Cycle 1
Health 2025-03-27 · Fire 2025-03-27
2 health deficiencies
Top issue: Infection Control (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Macomb, IL
Elms, The
5-star overall rating with 5-star inspections with 2 recent health deficiencies
1212 Madelyn Avenue, Macomb, IL
(309) 837-5482
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
98
Certified beds
Average residents
70
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2002-09-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.13
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.48
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
3.14
Nurse aide staffing · state 2.13 · national 2.35
Total nurse hours
4.75
All reported nurse hours · state 3.49 · national 3.89
Licensed hours
1.61
RN + LPN hours · state 1.36 · national 1.54
Weekend hours
4.03
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.72
Weekend registered nurse coverage · state 0.56 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
1.13
CMS adjusted RN staffing hours
Adjusted total hours
4.74
CMS adjusted total nurse staffing hours
Case-mix index
1.37
Higher values indicate more complex resident acuity
RN turnover
32%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
31%
Annual nurse turnover · state 46% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,628
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
32.22
Composite VBP score used to determine payment impact.
Payment multiplier
0.9870
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 18.48% · Performance 21.33% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 5.56% · Performance 7.83% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
9.29
Baseline 28.07% · Performance 25.71% · Measure score 9.29 · Achievement 9.29 · Improvement 6.82
Adjusted total nurse staffing
3.6
Baseline 3.37 hours · Performance 4.10 hours · Measure score 3.6 · Achievement 3.6 · Improvement 2.54
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.81% |
10.72%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 107 · Observed rate 12.15% · Lower 95% interval 6.99% |
| Discharge to community | 41.07% |
50.57%
9.5 pts worse
|
Worse than the National Rate · Eligible stays 93 · Observed rate 35.48% · Lower 95% interval 32.82% |
| Medicare spending per beneficiary | 1.24 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 87.1% |
95.27%
8.2 pts worse
|
Numerator 54 · Denominator 62 |
| Falls with major injury | 1.61% |
0.77%
0.8 pts worse
|
Numerator 1 · Denominator 62 |
| Discharge self-care score | 36.73% |
53.69%
17 pts worse
|
Numerator 18 · Denominator 49 |
| Discharge mobility score | 48.98% |
50.94%
2 pts worse
|
Numerator 24 · Denominator 49 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 61 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.83% |
7.12%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 58 · Observed rate 8.62% · Lower 95% interval 4.44% |
| Staff COVID-19 vaccination coverage | 5.08% |
8.2%
3.1 pts worse
|
Numerator 6 · Denominator 118 |
| Staff flu vaccination coverage | 64.8% |
42%
22.8 pts better
|
Numerator 81 · Denominator 125 |
| Discharge function score | 46.94% |
56.45%
9.5 pts worse
|
Numerator 23 · Denominator 49 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 96.97% |
96.28%
0.7 pts better
|
Numerator 32 · Denominator 33 |
| Resident COVID-19 vaccinations up to date | 19.23% |
25.2%
6 pts worse
|
Numerator 5 · Denominator 26 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.2 |
2.0
0.8 pts better
|
1.9
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.2 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.9 |
2.3
0.6 pts worse
|
1.8
1.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.9 · Observed 2.8 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 89.0% |
89.6%
0.6 pts worse
|
93.4%
4.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 91.7% · Q2 90.8% · Q3 81.2% · Q4 92.3% · 4Q avg 89.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
91.6%
8.4 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.5% |
3.3%
0.2 pts worse
|
3.3%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 3.1% · Q3 4.7% · Q4 4.6% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
50.3%
50.3 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 17.6% |
6.5%
11.1 pts worse
|
5.4%
12.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.6% · Q2 17.0% · Q3 26.9% · Q4 17.0% · 4Q avg 17.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.2% |
18.5%
0.7 pts worse
|
19.6%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.0% · Q2 18.5% · Q3 17.3% · Q4 27.8% · 4Q avg 19.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 9.9% |
22.8%
12.9 pts better
|
16.7%
6.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.9% · Q2 9.1% · Q3 7.5% · Q4 7.3% · 4Q avg 9.9% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 18.5% |
17.2%
1.3 pts worse
|
16.3%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.2% · Q2 30.0% · Q3 10.7% · Q4 14.3% · 4Q avg 18.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 17.0% |
15.0%
2 pts worse
|
14.9%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 29.4% · Q3 12.5% · Q4 5.9% · 4Q avg 17.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.0% |
1.1%
0.9 pts worse
|
1.0%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.4% · Q3 2.4% · Q4 4.1% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 8.8% |
1.7%
7.1 pts worse
|
1.7%
7.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 12.5% · Q3 7.8% · Q4 12.5% · 4Q avg 8.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 27.9% |
21.3%
6.6 pts worse
|
19.8%
8.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.8% · Q2 33.3% · Q3 21.8% · Q4 33.2% · 4Q avg 27.9% |
| Percentage of long-stay residents with pressure ulcers | 3.3% |
5.2%
1.9 pts better
|
5.1%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 2.0% · Q3 4.2% · Q4 4.8% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 84.3% |
68.8%
15.5 pts better
|
81.7%
2.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 87.3% · Q3 78.1% · Q4 71.2% · 4Q avg 84.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 25.5% |
14.0%
11.5 pts worse
|
12.0%
13.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.5% · Observed 24.6% · Expected 10.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
2.3%
2.3 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 79.4% |
63.0%
16.4 pts better
|
79.7%
0.3 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 79.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.4% |
26.2%
1.8 pts better
|
23.9%
0.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.4% · Observed 22.8% · Expected 22.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-04-25 · Fire 2024-04-25
8 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
2 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Cycle 3
Health 2023-02-24 · Fire 2023-02-24
3 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-04-25
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2024-05-02
F · Potential for more than minimal harm
2024-04-25
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-05-02
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-03-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-14
D · Potential for more than minimal harm
2025-03-27
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2025-04-15
G · Actual harm
2024-04-25
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-05-10
D · Potential for more than minimal harm
2024-04-25
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-05-14
D · Potential for more than minimal harm
2024-04-25
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-05-14
D · Potential for more than minimal harm
2024-04-25
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-05-10
D · Potential for more than minimal harm
2024-04-25
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-05-10
D · Potential for more than minimal harm
2024-04-25
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2024-05-10
D · Potential for more than minimal harm
2024-04-25
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-05-10
D · Potential for more than minimal harm
2024-04-25
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-05-13
D · Potential for more than minimal harm
2024-01-25
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-02-15
D · Potential for more than minimal harm
2023-02-24
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-03-13
D · Potential for more than minimal harm
2023-02-24
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-03-13
Penalties and ownership
What sits behind the stars
Ownership
Bickers, Gina
Operational/Managerial Control · Individual
County Of Mcdonough Mcdonough County Clerk
5% Or Greater Direct Ownership Interest · Organization
Howd, Jeff
Operational/Managerial Control · Individual
Minter, Richard
Operational/Managerial Control · Individual
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#2
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3-star overall rating with 4-star inspections with 5 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Countryside Care Center
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1-star overall rating with 1-star inspections with $260,571 in total fines with 21 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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