Macomb, IL

Wesley Village

3-star overall rating with 4-star inspections with 5 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle

1200 East Grant Street, Macomb, IL

(309) 833-2123

Compare this facility

Overall

3 / 5

CMS overall stars

Health inspections

4 / 5

Survey and complaint cycles

Staffing

1 / 5

RN + nurse staffing

Quality measures

3 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

73

Certified beds

Average residents

49

Average occupied residents

Ownership

Non-Profit

Publicly displayed owner type

Chain

No chain reported

Operator or chain grouping

Approved since

2003-06-15

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

0.00

Registered nurse staffing

LPN hours / resident day

0.00

Licensed practical nurse staffing

Aide hours / resident day

0.00

Nurse aide staffing

Total nurse hours

0.00

All reported nurse hours

Licensed hours

0.00

RN + LPN hours

Weekend hours

0.00

Weekend nurse staffing

Weekend RN hours

0.00

Weekend registered nurse coverage

Physical therapist

0.00

Reported PT staffing

Adjusted RN hours

0.00

CMS adjusted RN staffing hours

Adjusted total hours

0.00

CMS adjusted total nurse staffing hours

Case-mix index

0.00

Higher values indicate more complex resident acuity

RN turnover

0%

Annual RN turnover

Total nurse turnover

0%

Annual nurse turnover

SNF VBP

Value-based purchasing

Program rank

4,739

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

38.77

Composite VBP score used to determine payment impact.

Payment multiplier

0.9918

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

2.97

Baseline 22.01% · Performance 20.29% · Measure score 2.97 · Achievement 2.47 · Improvement 2.97

Healthcare-associated infections

2.12

Baseline 7.58% · Performance 7.20% · Measure score 2.12 · Achievement 2.12 · Improvement 0.97

Total nurse turnover

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Adjusted total nurse staffing

6.54

Baseline 5.14 hours · Performance 4.94 hours · Measure score 6.54 · Achievement 6.54 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	11.81%	10.72% 1.1 pts worse	No Different than the National Rate · Eligible stays 79 · Observed rate 11.39% · Lower 95% interval 8%
Discharge to community	54.76%	50.57% 4.2 pts better	No Different than the National Rate · Eligible stays 61 · Observed rate 55.74% · Lower 95% interval 44.91%
Medicare spending per beneficiary	1.02	1.02 About the same
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 44 · Denominator 44
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 44
Discharge self-care score	12.5%	53.69% 41.2 pts worse	Numerator 4 · Denominator 32
Discharge mobility score	25%	50.94% 25.9 pts worse	Numerator 8 · Denominator 32
Pressure ulcers or injuries, new or worsened	11.36%	2.29% 9.1 pts worse	Numerator 5 · Denominator 44 · Adjusted rate 12.31%
Healthcare-associated infections requiring hospitalization	7.2%	7.12% 0.1 pts worse	No Different than the National Rate · Eligible stays 54 · Observed rate 5.56% · Lower 95% interval 4.02%
Staff COVID-19 vaccination coverage	1.91%	8.2% 6.3 pts worse	Numerator 3 · Denominator 157
Staff flu vaccination coverage	66.44%	42% 24.4 pts better	Numerator 99 · Denominator 149
Discharge function score	25%	56.45% 31.5 pts worse	Numerator 8 · Denominator 32
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly.
Transfer of health information to patient	100%	96.28% 3.7 pts better	Numerator 22 · Denominator 22
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly.

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	0.9	2.0 1.1 pts better	1.9 1 pts better	Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.8 · Expected 1.6 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	2.1	2.3 0.2 pts better	1.8 0.3 pts worse	Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 1.9 · Expected 1.5 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	98.3%	89.6% 8.7 pts better	93.4% 4.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 93.5% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 98.3%
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	5.7%	3.3% 2.4 pts worse	3.3% 2.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 6.7% · Q3 4.8% · Q4 4.7% · 4Q avg 5.7% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	8.8%	50.3% 41.5 pts better	11.4% 2.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 10.9% · Q2 6.8% · Q3 11.9% · Q4 5.1% · 4Q avg 8.8%
Percentage of long-stay residents who lose too much weight	13.0%	6.5% 6.5 pts worse	5.4% 7.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 20.5% · Q2 12.8% · Q3 14.7% · Q4 2.9% · 4Q avg 13.0%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	16.6%	18.5% 1.9 pts better	19.6% 3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 14.6% · Q2 15.0% · Q3 17.1% · Q4 20.0% · 4Q avg 16.6%
Percentage of long-stay residents who received an antipsychotic medication	4.9%	22.8% 17.9 pts better	16.7% 11.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 6.1% · Q3 0.0% · Q4 7.7% · 4Q avg 4.9% · 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	11.8%	17.2% 5.4 pts better	16.3% 4.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 19.5% · Q2 7.3% · Q3 5.4% · Q4 15.9% · 4Q avg 11.8% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	9.2%	15.0% 5.8 pts better	14.9% 5.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 20.5% · Q2 2.7% · Q3 12.1% · Q4 0.0% · 4Q avg 9.2% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.0%	1.1% 1.1 pts better	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% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	4.7%	1.7% 3 pts worse	1.7% 3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 2.3% · Q3 4.9% · Q4 9.5% · 4Q avg 4.7% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	28.2%	21.3% 6.9 pts worse	19.8% 8.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 27.4% · Q2 27.8% · Q3 20.3% · Q4 37.2% · 4Q avg 28.2%
Percentage of long-stay residents with pressure ulcers	3.1%	5.2% 2.1 pts better	5.1% 2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 0.0% · Q3 2.7% · Q4 4.6% · 4Q avg 3.1% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	93.1%	68.8% 24.3 pts better	81.7% 11.4 pts better	Short Stay · 2024Q4-2025Q3 · Q1 84.6% · Q2 95.7% · Q3 98.0% · Q4 91.9% · 4Q avg 93.1%
Percentage of short-stay residents who had an outpatient emergency department visit	10.8%	14.0% 3.2 pts better	12.0% 1.2 pts better	Short Stay · 20240701-20250630 · Adjusted 10.8% · Observed 9.3% · Expected 9.6% · 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	93.8%	63.0% 30.8 pts better	79.7% 14.1 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 93.8%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	31.3%	26.2% 5.1 pts worse	23.9% 7.4 pts worse	Short Stay · 20240701-20250630 · Adjusted 31.3% · Observed 25.6% · Expected 19.5% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-02-20 · Fire 2025-02-20

5 health deficiencies

Top issue: Administration (1 deficiency)

2 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)

Cycle 2 Health 2024-03-20 · Fire 2024-03-20

1 health deficiencies

Top issue: Infection Control (1 deficiency)

5 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Cycle 3 Health 2023-03-09 · Fire 2023-03-09

2 health deficiencies

Top issue: Infection Control (1 deficiency)

4 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-02-20

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2025-03-10

E · Potential for more than minimal harm 2025-02-20

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2025-03-10

F · Potential for more than minimal harm 2024-03-20

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-03-19

F · Potential for more than minimal harm 2024-03-20

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2024-03-19

E · Potential for more than minimal harm 2024-03-20

K133 · Construction Deficiencies

Fire Safety

Install a two-hour-resistant firewall separation.

Corrected 2024-03-19

E · Potential for more than minimal harm 2024-03-20

K271 · Egress Deficiencies

Fire Safety

Have exits that are accessible at all times.

Corrected 2024-04-05

E · Potential for more than minimal harm 2024-03-20

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2024-03-19

F · Potential for more than minimal harm 2023-03-09

E39 · Emergency Preparedness Deficiencies

Fire Safety

Conduct testing and exercise requirements.

Corrected 2023-03-14

F · Potential for more than minimal harm 2023-03-09

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2023-03-14

E · Potential for more than minimal harm 2023-03-09

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2023-03-14

E · Potential for more than minimal harm 2023-03-09

K374 · Smoke Deficiencies

Fire Safety

Install smoke barrier doors that can resist smoke for at least 20 minutes.

Corrected 2023-03-14

Inspection history

Recent health citations

F · Potential for more than minimal harm 2025-02-20

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2025-03-12

E · Potential for more than minimal harm 2025-02-20

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-03-17

D · Potential for more than minimal harm 2025-02-20

F644 · Resident Assessment and Care Planning Deficiencies

Health

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Corrected 2025-03-01

D · Potential for more than minimal harm 2025-02-20

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 2025-03-14

D · Potential for more than minimal harm 2025-02-20

F849 · Administration Deficiencies

Health

Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

Corrected 2025-03-17

F · Potential for more than minimal harm 2024-03-20

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-04-03

E · Potential for more than minimal harm 2023-09-15

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2023-10-05

D · Potential for more than minimal harm 2023-03-09

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 2023-03-20

Penalties and ownership