Elyria, OH

Wesleyan Village

1-star overall rating with 1-star inspections with $219,798 in total fines with 3 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle

807 West Ave, Elyria, OH

(440) 284-9000

Compare this facility

Overall

1 / 5

CMS overall stars

Health inspections

1 / 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

Certified beds

Average residents

Average occupied residents

Ownership

Non-Profit

Publicly displayed owner type

Chain

No chain reported

Operator or chain grouping

Approved since

1967-05-01

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Changed ownership

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

0.32

Registered nurse staffing · state 0.63 · national 0.68

LPN hours / resident day

1.26

Licensed practical nurse staffing · state 0.96 · national 0.87

Aide hours / resident day

2.08

Nurse aide staffing · state 2.14 · national 2.35

Total nurse hours

3.66

All reported nurse hours · state 3.72 · national 3.89

Licensed hours

1.58

RN + LPN hours · state 1.59 · national 1.54

Weekend hours

3.32

Weekend nurse staffing · state 3.29 · national 3.43

Weekend RN hours

0.19

Weekend registered nurse coverage · state 0.41 · national 0.47

Physical therapist

0.02

Reported PT staffing · state 0.05 · national 0.07

Adjusted RN hours

0.26

CMS adjusted RN staffing hours

Adjusted total hours

2.97

CMS adjusted total nurse staffing hours

Case-mix index

1.68

Higher values indicate more complex resident acuity

RN turnover

83%

Annual RN turnover · state 47% · national 45%

Total nurse turnover

76%

Annual nurse turnover · state 50% · national 46%

SNF VBP

Value-based purchasing

Program rank

9,541

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

Performance score

23.35

Composite VBP score used to determine payment impact.

Payment multiplier

0.9831

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

1.84

Baseline 22.11% · Performance 20.92% · Measure score 1.84 · Achievement 1.10 · Improvement 1.84

Healthcare-associated infections

3.77

Baseline 6.61% · Performance 6.71% · Measure score 3.77 · Achievement 3.77 · Improvement 0

Total nurse turnover

Baseline 74.13% · Performance 73.33% · Measure score 0 · Achievement 0 · Improvement 0

Adjusted total nurse staffing

3.73

Baseline 3.56 hours · Performance 4.14 hours · Measure score 3.73 · Achievement 3.73 · Improvement 2.11

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	10.44%	10.72% 0.3 pts better	No Different than the National Rate · Eligible stays 68 · Observed rate 8.82% · Lower 95% interval 6.81%
Discharge to community	52.26%	50.57% 1.7 pts better	No Different than the National Rate · Eligible stays 62 · Observed rate 46.77% · Lower 95% interval 42.07%
Medicare spending per beneficiary	1.15	1.02 0.1 pts worse
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 26 · Denominator 26
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 26
Discharge self-care score	Not Available	53.69%	Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly.
Discharge mobility score	Not Available	50.94%	Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly.
Pressure ulcers or injuries, new or worsened	3.85%	2.29% 1.6 pts worse	Numerator 1 · Denominator 26 · Adjusted rate 3.22%
Healthcare-associated infections requiring hospitalization	6.71%	7.12% 0.4 pts better	No Different than the National Rate · Eligible stays 35 · Observed rate 5.71% · Lower 95% interval 3.78%
Staff COVID-19 vaccination coverage	8.08%	8.2% 0.1 pts worse	Numerator 16 · Denominator 198
Staff flu vaccination coverage	0%	42% 42 pts worse	Numerator 0 · Denominator 198
Discharge function score	Not Available	56.45%	Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly.
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator 18 · 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	1.9	1.8 0.1 pts worse	1.9 About the same	Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 2.3 · Expected 2.2 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	3.1	1.8 1.3 pts worse	1.8 1.3 pts worse	Long Stay · 20240701-20250630 · Adjusted 3.1 · Observed 3.3 · Expected 1.8 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	73.3%	92.4% 19.1 pts worse	93.4% 20.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 60.5% · Q2 76.9% · Q3 80.0% · Q4 75.3% · 4Q avg 73.3%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	91.7%	94.5% 2.8 pts worse	95.5% 3.8 pts worse	Long Stay · 2024Q3-2025Q2 · 4Q avg 91.7%
Percentage of long-stay residents experiencing one or more falls with major injury	3.9%	3.3% 0.6 pts worse	3.3% 0.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 3.8% · Q3 6.2% · Q4 3.9% · 4Q avg 3.9% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	47.6%	26.1% 21.5 pts worse	11.4% 36.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 26.2% · Q2 50.0% · Q3 54.2% · Q4 59.1% · 4Q avg 47.6%
Percentage of long-stay residents who lose too much weight	7.9%	6.2% 1.7 pts worse	5.4% 2.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 10.4% · Q2 7.1% · Q3 10.4% · Q4 3.2% · 4Q avg 7.9%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	24.6%	25.4% 0.8 pts better	19.6% 5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 26.1% · Q2 20.8% · Q3 25.0% · Q4 27.0% · 4Q avg 24.6%
Percentage of long-stay residents who received an antipsychotic medication	14.9%	11.5% 3.4 pts worse	16.7% 1.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 16.0% · Q2 14.3% · Q3 11.6% · Q4 17.4% · 4Q avg 14.9% · 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	0.0%	7.7% 7.7 pts better	16.3% 16.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	1.6%	6.2% 4.6 pts better	14.9% 13.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.1% · Q3 1.6% · Q4 1.7% · 4Q avg 1.6% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.0%	0.2% 0.2 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	0.0%	0.5% 0.5 pts better	1.7% 1.7 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 new or worsened bowel or bladder incontinence	33.8%	21.7% 12.1 pts worse	19.8% 14 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 35.0% · Q2 32.6% · Q3 37.4% · Q4 29.9% · 4Q avg 33.8%
Percentage of long-stay residents with pressure ulcers	3.8%	3.7% 0.1 pts worse	5.1% 1.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 3.8% · Q3 3.7% · Q4 3.9% · 4Q avg 3.8% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	50.6%	78.1% 27.5 pts worse	81.7% 31.1 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 45.9% · Q2 45.6% · Q3 52.2% · Q4 59.6% · 4Q avg 50.6%
Percentage of short-stay residents who had an outpatient emergency department visit	15.7%	12.5% 3.2 pts worse	12.0% 3.7 pts worse	Short Stay · 20240701-20250630 · Adjusted 15.7% · Observed 16.0% · Expected 11.4% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	2.2%	1.2% 1 pts worse	1.6% 0.6 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 0.0% · Q3 0.0% · Q4 4.3% · 4Q avg 2.2% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	57.7%	75.6% 17.9 pts worse	79.7% 22 pts worse	Short Stay · 2024Q3-2025Q2 · 4Q avg 57.7%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	25.3%	25.1% 0.2 pts worse	23.9% 1.4 pts worse	Short Stay · 20240701-20250630 · Adjusted 25.3% · Observed 24.0% · Expected 22.6% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-02-27 · Fire 2025-02-27

3 health deficiencies

Top issue: Quality of Life and Care (2 deficiencies)

1 fire-safety deficiencies

Top issue: Smoke (1 deficiency)

Cycle 2 Health 2022-05-16 · Fire 2022-05-16

33 health deficiencies

Top issue: Quality of Life and Care (13 deficiencies)

7 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Cycle 3 Health 2019-05-09 · Fire 2019-05-09

18 health deficiencies

Top issue: Quality of Life and Care (7 deficiencies)

9 fire-safety deficiencies

Top issue: Smoke (5 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-02-27

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-03-14

F · Potential for more than minimal harm 2024-06-12

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2024-07-30

F · Potential for more than minimal harm 2022-05-16

K222 · Egress Deficiencies

Fire Safety

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

Corrected 2022-07-21

F · Potential for more than minimal harm 2022-05-16

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2022-07-21

F · Potential for more than minimal harm 2022-05-16

K362 · Smoke Deficiencies

Fire Safety

Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.

Corrected 2022-07-21

F · Potential for more than minimal harm 2022-05-16

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2022-07-21

E · Potential for more than minimal harm 2022-05-16

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2022-07-21

E · Potential for more than minimal harm 2022-05-16

K541 · Services Deficiencies

Fire Safety

Install properly constructed and protected linen or trash chutes.

Corrected 2022-07-21

F · Potential for more than minimal harm 2019-05-09

E1 · Emergency Preparedness Deficiencies

Fire Safety

Establish an Emergency Preparedness Program (EP).

Corrected 2019-06-14

F · Potential for more than minimal harm 2019-05-09

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2019-06-14

F · Potential for more than minimal harm 2019-05-09

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2019-06-14

E · Potential for more than minimal harm 2019-05-09

K293 · Egress Deficiencies

Fire Safety

Have properly located and lighted "Exit" signs.

Corrected 2019-06-14

E · Potential for more than minimal harm 2019-05-09

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2019-06-14

E · Potential for more than minimal harm 2019-05-09

K342 · Smoke Deficiencies

Fire Safety

Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.

Corrected 2019-06-14

E · Potential for more than minimal harm 2019-05-09

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2019-06-14

E · Potential for more than minimal harm 2019-05-09

K372 · Smoke Deficiencies

Fire Safety

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

Corrected 2019-06-14

E · Potential for more than minimal harm 2019-05-09

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2019-06-14

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-02-27

F584 · Resident Rights Deficiencies

Health

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Corrected 2025-03-14

D · Potential for more than minimal harm 2025-02-27

F791 · Quality of Life and Care Deficiencies

Health

Provide or obtain dental services for each resident.

Corrected 2025-03-14

D · Potential for more than minimal harm 2025-02-27

F825 · Quality of Life and Care Deficiencies

Health

Provide or get specialized rehabilitative services as required for a resident.

Corrected 2025-03-14

E · Potential for more than minimal harm 2024-12-11

F725 · Nursing and Physician Services Deficiencies

Health

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Corrected 2024-12-26

D · Potential for more than minimal harm 2024-12-11

F692 · Quality of Life and Care Deficiencies

Health

Provide enough food/fluids to maintain a resident's health.

Corrected 2024-12-26

D · Potential for more than minimal harm 2024-12-11

F755 · Pharmacy Service Deficiencies

Health

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected 2024-12-26

D · Potential for more than minimal harm 2024-12-11

F757 · Pharmacy Service Deficiencies

Health

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Corrected 2024-12-26

D · Potential for more than minimal harm 2024-12-11

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2024-12-26

D · Potential for more than minimal harm 2024-08-26

F677 · Quality of Life and Care Deficiencies

Health

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected 2024-09-05

D · Potential for more than minimal harm 2024-08-26

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 2024-09-05

J · Immediate jeopardy 2024-06-27

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2024-07-17

J · Immediate jeopardy 2024-06-27

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2024-07-17

J · Immediate jeopardy 2024-06-27

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2024-07-17

G · Actual harm 2024-06-27

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2024-07-17

G · Actual harm 2024-06-27

F690 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Corrected 2024-07-17

F · Potential for more than minimal harm 2024-06-27

F725 · Nursing and Physician Services Deficiencies

Health

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Corrected 2024-07-17

F · Potential for more than minimal harm 2024-06-27

F838 · Administration Deficiencies

Health

Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.

Corrected 2024-07-17

D · Potential for more than minimal harm 2024-06-27

F584 · Resident Rights Deficiencies

Health

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Corrected 2024-07-17

D · Potential for more than minimal harm 2024-06-27

F694 · Quality of Life and Care Deficiencies

Health

Provide for the safe, appropriate administration of IV fluids for a resident when needed.

Corrected 2024-07-17

D · Potential for more than minimal harm 2024-04-16

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2024-04-24

D · Potential for more than minimal harm 2024-04-16

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2024-04-24

D · Potential for more than minimal harm 2024-04-16

F677 · Quality of Life and Care Deficiencies

Health

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected 2024-04-24

D · Potential for more than minimal harm 2024-04-16

F806 · Nutrition and Dietary Deficiencies

Health

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Corrected 2024-04-24

D · Potential for more than minimal harm 2024-03-04

F691 · Quality of Life and Care Deficiencies

Health

Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.

Corrected 2024-03-18

F · Potential for more than minimal harm 2023-12-20

F725 · Nursing and Physician Services Deficiencies

Health

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Corrected 2024-01-08

D · Potential for more than minimal harm 2023-12-20

F550 · Resident Rights Deficiencies

Health

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected 2024-01-08

D · Potential for more than minimal harm 2023-12-20

F690 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Corrected 2024-01-08

J · Immediate jeopardy 2023-11-03

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 2024-01-08

E · Potential for more than minimal harm 2023-11-03

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 2024-01-08

F · Potential for more than minimal harm 2022-05-16

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 2022-07-20

E · Potential for more than minimal harm 2022-05-16

F761 · Pharmacy Service Deficiencies

Health

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Corrected 2022-07-20

D · Potential for more than minimal harm 2022-05-16

F561 · Resident Rights Deficiencies

Health

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Corrected 2022-07-20

D · Potential for more than minimal harm 2022-05-16

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 2022-07-20

D · Potential for more than minimal harm 2022-05-16

F677 · Quality of Life and Care Deficiencies

Health

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected 2022-07-20

D · Potential for more than minimal harm 2022-05-16

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2022-07-20

D · Potential for more than minimal harm 2022-05-16

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 2022-07-20

D · Potential for more than minimal harm 2022-05-16

F693 · Quality of Life and Care Deficiencies

Health

Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

Corrected 2022-07-20

D · Potential for more than minimal harm 2022-05-16

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2022-07-20

D · Potential for more than minimal harm 2022-05-16

F810 · Nutrition and Dietary Deficiencies

Health

Provide special eating equipment and utensils for residents who need them and appropriate assistance.

Corrected 2022-07-20

D · Potential for more than minimal harm 2022-05-16

F921 · Environmental Deficiencies

Health

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Corrected 2022-07-22

C · Minimal harm 2022-05-16

F577 · Resident Rights Deficiencies

Health

Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.

Not marked corrected

E · Potential for more than minimal harm 2019-05-09

F585 · Resident Rights Deficiencies

Health

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.

Corrected 2019-06-14