Inspection visit
Inspection
12 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 12 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview, and record review, the facility failed to provide wound care treatment as
prescribed by the physician and in manner to promote resident comfort. This failure applies to 1 of 1 (R126)
residents in the sample of 13.
Residents Affected - Few
The findings include:
R126's Transfer/Discharge Report (Face Sheet) showed an admission date of 4/25/23, with diagnoses to
include: venous insufficiency, obesity, right artificial hip joint.
On 5/2/23 at 2:20 PM, R126 had a dressing to her right hip, left calf, and right calf. R126 was alert and
oriented to person, place, time, and her condition. V4, Licensed Practical Nurse (LPN), entered R126's
room to provide wound care. V4 provided wound care to R126's right hip and completed the care at 2:30
PM. V4 then proceeded to R126's right leg wound. Prior to removing the right leg dressing, R126 asked if
V4 was going to soak the dressing prior to removal; V4 did not respond. After V4 removed R126's right leg
dressing she applied an antimicrobial/petroleum based gauze dressing. V4 covered this dressing with an
absorbent pad and gauze wrap. V4 completed the right leg dressing change at 2:48 PM. At 2:53 PM, prior
to starting the left leg dressing change, R126 stated the left leg was her most painful leg, and she again
asked V4 to soak the dressing prior to removal. V4 did not respond. R126 stated soaking the dressing with
saline solution allows the dressing to come off more easily, and with less pain. V4 did not soak R126's left
leg dressing and began removing the dressing. As V4 removed the antimicrobial/petroleum dressing, the
dressing was adhered to an open area on R126's left outer shin area. As V4 reached this area R126 yelled
Owww. R126 shut her eyes covered her face, and again asked V4 to soak the dressing. V4 soaked the area
with wound cleanser and attempted to remove the dressing; R126 again yelled Owww. R126 stated other
nurses soak it with water, let it soak for a time, then remove the dressing. At 3:12 PM, V4 returned to
R126's room with saline solution, soaked the wound, and removed the dressing. V4 again applied a
antimicrobial/petroleum based dressing; then absorbent pad; then covered with a gauze wrap. V4
completed the wound care at 3:30 PM. (An hour and 10 minutes later.)
On 5/03/23 at 8:44 AM, R126 stated, I've never had a dressing change hurt like that before, at least not
since I was in the hospital. I told her to soak the dressing. That makes the dressings come off so much
easier. The other nurse that does the dressing change on nights will soak the dressing and they come right
off and it doesn't hurt. If she had offered me a pain pill before the dressing change, I wouldn't have
accepted it, because it never hurt like that before. All the nurses should know how to take care of my
dressing. There was an agency nurse that did my dressing change, and she was even aware of soaking the
dressing. I think she was aware of it because of how badly the dressing change went yesterday. Normally,
they can change all three dressings in about 20 minutes; that took too long. Yes, all nurses should know
how to do my dressing changes and they should know to soak both
(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:
146147
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
146147
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/04/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Allure of Stockton
501 Front Street
Stockton, IL 61085
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 0684
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
legs dressing to make it less painful. I did tell her many times to soak the dressings. Normally they soak
them before they remove them, long before it gets to the point of it hurting.
On 5/03/23 at 1:31 PM, V2, Director of Nursing, stated dressing changes can be painful because the
wounds are sensitive and inflamed. V2 stated some techniques to minimize pain during dressing changes
are to pre-medicate with pain medication; moisten the dressing; and to remove the dressing slowly and
gently. V2 stated if a resident requested the dressing be soaked prior to removal. she would check for an
order to do so. and if there was not order, she would obtain the order. V2 stated while reviewing R126's
wound care orders, V4 should have applied the antimicrobial/petroleum dressing as well as a second
petroleum only dressing. V4 stated the additional petroleum based dressing could aid in the dressing
removal, and possibly be more comfortable for the resident.
R126's Medication Review Report (Physician Order Sheet) showed an active order starting on 4/26/23 to
apply a antimicrobial/petroleum based dressing as well as a petroleum only based dressing.
The facility's Wound Treatment Management policy (Implemented 9/2021) showed, Wound treatments will
be provided in accordance with physician orders, including the cleansing method, type of dressing, and
frequency of dressing change . The policy showed, Treatment decisions will be based on .Goals and
preferences of the resident .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146147
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
146147
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/04/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Allure of Stockton
501 Front Street
Stockton, IL 61085
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 0755
Level of Harm - Minimal harm
or potential for actual harm
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a
licensed pharmacist.
Based on observation, interview, and record review, the facility failed administer the correct dose of an
antipsychotic medication and failed to notice an antipsychotic medication on the floor of the facility.
Residents Affected - Few
This applies to 1 resident (R15) outside the sample.
The findings include:
On 5/2/23 at 2:00 PM, a white and brown, oblong capsule was seen on the floor next to the medication cart
parked by the dining area. The medication cart showed the only resident in the facility taking that
medication was R15.
The blister card listed that medication as Thiothixene 5 mg (milligrams) with 2 capsules in each blister.
R15's Face Sheet showed her diagnoses includes, schizoaffective bipolar type, anxiety and dementia with
agitation.
R15's 5/2023 POS (Physician Order Sheet) shows, she (R15) is ordered Thiothixene 5 mg, 2 capsules, by
mouth, every morning for schizoaffective disorder.
On 5/4/23 at 10:20 AM, V1 (Administrator) said, (R15) is the only resident to get Thiothixene, and if a pill
was found on the floor, it means she didn't get her full dose. V1 said it's important to administer medications
as ordered by the Physician so the resident can get the full benefits from the medication.
On 5/4/23 at 11:15 AM, V5, RN (Registered Nurse), said, The nurse should inspect the med cup before
giving the cup to the resident to make sure all pills made it into the cup. The Nurse should inspect the med
cart surface and the floor for accidental spills of medication and waste any dropped medication, so no other
residents take medication not prescribed to them.
The 9/2021 Medication Administration Policy and Procedure shows, the MAR (Medication Administration
Record) should be reviewed to identify all medication to be administered, all medications should be
administered 60 minutes prior or after scheduled time, and all medication should be administered as
ordered by a Physician.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146147
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
146147
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/04/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Allure of Stockton
501 Front Street
Stockton, IL 61085
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 0759
Ensure medication error rates are not 5 percent or greater.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview, and record review, the facility failed to administer medications at ordered
times. There were 27 opportunities with 9 errors, resulting in a 33.33% medication error rate.
Residents Affected - Some
This applies to 4 of 4 residents (R7,R15,R28,R126) observed in the medication pass.
The findings include:
1) R7's electronic face sheet printed on 5/3/23 showed R7 has diagnoses including but not limited to heart
disease, major depressive disorder, hypertension, and venous insufficiency.
R7's medication administration record (MAR) for May 2023 showed R7 receives Carvedilol 25mg and
Sacubitril-Valsartan 97-103mg at 8AM and 5PM.
On 5/2/23 at 9:35AM, V4 (Licensed Practical Nurse-LPN) administered R7's Carvedilol 25mg and
Sacubitril-Valsartain 97-104mg. (1 hour and 35 minutes past the scheduled administration time)
On 5/2/23 at 9:40AM, V4 stated, My whole screen is red and I'm late on all of my remaining medications. I
was busy this morning doing skin checks and wound treatments so that is why I am late giving medications.
I probably should have prioritized my time better but there's nothing I can do about it now.
2) R15's electronic face sheet, printed on 5/3/23, showed R15 has diagnoses including but not limited to
altered mental status, major depressive disorder, schizoaffective disorder, disorder or psychological
development, anxiety disorder, and dementia with agitation.
R15's MAR for May 2023 showed R15 receives amantadine 100mg and oxcarbazepine 600mg at 8AM and
8PM, benztropine 0.5mg, lithium 150mg, and Haldol 1mg at 8AM and 5PM.
On 5/2/23 at 10:14AM, V5 (Registered Nurse) administered R15's amatadine 100mg, benztropine 0.5mg,
Haldol 1mg, lithium 150mg, and oxcarbazepine 600mg. (2 hours and 14 minutes past the scheduled
administration time)
3) R28's electronic face sheet, printed on 5/3/23, showed R28 has diagnoses including but not limited to
anxiety disorder, psychotic disorder, and major depressive disorder.
R28's MAR for May 2023 showed R28 receives Dilantin 100mg at 8AM, 12PM, and 8PM.
On 5/2/23 at 9:41AM, V4 administered R28's Dilantin 100mg. (1 hour and 41 minutes past the scheduled
administration time)
4) R126's electronic face sheet, printed on 5/2/23, showed R126 has diagnoses including but not limited to
hypertension, venous insufficiency, acute cystitis, and severe sepsis.
R126's MAR for May 2023 showed R126 receives Potassium Chloride 10meq at 8AM and 5PM.
On 5/2/23 at 10:03AM, V4 administered R126's Potassium Chloride 10meq. (2 hours and 3 minutes past
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146147
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
146147
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/04/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Allure of Stockton
501 Front Street
Stockton, IL 61085
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 0759
the scheduled administration time)
Level of Harm - Minimal harm
or potential for actual harm
On 5/3/23 at 11:41AM, V2 (Director of Nursing) stated, Medications administered over 1 hour before or 1
hour after their scheduled time would be considered a medication error. (V4, LPN) did inform me of the late
medications yesterday, but she notified the physician, so we thought that would be sufficient. I didn't realize
she was that late on administering medications. She can always let us know so that a nursing supervisor
can help her pass medications.
Residents Affected - Some
The facility's policy titled, Medication Administration, dated 09/2021, showed, Medications are administered
by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the
physician and in accordance with professional standards of practice .11. Compare medication source with
MAR (Medication Administration Record) to verify resident name, medication name, form, dose, route, and
time .b. Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by a
physician .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146147
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
146147
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/04/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Allure of Stockton
501 Front Street
Stockton, IL 61085
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
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 label food items, failed to ensure a
functional thermometer was utilized in two freezers, and failed to maintain a freezer to prevent ice buildup.
These failures have the potential to affect all residents in the building.
The findings include:
The Resident Census and Condition Report, dated 5/2/23, showed 29 residents residing in the building.
On 5/2/23 at 8:59AM, The facility's standing freezer located in the dry storage room had an unlabeled fast
food cup full of a pink frozen substance and 2 packages of unlabeled food. The thermometer in the freezer
was unable to measure an accurate temperature, due to the scale line being broken and tilted, giving an
inaccurate temperature reading. The freezer shelves were all lined with thick blocks of ice and packed full of
bags of frozen food items. There was no additional room in the freezer and bags were falling off shelves
during observation.
On 5/2/23 at 9:09AM, containers of brown sugar, butter, and peanut butter were placed in a cabinet
underneath the food preparation area. All 3 containers had no label showing the contents or date on them.
On 5/2/23 at 9:20AM, the facility's free-standing freezer had 2 packs of unlabeled meat with no date, 3 bags
of breaded meat that were unlabeled, and 1 bag of hamburger patties that did not have a date on it and
was opened. The thermometer for the freezer was buried under 4 packs of bread and covered in ice. V3
(Dietary Manager) dug the thermometer out of the freezer and chipped the ice off the outside of the
thermometer. V3 stated the thermometers should be in working condition, and able to be easily read to
ensure that the freezers are at the appropriate temperature.
On 5/2/23 at 10:45AM, V3 stated the freezers should be free of ice buildup to allow adequate cooling and
freezing in the freezer. V3 stated if too much ice builds up, then the freezer will shut down and the food will
not be kept frozen. V3 stated all food items should be labeled with a received date and when they are
opened; that date and a use by date should be put on the package or container. V3 stated all items should
have a label with what the item is so all staff know what they are pulling form the refrigerator or freezer to
cook, and it will help them know how to thaw and prepare the food.
The facility's policy titled, Food Safety Requirements, dated 09/2021, showed, It is the policy of this facility
to procure food from sources approved or considered satisfactory by federal, state and local authorities.
Food will also be stored, prepared, distributed, and served in accordance with professional standards for
food service safety .c .Practices to maintain safe refrigerated/frozen storage include: i. Monitoring food
temperatures and functioning of the equipment daily and at routine intervals during all hours of operation.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146147
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
146147
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/04/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Allure of Stockton
501 Front Street
Stockton, IL 61085
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 provide incontinence care to
prevent cross-contamination. This failure applies to 1 of 2 residents (R11) in the sample of 13.
Residents Affected - Few
The findings include:
R11's Transfer/discharge Report (Face Sheet) showed and original admission date of 7/28/2020, with
diagnoses to include: Alzheimer's disease, diabetes, and overactive bladder.
R11's 4/6/23 Minimum Data Set (MDS) showed she had moderate cognitive impairment with a brief
interview for mental status score (BIMS) of 12 out of 15. The MDS showed R11 required extensive
assistance of two staff for toilet use to include cleaning herself after elimination. The MDS showed she was
always incontinent of bowel and bladder.
R11's Medication Review Report (Physician Orders Sheet) showed an active order for an antibiotic to
prevent urinary tract infections (UTIs).
On 5/02/23 at 1:13 PM, R11 stated, I have had many UTIs (urinary tract infections). I'm not sure the last
time I had one.
On 5/02/23 at 10:28 AM, V6 and V7 Certified Nursing Assistants (CNAs) provided incontinence care for
R11. While providing incontinence care, V7 wiped a bowel movement (BM) from R11's buttocks with a
washcloth. Without changing gloves, V7 then touched R11 as well as R11's clean brief with the same
gloved hand used to wipe the bowel movement.
On 5/03/23 at 1:31 PM, V2, Director of Nursing, stated, The purpose of glove use is to protect us (staff) and
the resident from cross-contamination. I would agree that when gloves are grossly contaminated, removing
gloves is an easy way to remove a lot of contamination and should be followed up with hand hygiene.
During incontinence care, staff should change gloves after wiping a BM prior to touching any clean surface
including the resident. This is to prevent contamination of those surfaces.
The facility's Helping a Resident with Toileting Needs policy (implemented 9/2021) showed .If the resident
needs help with wiping when finished, put on new gloves. Help with wiping .removed your gloves and
dispose of them in the trash bag .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146147
If continuation sheet
Page 7 of 7
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Back to topCitations
12 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.
F880 - Infection Control
Provide and implement an infection prevention and control program.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F759 - Medication Errors
Ensure medication error rates are not 5 percent or greater.
- 0324GeneralS&S Epotential for harm
Provide properly protected cooking facilities.
- 0345GeneralS&S Fpotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
- 0351GeneralS&S Epotential for harm
Install an approved automatic sprinkler system.
- 0353GeneralS&S Fpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0363GeneralS&S Epotential for harm
Install corridor and hallway doors that block smoke.
F712 - Frequency of physician visits
Have simulated fire drills held at unexpected times.
F923 - Have adequate outside ventilation by means of windows, or mechanical
Have proper medical gas storage and administration areas.
FAQ · About this visit
Common questions about this visit
What happened during the May 4, 2023 survey of ALLURE OF STOCKTON?
This was a inspection survey of ALLURE OF STOCKTON on May 4, 2023. The surveyor cited 12 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at ALLURE OF STOCKTON on May 4, 2023?
Yes, 12 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide and implement an infection prevention and control program."
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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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.