Health inspection·December 4, 2025

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure hairnets were worn in the kitchen, failed to ensure all in-use dishwasher machines reached the required dish surface sanitation temperature during the rinse cycle, failed to ensure opened food items in the refrigerator and freezer were dated and labeled, failed to ensure food items were kept off of the floor in the kitchen, failed to complete and record cool down temperatures for food items that were prepared ahead and stored for future use, and failed to ensure the ceiling in the kitchen was kept clean and free of debris and dust. These failures have the potential to affect all 45 residents residing in the facility.Findings include: The facility's Hairnet Use policy, dated 2/15/24, documents To maintain the highest standards of sanitation and food safety in all dietary service operations at (the facility) and to comply with state and federal food service regulations. All employees, volunteers, students, and contractors working in the dietary services department must wear an approved hairnet or other approved hair restraints at all times while in food production, preparation, service or dishwashing areas. Hairnets must be worn before entering any food handling area.On 12/1/2025 at 10:18 AM, V9 (Dietary Manager) exited the facility's kitchen without a hairnet. V9 then stated before re-entering the kitchen Let me grab a hairnet. On 12/1/2025 at 10:35 AM, V9 confirmed she was in the kitchen without a hairnet earlier in the morning and stated all employees should be wearing a hairnet whenever they enter the kitchen.The facility's Open Food Labeling and Storage policy (undated), documents Purpose: To ensure all food items stored within the facility are safely labeled, dated, and organized to prevent foodborne illness, maintain quality, and comply with healthcare regulatory standards. All opened, prepared, or repackaged food items must be labeled immediately, including bulk items, leftovers, portioned items, drinks, and resident-specific prepared foods. Each label must include: Product name, date opened or prepared, use by/discard date, and staff initials. Foods must be sealed, covered, stored off the floor, and separated properly.The facility's Cooling Food policy (undated), documents To ensure all hot foods requiring cooling are cooled safely and rapidly to prevent bacterial growth and foodborne illness in compliance with healthcare and food safety regulations. This policy applies to all dietary staff who prepare, handle, cool, and store hot foods within the facility. All potentially hazardous foods must be cooled as follows: 135 degrees (Fahrenheit, F) to 70 degrees F within two hours, and 70 degrees F to 41 degrees F within an additional four hours. Total cooling time must not exceed six hours. Foods that require rapid cooling: Soups, stews, sauces, gravies, cooked meats, casseroles, pasta, rice, vegetables, large batches of hot foods, and leftovers intended for reheating. This policy also documents Record temperatures when cooling begins, at two hours, and at six hours or when the 41 degrees F is reached. Once the food reached 41 degrees F, cover it and label with product name, date prepared, discard date, and staff initials.On 12/1/25 at 10:20 AM the facility's kitchen walk in cooler contained open food items that did not contain a label or an open date/date expired. These unlabeled items included a package of chocolate chips, a bag of almonds, a carton of heavy whipping cream, a partial block of butter, and a carton of liquid scrambled eggs. At this time, V9 confirmed the food items were opened and were not labeled. V9 stated Staff should be applying a label when the items are opened and initially placed in the refrigerator.On 12/1/25 at 10:25 AM, the facility's dry storage room contained a large mesh bag of red onions that was resting on the floor at the storage rooms entryway. At this time, V9 picked up the bag of onions and stated These should not be placed here.On 12/1/25 at 10:28 AM, the facility's walk-in freezer contained a large zipper closed bag with a large portion of frozen meat and Turkey, 11/27 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146047 If continuation sheet Page 2 of 3 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 12/04/2025 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 Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete written on the bag. This same freezer contained a second large bag with frozen light brown contents and Turkey Gravy, 11/27 was written on the bag. At this time V9 confirmed the contents of the larger zippered bags were roasted turkey and turkey gravy from 11/27/25 and both items did not contain a label with expiration dates or employee initials.The facility's Cooling Log dated, 11/16/25-11/30/25 does not document any food items were monitored for cool down temperatures on 11/27/25 and does not document any cool down temperatures for roasted turkey or turkey gravy. This same cooling log also documents cool down temperatures were started for ham and bean soup, ground beef, cream of asparagus, pork loin, white chicken chili, cream of chicken soup, and French onion soup. Several of these food items document only an initial time and temperature that cooling was started. All of these recorded food items do not document any cool down temperatures below 90 degrees F.On 12/1/25 at 10:35 AM, V9 confirmed the cool down logs for November do not document temperature recordings for roasted turkey or turkey gravy and stated those items would have been from the recent holiday meal.The facility's Dishwasher Sanitizing policy (undated), documents Machine temperature requirements (High-Temperature Dishwashers). Wash cycle: Minimum 150 degrees (Fahrenheit, F). Final rinse/ sanitize cycle: Minimum 180 degrees F at the dish surface. This policy also documents Record daily wash and rinse temperatures.The facility's Kitchen Deep Cleaning List (undated), documents Dish Area: Clean wall behind dish machine floor to ceiling. Clean wall behind the three-compartment sink floor to ceiling.On 12/1/25 at 10:30 AM the facility's dishwasher machine was running a cycle. V9 stated the machine is a high temperature sanitation machine and that employees check the outside recording to ensure the water gets hot enough. V9 stated I am not sure how we know the external temperature reading is accurate. V9 confirmed that staff are not placing any test strips or thermometers inside of the machine to check the surface temperatures. At this same time the kitchen area that contained the dishwasher became filled with steam abundant to the ceiling. The ceiling directly above the dishwash machine and clean pans, contained ceiling tiles that were bubbled in parts, stained with light brown or gray outlined damage, and areas of grey debris and a grey, fuzzy, dangling, dust-like substance. At this time V9 stated that dishes are removed from dishwasher and then placed on cart racks to dry (below the debris filled ceiling). V9 stated The ceiling is lower in this area so there is a lot of moisture when the dish cycle runs which might be why the dust clings there. On 12/1/25 at 10:40 AM, V10 (Certified Nursing Assistant/Cook) stated she prepares food in the facility's [NAME] neighborhood kitchen with its own private high temperature dishwasher. V10 stated the dishwasher temperatures are monitored from the external reading and there is nothing placed inside to monitor the dish surface temperatures. On 12/1/25 at 11:00 AM, V11 (Cook) stated she prepares food in the facility's Pearson North and Pearson South neighborhood kitchens, and they have their own private high temperature dishwashers. V11 stated the dishwasher temperatures are monitored from the external reading and there is nothing placed inside to monitor the dish surface temperatures. On 12/1/25 at 11:10 AM, V7 (Cook) stated she prepares food in the facility's [NAME] neighborhood kitchen with its own private high temperature dishwasher. V7 stated the temperatures are monitored from the external reading and there is nothing placed inside to monitor the dish surface temperatures. The facility's CMS (Centers for Medicare and Medicaid Services) Long Term Care Facility Application for Medicare and Medicaid Form 671 dated 12/1/25 and signed by V1 (Administrator) documents 45 residents currently reside within the facility. Event ID: Facility ID: 146047 If continuation sheet Page 3 of 3