Health inspection·November 4, 2024

F 0600 Level of Harm - Minimal harm or potential for actual harm Staff should be re-directing R9 and be professional and not engage with any arguments. V1 said it would be considered abuse if an aide called a resident fat, and made comments to a resident about not getting paid enough to clean them up. On 11/2/24 at 1:30 PM, attempts were made to contact V15, without any response. Residents Affected - Few The facility's 10/2022 policy for Abuse prevention and reporting documents this facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. Mental abuse is the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation or degradation. Verbal abuse may be considered to be a type of mental abuse. Verbal abuse includes the use of oral, written, or gestured communication, or sounds to resident within hearing distance, regardless of age, ability to comprehend, or disability. Examples of mental and verbal abuse include, but are not limed to: mocking, insulting, ridiculing. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145418 If continuation sheet Page 2 of 4 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 145418 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avenues at Royal Oak 605 East Church Street Kewanee, IL 61443 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 Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure allegations of abuse were immediately reported to the administrator for 1 of 4 residents (R9) reviewed for abuse in the sample of 9. The findings include: R9's admission record shows she was admitted to the facility on [DATE] with multiple diagnoses including bipolar disorder, borderline personality disorder, other obesity due to excessive calories and polycystic ovarian syndrome. Her 9/2/24 quarterly assessment documents she is cognitively intact with verbal behaviors and other behaviors not directed at others to include verbal yelling out. On 11/2/24 at 11:10 AM, R9 stated she had concerns with her treatment from a night shift CNA (Certified Nursing Assistant), V15. R9 said a couple days ago she started her period for the first time in awhile so she was wearing her underwear to bed. R9 said she put on her call light during the night to use the bedpan, and V15 entered her room to assist her. She said when V15 asked her why she was wearing underwear, she told her about being on her period. R9 said V15 then threw back the covers and said she does not get paid enough to deal with cleaning up someone else's blood. She has also heard the staff calling her big [NAME], and fat. She said V15 makes her feel very insecure. R9 said she was told to fill out a grievance form if she had any issues, but then it seems nothing gets done and the staff find out about the grievance and then has to deal with the drama they cause. R9 said due to the grievances some staff will not even go into her room, or answer her call light. On 11/2/24 at 12:24 PM V11 and V12 CNA's said R9 has complained to staff about verbal abuse but nothing specific, just that it involved V15. V12 said R9 reported to her V15 ignores her call light, and not change her, and call her fat. V11 and V12 said they reported the incidents to V10 (CNA Supervisor) but it does not seem to be addressed. On 11/2/24 at 1:00 PM, V10 (CNA supervisor) said she had not received any reports of verbal abuse towards R9. She had no reports of the previous incident, or the staff calling R9 fat. V10 said if it had been reported to her, she would notify the administrator due to being abusive behavior. On 11/2/24 at 1:40 PM, V14 CNA said she works the night shift and has heard R9 complain about V15, and how she downgrades her and makes her feel less of a person. She said R9 is a large person and has bed sores. She has been walking through the unit and overheard staff being short with R9. V14 said she did not recall reporting any of these concerns to the administrator. She said a lot of staff just seem to take it with a grain of salt, and do not do anything about the staff behavior towards R9. On 11/2/24 at 1:16 PM, V1 Administrator said R9 had not reported any incidents of abuse to her. Staff should be re-directing R9 and be professional and not engage with any arguments. V1 said it would be considered abuse if an aide called a resident fat, and made comments to a resident about not getting paid enough to clean them up. V1 said the previous administrator would advise R9 to fill out a grievance form if she had complaints about her care or staff. V1 said the issues would be addressed whenever she would get to the grievance. The facility's 10/2022 policy for Abuse prevention and reporting documents this facility affirms (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145418 If continuation sheet Page 3 of 4 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 145418 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avenues at Royal Oak 605 East Church Street Kewanee, IL 61443 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 Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. Mental abuse is the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation or degradation. Verbal abuse may be considered to be a type of mental abuse. Verbal abuse includes the use of oral, written, or gestured communication, or sounds to resident within hearing distance, regardless of age, ability to comprehend, or disability. Examples of mental and verbal abuse include, but are not limed to: mocking, insulting, ridiculing. Internal reporting requirements and identification of allegations: Employees are required to report any incident, allegation or suspicion of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property they observe, hear about, or suspect to the administrator immediately, or to an immediate supervisor who must then immediately report it to the administrator. Event ID: Facility ID: 145418 If continuation sheet Page 4 of 4