Inspection visit
Health inspection
5 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 5 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0644
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Coordinate assessments with the pre-admission screening and resident review program; and referring for
services as needed.
Based on interview and record review, the facility failed to notify the state mental health authority to
reevaluate a resident with a significant change in mental status for one of two residents (R20) with a
significant change in mental status in a sample of 31 residents.
Findings include:
The Preadmission Screening and Resident Review (PASRR) policy, no date, documented the policy was
reviewed and updated annually to ensure compliance with CMS regulations and referenced the State
Operations Manual, Appendix PP Guidance to Surveyors for Long Term Care Facilities and State-Specific
PASRR regulations and guidelines. The policy documented the Level 1 screening was conducted by the
nursing facility and did not include guidance for a reevaluation when a resident had a significant change in
condition.
R20's OBRA (PASRR) Initial Screen form dated 5/17/19 documented R20 was not suspected as having a
mental illness and did not require a level 2 screening.
R20's Medical Diagnosis record documented R20 was admitted from another Skilled Nursing Facility on
10/22/2019 with Unspecified Dementia, unspecified severity, without behavioral disturbance, psychotic
disturbances, mood disturbances and anxiety, on 9/8/20 Unspecified Psychosis and on 10/27/21 Anxiety
Disorder.
R20's Minimum Data Set (MDS) section E-Behaviors dated 7/9/20 documented R20 developed physical
and verbal behavior symptoms toward others; 8/20/21 documented R20 had delusions; 12/19/22 had
physical symptoms such as hitting, scratching self, pacing, rummaging, public sexual acts, disrobing,
throwing or smearing food or bodily waste or verbal symptoms like screaming or disruptive sounds and
overall behaviors were worsening.
R20's Care Plan documented on 5/10/23 R20 will be started on tracking for paranoid delusions noted by
believing the facility is holding her hostage and family is trying to get rid of her.
R20's medical record did not include documentation a new referral to the state mental health authority was
made or a reevaluation was conducted by the state mental health authority for a significant change in
mental status.
On 2/20/25 at 2:27 PM, V2 (Director of Nursing) stated R20 was not referred or reevaluated by the state
mental health and should have been revaluated with the change in R20's behavior.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 7
Event ID:
146047
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
146047
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/20/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Wesley Village
1200 East Grant Street
Macomb, IL 61455
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0758
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
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.
Based on observation, interview, and record review the facility failed to have documented rationale or
appropriate diagnosis for the use of an antipsychotic for one (R101) of five residents reviewed for
unnecessary medications in the sample of 31.
Findings include:
The Diagnosis Report for R101, documents the following diagnoses as: Dementia without behavioral
disturbance, psychotic disturbance, mood disturbance, and anxiety and Major depressive disorder, single
episode. R101's medical record does not include any other mental health diagnoses.
The Medication Review Report for R101, dated 2/20/25, documents a physician order as of 2/14/25 for
Quetiapine 25 mg (milligrams) one tablet by mouth at bedtime for depression.
The current Care Plan for R101 documents (R101) is at risk for side effects to psychotropic medications.
R101 was admitted with order for Quetiapine 25mg for depression. Interventions include to monitor for side
effects, effectiveness and to notify physician of any pharmacy recommendations. Pharmacy to review
medication at least monthly and give recommendations.
On 2/18/25 through 2/20/25 between 9:30 am through 3:00 pm R101 exhibited no behaviors to support the
use of an antipsychotic. R101 was pleasant, cooperative, and denied having any psychological issues.
On 2/20/25 at 2:25 pm, V2 DON (Director of Nursing) confirmed R101 is receiving the antipsychotic
medication Quetiapine (Seroquel) for Depression and the diagnosis of Depression is not a clinical rationale
for the use of this medication. V2 DON stated R101 will be discharging tomorrow or (V2) would have called
R101's physician for clarification of the medication. V2 DON stated the facility pharmacist has not yet
reviewed R101's medications.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146047
If continuation sheet
Page 2 of 7
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
146047
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/20/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Wesley Village
1200 East Grant Street
Macomb, IL 61455
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0812
Level of Harm - Minimal harm
or potential for actual harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on observation, interview and record review, the facility failed to ensure safe and sanitary kitchens to
prevent foodborne illnesses. This failure has the potential to affect 48 residents who reside in the facility.
Residents Affected - Many
Findings include:
The Facility Resident Census Roster and Facility Matrix/802, dated 2/18/25, were reviewed. The Census
Roster documented 48 Residents residing in the Facility.
The 1st Shift and 2nd Shift Dietary Aide Responsibilities handout, not dated, instructed the Dietary Aides to
record equipment (dishwashers, freezers and refrigerators) temperatures at 7:00 AM, 11:00 AM and
between 4:30 PM and 4:45 PM.
On 02/18/25 at 9:30 AM through 10:00 AM, Kitchen 1, Kitchen 2, Kitchen 3 and Kitchen 4 were toured with
V5 (Food Service Advisor). The following dishwasher temperature logs, freezer logs and refrigerator logs
indicated temperatures were not monitored three times daily: Kitchen 1 - December 2024, 15 of 31 days
and January 14 of 31 days were missing temperatures; Kitchen 2 - January 2025, 2 of 31 days were
missing temperatures; Kitchen 3 - December 2024, 6 of 31 days, January 2025, 10 of 31 days and
February 2025, 10 of 17 days were missing temperatures; and Kitchen 4 - December 2024, 5 of 31days
and January 2025, 1 of 31 days were missing temperatures. V5 agreed the logs should have been
competed three times daily and had not been.
On 2/20/25 at 1:00 AM, V10 (Dietary Manager) reviewed the dishwasher, freezer and refrigerator
temperature logs for Kitchen 1, Kitchen 2, Kitchen 3 and Kitchen 4 and stated temperatures had not been
monitored as required and should have been monitored three times daily by the Dietary Aide at 7:00 AM,
11:00 AM and between 4:30 PM and 4:45 PM.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146047
If continuation sheet
Page 3 of 7
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
146047
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/20/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Wesley Village
1200 East Grant Street
Macomb, IL 61455
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0849
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
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.
Based on interview and record review, the facility failed to ensure the Hospice's coordinated communication
and required documents were available and accessible to the facility staff. This deficiency affects one of one
resident (R34) reviewed for Hospice care management in a sample of 31 residents.
Findings include:
The Nursing Facility Contract with the Hospice provider, dated 4/20/22, documented
Information/Documentation provided to Facility on admission and on-going: Most recent hospice plan of
care; Hospice election form and any advance directive specific to each patient; Physician certification and
recertification of the terminal illness specific to each patient; Hospice medication information specific to
each patient; Hospice physician and attending physician orders specific to each patient; Copies of clinical
notes after each visit; Instructions on how to access Hospice's 24-hour on-call system; Name and contact
information for hospice personnel involved in care of each patient.
R34's Care Plan documented R34 was admitted to Hospice services on 10/11/24 with a diagnosis of
Atherosclerotic heart disease and lacks specific Hospice responsibilities/interventions.
R34's medical record lacked a Hospice plan of care, Election forms, Physician certification of terminal
illness and/or copies of clinical notes.
On 2/19/25 at 2:05 PM, V14 (Registered Nurse/RN) stated she was the second shift nurse for R34. While
looking through R34's record, V14 stated there should be a Hospice sticker on the front of the chart and a
tab labeled Hospice that has all the Hospice's documentation. V14 confirmed there was no sticker and no
Hospice documentation in R34's medical record and did not know which company provided Hospice care to
R34.
On 2/19/25 at 2:15 PM, V13 (Licensed Practical Nurse/LPN) stated We don't keep Hospice documentation.
On 2/20/25 at 9:55 AM, V4 (Registered Nurse) stated We call the Hospice and verbally give updates and
notify them if there is a change in condition. The Hospice Nurse and Hospice Aide come together twice a
week to give (R34) a bath.
On 2/20/25 at 2:30 PM, V2 (Director of Nursing) stated the Hospice residents should have a Hospice binder
with all the required information in it on the unit and available for staff.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146047
If continuation sheet
Page 4 of 7
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
146047
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/20/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Wesley Village
1200 East Grant Street
Macomb, IL 61455
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview and record review the facility failed to ensure required Personal Protective
Equipment was donned prior to entering a COVID Positive Resident (R33) Room.
Residents Affected - Some
This failure has the potential to affect all 12 residents (R1, R7, R8, R11, R17, R22, R23, R28, R3, R36,
R38, R43) who reside in R33's Household Unit. The facility also failed to follow Enhanced Barrier
Precautions and ensure required Personal Protective Equipment was donned during cares for two residents
(R14 and R29) of 12 residents reviewed for direct cares in a total sample of 31.
Findings include:
1. Facility Policy/COVID-19 Outbreak Investigation and Management dated 1/10/25 documents:
It is the policy of this facility to recognize and contain COVID-19 outbreaks and outbreak measures will be
instituted whenever there is evidence of an outbreak as outlined below.
The Centers for Medicare and Medicaid Services indicates An outbreak is defined as a new COVID-19
infection in any healthcare personnel (HCP) or any nursing home-onset COVID-19 infection in a resident.
To implement immediate response for resident confirmed COVID-19 positive:
Isolation
Full PPE (Personal Protective Equipment) to prevent spread of the COVID-19 outbreak:
Gloves, Gown, Eye protection, N95 mask or higher respirator.
Facility COVID-19 Response Plan dated 5/23/23 documents:
If a resident is suspected or confirmed to have COVID-19, HCP must wear an N95 respirator, eye
protection, gown, and gloves.
Infection Control tracking line list dated 2/2025 indicates R33 was COVID-19 and Influenza A positive on
2/17/25.
On 2/18/25 at 10:50 am V8, CNA (Certified Nurse Assistant) entered and exited R33's room with a
surgical-style mask. Posted on the outside of R33's door were the following signs:
Airborne Precautions - Everyone Must:
Clean their hands, including before and when leaving room.
Put on a fit-tested N95 or higher level respirator (mask) before room entry.
Remove respirator after exiting room and closing door.
Door to room must remain closed.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146047
If continuation sheet
Page 5 of 7
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
146047
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/20/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Wesley Village
1200 East Grant Street
Macomb, IL 61455
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
Contact Precautions - Everyone Must:
Level of Harm - Minimal harm
or potential for actual harm
Clean their hands, including before and when leaving the room.
Provider and Staff must also:
Residents Affected - Some
Put on gloves before room entry. Discard gloves before room exit.
Put on gown before room entry. Discard gown before room exit.
Do not wear the same gown and gloves for the care of more than one person.
On 2/18/25 at 12:45pm V8, CNA donned PPE to bring lunch food items into R33's room. V8 wore a
surgical-style mask into and when exiting R33's room. PPE equipment hanging on the outside of R33's
door did include a supply of N95 respirator masks for staff to utilize.
After exiting R33's room V8 stated that all of the isolation rooms are positive for Influenza A except for R33
as she is both Influenza A and COVID-19 positive. V8 stated We do the same PPE for all of the isolation
rooms.
On 2/19/25 at 11:10am V7, RN (Registered Nurse) stated an N95 mask is required to enter R33's room
because she has COVID. V7 stated the other residents in isolation have Influenza A and staff only need to
wear a surgical mask.
On 2/21/25 at 2:45pm V3, Infection Preventionist stated an N95 mask is required when entering R33's
room.
2. The Facility's undated Enhanced Barrier Precautions policy documents It is the policy of this facility to
implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant
organisms. Enhanced Barrier Precautions refer to an infection control intervention designed to reduce
transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high
contact resident care activities. Initiation of Enhanced Barrier Precautions: a. enhanced barrier precautions
will be initiated for residents with any of the following: ii. Chronic wounds (pressure ulcer stage III & IV,
diabetic foot ulcers and venous ulcers) >6 weeks old, even if resident is not known to be infected or
colonized with a MDRO. iii. Indwelling medical devices (Central Lines, Urinary Catheters, Gastronomy
Tubes, and Tracheotomy), even if resident is not known to be infected or colonized with a MDRO.
The Facility's undated Enhanced Barrier Precautions documents Implementing Contact versus Enhanced
Barrier Precautions has wound or indwelling medical device, without secretions or excretions that are
unable to be covered or contained and are not known to be infected or colonized with any MDRO: Contact
Precautions: no; Enhanced Barrier Precautions: yes. High-contact resident care activities include: g. device
care or use: central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes h. Wound care:
any skin opening requiring a dressing. Enhanced barrier precautions should be used for the duration of the
affected resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling
medical device that placed them at higher risk.
The facility's Enhanced Barrier Precautions signage documents everyone must: clean their hands, including
before and entering and when leaving the room. Providers and staff must also: wear gloves and
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146047
If continuation sheet
Page 6 of 7
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
146047
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/20/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Wesley Village
1200 East Grant Street
Macomb, IL 61455
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
Level of Harm - Minimal harm
or potential for actual harm
a gown for the following high-contact resident care activities: dressing, bathing/showering, transferring,
changing lines, providing hygiene, changing briefs or assisting with toileting, device care or use: central line,
urinary catheter, feeding tube, tracheostomy, wound care: any skin opening requiring a dressing.
R29's Physician Order Sheet dated February 2025 documents Indwelling catheter for neurogenic bladder.
Residents Affected - Some
On 2/19/2025 at 11:30 AM V5 (Certified Nurse Aid) performed catheter care. V5 only used gloves as PPE
(Personal Protective Equipment) during catheter care.
On 2/19/2025 at 1:00 PM V5 (Certified Nurse Aid) confirmed that R29 is in Enhanced Barrier Precautions
and that she should have worn a gown while performing catheter care.
R14's Physician Order Sheet dated February 2025 documents Silver hydrogel ointment to wound and cover
with (gauze dressing) daily and PRN (as needed).
On 2/19/25 at 2:00 PM V7 (Registered Nurse) performed wound care as ordered. V7 only used gloves as
PPE (Personal Protective Equipment).
On 2/19/25 at 2:10 PM V7 (Registered Nurse) confirmed that R14 is in Enhanced Barrier Precautions and
that she (V7) should have worn a gown while performing wound cares.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146047
If continuation sheet
Page 7 of 7
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Back to topCitations
5 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F644 - Coordination
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
F758 - Medication Errors
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.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F849 - Hospice services
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.
F880 - Infection Control
Provide and implement an infection prevention and control program.
FAQ · About this visit
Common questions about this visit
What happened during the February 20, 2025 survey of WESLEY VILLAGE?
This was a inspection survey of WESLEY VILLAGE on February 20, 2025. The surveyor cited 5 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at WESLEY VILLAGE on February 20, 2025?
Yes, 5 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Coordinate assessments with the pre-admission screening and resident review program; and referring for services as neede..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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