 105 will be interviewed weekly by an IDT member or designee to ensure food temperatures are sufficient from a regulatory and satisfaction standard.
2. Test trays will be randomly inserted into the food trucks at various places and will be temped by NHA or designee. There will be multiple consistency trays checked for temperature and palatability. Results will be recorded.
3. Dietary and Nursing staff will be educated on the policy for food temperature and palatability, as well as the expectation for timely tray pass once the truck arrives on the unit.
4. An audit will be done weekly x 4 and monthly x2 to ensure appropriate temperature, palatability is consistent with regulation and resident satisfaction. The results of this audit will be discussed in facility QAPI meeting.

483.45(d)(1)-(6) REQUIREMENT Drug Regimen is Free from Unnecessary Drugs:

§483.45(d) Unnecessary Drugs-General.
Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used-

§483.45(d)(1) In excessive dose (including duplicate drug therapy); or

§483.45(d)(2) For excessive duration; or

§483.45(d)(3) Without adequate monitoring; or

§483.45(d)(4) Without adequate indications for its use; or

§483.45(d)(5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or

§483.45(d)(6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section.

Observations:

Based on a review of clinical records, select facility policy, and staff interviews, it was determined the facility failed to ensure that a resident's drug regimen was free of unnecessary antibiotics for one out of 25 residents sampled (Resident 83).

Findings include:

A review of the facility policy titled "Antibiotic Stewardship," last reviewed by the facility on March 19, 2025, revealed it is facility policy to maintain an antibiotic stewardship program that promotes the appropriate use of antibiotics and includes a system of monitoring to improve resident outcomes and reduce antibiotic resistance. The policy indicates that diagnostic tests should be used wisely to avoid unnecessary antibiotic therapy or therapy that is unnecessarily broad-spectrum, with consideration to healthcare value. Bacterial cultures with susceptibility testing should be collected, handled, and processed promptly and appropriately to identify specific bacteria causing infection and facilitate the use of narrow-spectrum antibiotics whenever possible.

A clinical record review revealed that Resident 83 was admitted to the facility on September 1, 2022, with diagnoses that include chronic heart failure (a condition that develops when the heart doesn't pump enough blood to meet the body's needs). A progress note dated January 4, 2026, at 4:19 PM indicated the resident had a 101.9temperature but was resolved. The resident denied abdominal pain, dysuria (pain, burning, or discomfort during urination), and confusion. The note indicated if clinical infection is suspected, then initiate antibiotics after urine cultures were obtained.

A urine culture and sensitivity report (C and S report, which detects, identifies, and determines the best treatment for bacterial or fungal infections in the urinary tract) dated January 4, 2026, and reported on January 7, 2026, at 3:09 PM revealed Resident 83's urine was positive for the organism pseudomonas aeruginosa (a bacterium found in soil and water that thrives in moist environments, frequently causing infections in hospitalized or immunocompromised individuals). The results indicated the organism was resistant (medication type not effective in treating the specific bacteria) to ciprofloxacin (an antibiotic medication).

A progress note dated January 7, 2026, at 8:36 PM revealed as a result of the urine culture and sensitivity a new physician order for ciprofloxacin 500 mg twice a day for five days was ordered. A physician's order for ciprofloxacin HCI oral tablet 500 mg with directions to give 1 tablet by mouth two times a day for a culture and sensitivity result was initiated on January 7, 2026.

A Medication Administration Record dated January 2026 revealed Resident 83 was administered 1 dose of ciprofloxacin 500 mg on January 7, 2026, at 9:00 PM.

A progress note dated January 8, 2026, at 9:00 AM revealed ciprofloxacin 500 mg was discontinued.

During an interview on February 11, 2026, at 1:15 PM, the Infection Preventionist (IP) confirmed that Resident 83 was administered ciprofloxacin 500 mg on January 7, 2026, following a culture and sensitivity. The IP confirmed the culture and sensitivity reported on January 7, 2026, indicated the organism identified in Resident 83's urine was resistant to ciprofloxacin. The facility failed to ensure Resident 83's drug regimen was free of an unnecessary antibiotic when the resident received one dose of ciprofloxacin 500 mg on January 7, 2026.

28 Pa. Code 211.2(d)(3)(5) Medical Director.

28 Pa. Code 211.10(c)(d) Resident care policies.

28 Pa. Code 211.12(d)(3)(5) Nursing services.

Plan of Correction - To be completed: 03/31/2026

1. This is a past event and was corrected for resident #83 after one dose. The telemedicine physician was contacted at the time of administration.
2. After hour telemedicine organization received another copy of our antibiotic stewardship program expectations. Our in house full time IPIC RN ensures that orders given by physicians are correct and have appropriate med per the culture.
3. Licensed staff and Telemedicine organization will be educated on the antibiotic stewardship program and adhering to the culture and sensitivity. Nursing staff will further be educated to challenge orders that are not inline with the policy and document the result of their discussion with the physician.
4. An audit will be conducted on antibiotics ordered by telemedicine physicians weeklyx4 weeks and monthly x2 months to ensure appropriate antibiotic stewardship is adhered to. The results of this audit will be discussed in facility QAPI meeting.

483.25(k) REQUIREMENT Pain Management:

§483.25(k) Pain Management.
The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.

Observations:

Based on clinical record and select policy review, staff and resident interviews, it was determined the facility failed to timely assess and implement interventions to address one of 25 residents' pain (Resident 2).

Findings include:

A review of the facility's pain management policy dated March 19, 2025, revealed that it was the goal of the facility to promote the highest practicable level of physical, mental, and psychological well-being, in accordance with the comprehensive assessment and care plan, current professional standards of practice, and the resident's goals and preferences. The pain management policy also indicated the resident will have pain identified and assessed. The type of pain will be identified for appropriate management approaches to alleviate/eliminate the resident's pain.

A review of Resident 2's clinical record revealed the resident had a diagnosis of muscle weakness and diabetes (a chronic condition causing high blood sugar due to insufficient insulin production). An Admission Minimum Data Set Assessment (MDS, a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated January 22, 2026, revealed a BIMS score of 15 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13 to 15 indicates cognition is intact).

Nursing documentation dated January 21, 2026, at 4:41 AM, revealed the "resident was up most of the night asking for Tylenol," a mild pain reliever. The note further indicated the facility had no physician orders for the requested Tylenol and staff on the 3 pm-11 pm shift informed the resident there were no orders to administer her Tylenol.

A review of the pain assessments completed for January 2026 indicated that on the evening of January 20, 2026, a pain assessment was completed at 5:35 PM which indicated the resident was pain-free. There was no indication that a pain assessment was completed in conjunction with the nurse's note on January 21, 2026, at 4:41 AM, in which the resident requested Tylenol, or that an assessment was completed to further determine why the Tylenol was specifically requested.

A nurse's note dated January 22, 2026, at 12:05 PM, indicated the resident had complaints of overnight pain and that the physician assistant ordered the resident Tylenol 650 milligrams every 24 hours as needed. There was no indication the facility attempted to contact the physician for further direction to attempt to manage the resident's discomfort either during the evening or night shift hours.

An interview with Resident 2 on February 11, 2026, at 11:55 AM, revealed she was very uncomfortable in the bed and stated the bed mattress "is shot." The resident indicated that lying in bed was very uncomfortable, "her entire body hurt," and that she wanted medication/intervention to relieve the pain so she could sleep. The resident indicated her pain was a nine out of ten on a ten-point scale, where 1 would indicate mild pain and 10 would indicate severe pain. The resident indicated she was neither given any medication nor non-pharmacologic intervention to relieve/alleviate her pain.

Interview with the director of nursing on February 12, 2026, at 1:00 PM was unable to provide evidence the facility accurately and timely assessed this resident's pain, implemented interventions to alleviate pain, and/or documented the effectiveness/outcome of the interventions.

28 Pa. Code 211.12 (c)(d)(3) (5) Nursing services.

28 Pa. Code 211.10(d)Resident care policies.

Plan of Correction - To be completed: 03/31/2026

1. Resident #2 has appropriate orders to monitor, assess/evaluate, and treat pain of varying degrees.
2. Residents who are unable to have an order for PRN Tylenol, related to medical condition, will be audited to ensure physician notification and appropriate measures are in place if new onset of acute pain occurs.
3. Licensed nursing staff will be educated on the pain management policy to ensure appropriate and timely intervention is taking place.
4. A random audit will be done utilizing the 24 hour summary weekly x4 weeks and monthly x 2 to ensure that licensed staff is following the facility policy on pain management. The results of this audit will be discussed in facility QAPI meeting.

483.10(g)(10)(11) REQUIREMENT Right to Survey Results/Advocate Agency Info:

Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.

§483.10(g)(10) The resident has the right to-
(i) Examine the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility; and
(ii) Receive information from agencies acting as client advocates, and be afforded the opportunity to contact these agencies.

§483.10(g)(11) The facility must--
(i) Post in a place readily accessible to residents, and family members and legal representatives of residents, the results of the most recent survey of the facility.
(ii) Have reports with respect to any surveys, certifications, and complaint investigations made respecting the facility during the 3 preceding years, and any plan of correction in effect with respect to the facility, available for any individual to review upon request; and
(iii) Post notice of the availability of such reports in areas of the facility that are prominent and accessible to the public.
(iv) The facility shall not make available identifying information about complainants or residents.

Observations:

Based on observation and resident and staff interviews, it was determined the facility failed to post the most recent survey results which include any surveys, certifications, and complaint investigations made respecting the facility during the 3 preceding years, and any plan of correction in effect with respect to the facility and experiences reported by 5 out of 5 residents interviewed during a group interview (Residents 8, 44, 51, 55, and 105).

Findings include:

During a resident council interview on February 11, 2026, at 10:00 AM, five alert and oriented residents in attendance (Residents 8, 44, 51, 55, and 105) indicated they did not know where the facility posted the Department of Health survey results.

Observation of the facility reception area on February 11, 2026, at 11:19 AM revealed there was state survey inspection results available in a binder in the lobby of the facility.

Review of the binder revealed the most recent recertification results were not available in the binder.

Recertification survey results from the survey of May 9, 2025, were not available.

During an interview on February 11, 2026, at 11:30 AM, the Director of Nursing (DON) and Nursing Home Administrator (NHA) acknowledged the Department of Health survey results were not updated to include the most recent recertification survey results.

28 Pa. Code 201.14(a) Responsibility of licensee.

Plan of Correction - To be completed: 03/31/2026

1. Residents 8,44,51,55,and 105 will be spoken to regarding the whereabouts of the DOH historic survey results. A locking Binder will be purchased and used so that families do not take the original survey results. A note will be added to each resident's chart confirming that they understand where and how to receive survey results if needed or wanted.
2. An announcement will be made so that each resident is reminded that we have the past 3 years survey results available at request or in the lobby of the facility. If a resident requests the binder or a specific year we would comply with their request. A note will be added to each resident chart confirming understanding and satisfaction of the same.
3. Staff will be educated on the fact that a binder is updated and available to anyone who requests to read it in the lobby. This binder will minimally include the last 3 years survey, POC, as well as complaint visits if substantiated.
4. An audit will be done weekly x2 and monthly x2 on the residents who expressed concern to ensure they remember and have access to the DOH Binder. The results of this audit will be discussed in facility QAPI meeting.

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