F 0600
Level of Harm - Minimal harm
or potential for actual harm
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment,
and neglect by anybody.
Based on observation, interview, and record review the facility failed to prevent resident to resident physical
abuse for one resident (R3) of three residents reviewed for abuse in the sample of 3.
Residents Affected - Few
The Findings include:
Comprehensive Cognitive Assessment indicates R3 is moderately impaired and has diagnosis of Mild
Intellectual Disabilities.
Incident Investigation Report dated 6/6/25 at 2:45pm indicates R3 was asked if someone hit her and R3
responded, Yes. My Roommate.
Incident Investigation Report dated 6/6/25 at 2:45pm indicates R2 denied hitting R3 and stated that if she
did, she didn't mean to.
On 6/6/25 at 2pm, R3 was lying in bed and when asked if her previous roommate (R2) had ever hit her. R3
responded Yes. When asked where she was hit, R3 made eye contact and stated, All over. R3 denied being
physically hurt.
According to resident Census/Room assignments, both R2 and R3 were roommates until 5/28/25 when R2
was moved to another room on the same hall. R3 did not have another roommate after 5/28/25.
Current Comprehensive Assessment indicates R2 is independent with mobility.
Current Care Plan indicates R2 prefers to have a private room and has been manipulative and rude to past
roommates (Revised 10/4/24).
Current Comprehensive Assessment indicates R3 is total assist with transfers via mechanical lift and only
has limited use of her right arm; Hemiplegia/Hemiparesis affecting left side.
Social Service Progress Note dated 5/28/25 at 9:38am indicates R2 and guardian were notified and in
agreement with the room move due to roommate preferences.
Progress Note dated 5/29/25 at 2:48pm indicates R2 was noted to have behaviors of delusional thinking
regarding their roommate. Intervention added of room move.
Social Service Progress Note dated 5/28/25 at 9:41am indicates R3 and POA (Power of Attorney) notified
of room move due to resident preference for window side of room.
(continued on next page)
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:
145615
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
145615
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/11/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Allure of Sterling
612 West St Mary's Street
Sterling, IL 61081
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 0600
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
On 6/10/25 at 3pm V7, LPN (Licensed Practical Nurse) stated I don't remember who told me. I did hear
(R2) was on (R3's) bed and that (R2) hit (R3). V7 stated she heard it as gossip and stated she didn't know if
it was true or not. V7 stated, I heard in passing that's why (R3) was moved.
On 6/10/25 at 2:45pm V2, ADON (Assistant Director of Nursing) stated she heard R2 was on R3's side of
the room before they were moved.
On 6/11/25 at 7:15pm V8, LPN stated R2 was found on R3's side of the room insisting it was R2's side.
On 6/6/25 at 3:25pm V3, SSD (Social Service Director) denied R2 was moved to another room due to the
alleged altercation of R2 and R3.
Progress Notes did not include any documentation regarding a potential physical altercation between R2
and R3 or that R2 was insisting R3 was on the wrong side of the room.
Facility Policy/Abuse, Neglect and Exploitation dated 2025 documents:
It is the policy of this facility to provide protections for the heath, welfare and rights of each resident by
developing and implementing written policies and procedures that prohibit and prevent abuse, neglect,
exploitation and misappropriation resident property. Physical Abuse includes, but is not limited to hitting,
slapping, punching, biting and kicking.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145615
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
145615
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/11/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Allure of Sterling
612 West St Mary's Street
Sterling, IL 61081
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 0609
Level of Harm - Minimal harm
or potential for actual harm
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper
authorities.
Based on interview and record review the facility failed to report allegations of abuse to the Abuse
Coordinator for three residents (R1, R2, R3) of three residents reviewed for abuse in the sample of 3.
Residents Affected - Few
Findings include:
Comprehensive Cognitive Assessment indicates R1 is moderately impaired and has diagnosis of Mild
Intellectual Disabilities.
On 6/5/25 at 1:15pm R1 stated (with V1, Administrator present) that [female staff member name] threw her
up against the wall and she hit the left side of her head. R1 stated it hurt, but she didn't cry and there was
no bump or anything. R1 identified [female staff member name] as a night shift CNA (Certified Nurse
Assistant). R1 was unable to state the day/date of this incident.
On 6/6/25 at 11:30am R1 stated (with V5, Hospice RN/Registered Nurse present) that [female staff
member name] got her dressed for bed one night and then threw her against the wall getting her into bed.
R1 stated that she hit the left side of her head It didn't hurt, I didn't cry but it made me mad. R1 stated that
[female staff member name] does not have the temperament for the job and has a bad attitude. R1 stated
that she told V7, LPN (Licensed Practical Nurse) the nurse who comes in the morning and stated V7 told
R1 she would report her concerns.
On 6/10/25 at 10:45am V9, CNA stated that about two weeks ago she was getting R1 out of bed in the
morning and R1 told V9 Thank God it's you, because last night [female staff member name] threw me in the
bed. V9 stated she was pretty sure there wasn't any staff by the name of [female staff member name] and
(R1) talks all the time. V9 stated while she was still assisting R1 - V5, Hospice Nurse came into the room
and V9 asked V5 if she knew who [female staff member name] was and if she had ever heard R1 talk about
her. V5 told V9 that (V5) knew about R1's allegations and that (V5) was handling it.
V9 stated she did not tell V1, Administrator or any other facility staff about R1's allegations. V9
acknowledged even if someone is cognitively impaired their allegations should be reported to their
supervisor or to V1, Administrator.
On 6/5/25 at 3:45pm V5, Hospice RN stated that R1 did tell her that a CNA named [female staff member
name] had been rough while helping her to bed About 3-4 weeks ago and she reported R1's allegations to
V2, ADON (Assistant Director of Nursing) at that time. V5 stated that she believed R1 was referring to V12,
CNA who was usually R1's CNA on night shift. V5 stated she was told that R1 sometimes refers to V12 as
[female staff member name] although that is not V12's name.
On 6/6/25 at 2pm V7, LPN stated she also heard R1 calls V12 by [female staff member name]
On 6/5/25 and again on 6/10/25 V2, ADON denied V5 reported any allegations of abuse to her regarding
R1 or any other resident.
R1 was consistent in her reporting of allegations throughout the investigation. Internal reporting of an
allegation of abuse was not implemented until reported to the V1, Administrator by the State
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145615
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
145615
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/11/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Allure of Sterling
612 West St Mary's Street
Sterling, IL 61081
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 0609
Agency surveyor on 6/5/25.
Level of Harm - Minimal harm
or potential for actual harm
2) Current Comprehensive Assessment indicates R2 is independent with mobility.
Residents Affected - Few
Current Comprehensive Assessment indicates R3 is total assist with transfers via mechanical lift and only
has limited use of her right arm; Hemiplegia/Hemiparesis affecting left side.
According to resident Census/Room assignments - both R2 and R3 were roommates until 5/28/25 when R2
was moved to another room on the same hall.
Social Service Progress Note dated 5/28/25 at 9:38am indicates R2 and guardian notified and in
agreement with room move due to roommate preferences.
Progress Note dated 5/29/25 at 2:48pm indicates R2 noted to have behaviors of delusional thinking
regarding roommate. Intervention added of room move.
Social Service Progress Note dated 5/28/25 at 9:41am indicates R3 and POA (Power of Attorney) notified
of room move due to resident preference for window side of room.
On 6/10/25 at 3pm V7, LPN stated, I don't remember who told me - I did hear (R2) was on (R3's) bed and
that (R2) hit (R3). V7 stated she heard it as Gossip and stated she didn't know if it was true or not. V7
stated, I heard in passing, that's why (R3) was moved.
On 6/10/25 at 2:45pm V2, ADON stated that she did hear that R2 was on R3's side of the room before they
were moved.
On 6/6/25 at 2pm, R3 was lying in bed and when asked if her previous roommate (R2) had ever hit her - R3
responded Yes. When asked where she was hit, R3 stated, All over. R3 denied being physically hurt.
Progress Notes did not include any documentation regarding a potential physical altercation between R2
and R3.
No internal reporting of R2 being physically aggressive with R3 was made until 6/6/25 when State Agency
surveyor reported the allegation to V13, Regional Nurse Consultant.
Facility Policy/Abuse, Neglect and Exploitation dated 2025 documents:
It is the policy of this facility to provide protections for the health, welfare and rights of each resident by
developing and implementing written policies and procedures that prohibit and prevent abuse, neglect,
exploitation and misappropriation resident property.
The facility will have written procedures that include:
Reporting of alleged violations to the Administrator, state agency, adult protective services and to all other
required agencies within specified timeframe's:
Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation
involve abuse or result in serious bodily injury.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145615
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
145615
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/11/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Allure of Sterling
612 West St Mary's Street
Sterling, IL 61081
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 0609
The facility will provide ongoing oversight and supervision of staff in order to assure that its policies are
implemented as written.
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145615
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
145615
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/11/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Allure of Sterling
612 West St Mary's Street
Sterling, IL 61081
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 0610
Respond appropriately to all alleged violations.
Level of Harm - Minimal harm
or potential for actual harm
Based on interview and record review the facility failed to protect one resident (R1) from further potential
abuse for 1 of three residents reviewed for abuse in the sample of 3.
Residents Affected - Few
Findings include:
On 6/5/25 at 1:15pm R1 stated (with V1, Administrator present) that [female staff member name] threw her
up against the wall and she hit the left side of her head. R1 stated it hurt, but she didn't cry and there was
no bump or anything. R1 identified [female staff member name] as a night shift CNA (Certified Nurse
Assistant).
On 6/6/25 at 11:30am R1 stated (with V5, Hospice RN/Registered Nurse present) that [female staff
member name] got her dressed for bed one night and then threw her against the wall getting her into bed.
R1 stated that she hit the left side of her head, It didn't hurt, I didn't cry but it made me mad. R1 stated that
[female staff member name] does not have the temperament for the job and has a bad attitude. R1 stated
that she told V7, LPN (Licensed Practical Nurse) the nurse who comes in the morning and stated V7 told
R1 she would report her concerns. R1 never referred to the CNA in question [female staff member name]
by any other name. R1 stated she could not recall if [female staff member name] cared for her after the
incident or not.
On 6/10/25 at 11:45am V7 denied R1 reported being thrown into bed [female staff member name]. V7
stated R1 usually just sits next to her and talks non-stop has a very soft voice and is difficult to understand
at times. V7 stated R1 may have thought she told V7, But I might not have really been listening.
On 6/10/25 at 10:45am V9, CNA stated that about two weeks ago she was getting R1 out of bed in the
morning and R1 told V9 Thank God it's you, because (last night) [female staff member name] threw me in
the bed. V9 stated she was pretty sure there wasn't any staff by that name and (R1) talks all the time. V9
stated while she was still assisting R1 - V5, Hospice Nurse came into the room and V9 asked V5 if she
knew who [female staff member name] was and if she had ever heard R1 talk about her. V5 told V9 that
(V5) knew about R1's allegations and that (V5) was handling it.
V9 stated she did not tell V1, Administrator or any other facility staff about R1's allegations. V9
acknowledged even if someone is cognitively impaired their allegations should be reported to their
supervisor or to V1, Administrator.
On 6/5/25 at 3:45pm V5, Hospice RN stated that R1 did tell her that a CNA named [female staff member
name] had been rough while helping her to bed About 3-4 weeks ago and she reported R1's allegations to
V2, ADON (Assistant Director of Nursing) at that time. V5 stated she did look at R1's head and did not find
any signs of injury. V5 stated that she believed R1 was referring to V12, CNA who was usually R1's CNA on
night shift. V5 stated she was told that R1 sometimes refers to V12 as [female staff member name] although
that is not V12's name.
On 6/6/25 at 2pm V7, LPN stated she also heard R1 calls V12 [female staff member name].
Current list of all nursing staff employed at the facility were reviewed and no staff named [female staff
member name] was identified.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145615
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
145615
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/11/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Allure of Sterling
612 West St Mary's Street
Sterling, IL 61081
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 0610
On 6/5/25 at 1:15pm V1, Administrator stated the facility does not utilize CNA Agency staff.
Level of Harm - Minimal harm
or potential for actual harm
On 6/5/25 at 3:55pm V1 confirmed that V12 had quit yesterday due to an assignment dispute.
Residents Affected - Few
Human Resources: Change in Status Form indicates V12 Walked out and quit on 6/4/25 and was
terminated from employment at that time.
Prior to 6/4/25 - Time Card Reports indicate V12 remained working at the facility on Night shift until 6/4/25.
V5, Hospice Nurse stated she reported R1's allegation to V2, ADON 3-4 weeks ago, V2 denied receiving
the allegation from V5.
V9, CNA stated that R1 reported the allegation to her approximately 2 weeks ago and V9 did not report
R1's allegation to any facility staff.
V12, CNA was not suspended pending investigation and continued to work primarily as R1's CNA until
6/4/25.
Facility Policy/Abuse, Neglect and Exploitation dated 2025 documents:
It is the policy of this facility to provide protections for the health, welfare and rights of each resident by
developing and implementing written policies and procedures that prohibit and prevent abuse, neglect,
exploitation and misappropriation resident property.
Protection of Resident:
The facility will make all efforts to ensure all residents are protected from physical and psychosocial harm,
as well as additional abuse, during and after the investigation. Examples include but are not limited to:
Responding immediately to protect the alleged victim and integrity of the investigation;
Examining the alleged victim for any sign of injury, including a physical examination or psychosocial
assessment if needed;
Increased supervision of the alleged victim and residents.
Room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator;
Protect from retaliation;
Providing emotional support and counseling to the resident during and after the investigation, as needed.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145615
If continuation sheet
Page 7 of 7