Inspection visit
Health inspection
4 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 4 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0567
Honor the resident's right to manage his or her financial affairs.
Level of Harm - Minimal harm
or potential for actual harm
Based on record review and interview the facility failed to ensure funds were available for 100 of 100
residents (R2, R4, R5, R7-R10, R12-R104) reviewed for personal funds in a sample of 104.
Residents Affected - Some
Findings include:
The facility's Resident Funds Policy, dated 3/2024, documents Resident Funds- Guidelines: This facility
manages the personal funds of residents when such request is made by the resident. Access to Personal
Funds: Residents should have access to petty cash on an ongoing basis and be able to arrange for access
to larger funds. Although the facility need not maintain 100.00 dollars (50.00 dollars for Medicaid residents)
per resident on its premises, it is expected to maintain petty cash on hand to honor resident requests.
Banking hours shall be posted in a visible area and indicate where inquiries should be directed during the
posted hours. Resident request for access to their funds should be honored by facility staff as soon as
possible but not later than: The same day for amounts less than 100.00 dollars (50.00 dollars for Medicaid
residents); Three banking days for amounts of 100.00 dollars (50.00 dollars for Medicaid residents) or more.
A facility Email dated 11/25/24 and sent by V7/Regional Financial Coordinator to V8/Vice President of
Accounts Receivable, documents Good afternoon, can we (the facility) request for the cash box to be
increase to 2000.00 dollars. We have a lot of residents here that take out a lot of money and go out
shopping. Please advise. On 12/17/24 at 1:00PM V7 was unable to provide a response from V8 to the email
that was sent.
On 12/17/24 at 10:30 AM R10 was lying in his bed in his room. R10 stated, I am the resident council
president. Everyone, including myself, is complaining about the facility not giving us our money when we
ask. The banking hours at the facility used to be every Tuesday and Thursday. Now I only can only ask once
a week, and they only are giving me and other residents 10 dollars at a time. V4/Business Office Manager
told me that they don't have enough money in (the facility's) account to give us any more than that since the
facility changed ownership on November 1st, 2024. One week, V4/Business Office Manager only gave us
four dollars because they didn't have enough money. I would like to buy gifts for Christmas for people and
can't because I can't access all my money. They (the facility) don't even go shopping for us with our money
now, because they (the facility) don't have enough in the account. It's very upsetting.
On 12/17/24 at 10:40 AM R4 was sitting in a recliner across from the nurse's station. R4 stated, They (the
facility) keeps holding our money and stating that they don't have that money to give us. It's my money, I
should be able to ask for it. I haven't been able to get the money I have requested since November 1st,
2024. They changed the banking hours, so I don't even know when I can request money. They (the facility)
only have given me ten dollars per week or sometimes four dollars. I wanted
(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 9
Event ID:
145418
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
12/20/2024
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 0567
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
to buy a Christmas present for my husband, and I am upset I haven't been able to do so because I can't
have my money. No one gives me an explanation why I cannot have access to my own money, just that they
(the facility) don't have it.
On 12/17/24 at 10:45 AM R5 was standing in the hallway with his wheeled walker. R5 stated, I am
supposed to receive 60 dollars per month. The facility's banking used to be twice a week on Tuesday and
Thursdays. Now it's only once a week and it's when they come tell me they have money but can only give
me ten dollars. V3/Business Office Manager tells me not to worry that the money is in our account that is
ours, but they just can't give it to us. This has been going on for a month and a half and I would like to have
money to buy soda, snacks, and other things I need. I am really upset about not getting my own money.
On 12/17/24 at 10:47 AM R9 was sitting in the dining room. R9 stated she has not had access to her
money for the past month or so. R9 stated she would like to have her money to buy pop.
On 12/17/24 at 10:48 AM R9 stated, I didn't get my bank money as scheduled. It upsets me because my
family is coming for a nice holiday meal tomorrow and I couldn't buy any gifts with my money.
12/17/24 at 11:00 AM R3 stated that her guardian manages her finances but that she has friends at the
facility who are not getting their money when requested. R3 stated a few weeks ago, they would only be
allowed to receive two dollars, then five dollars and last week they were permitted to withdraw ten dollars.
R3 stated her friends have been upset because they would like to buy personal items and Christmas gifts
but are not able to.
On 12/17/24 at 11:16 AM R6 stated he receives 60 dollars a month which is held in a trust by the facility. R6
stated they used to be able to bank twice weekly, but recently, it has only been less. R6 stated banking is
sometimes once a week because they don't have enough money and the most they can receive is ten
dollars.
12/17/24 at 11:18 AM R7 stated, This new company doesn't have money from the old company. (This new
company) hasn't got it together yet.
On 12/17/24 at 11:20 AM V6/Social Service Director stated, I was responsible for getting shopping lists
from the resident's and going shopping for them. I have not been able to go shopping for any residents
since the facility ownership change on November 1st, 2024, because we (the facility) do not have enough
money in the petty cash fund to go shopping for the residents. Tons of resident's have asked me to go
shopping and I told them I cannot go shopping for them at this time and I direct them to the Business
Office.
On 12/17/24 at 11:30 AM V4/BOM (Business Office Manager) stated, The facility changed ownership on
November 1st, 2024. V4 stated the last company took all the resident funds from the cash box on October
28th, 2024, leaving us with no funds for the residents. It took two weeks for us (the facility) to receive a
check for the resident's trust fund. The first check was in the amount of 500 dollars, which we needed 1500
dollars to 2000 dollars for the size of this facility and all the resident's funds we manage. If a resident asks
for 30 dollars, we are not allowed to give it to them because we (the facility) do not have the funds. We (the
facility) were only able to give four dollars to the residents one week, and the past two weeks we were able
to give ten dollars each week. We (the facility) still do not have enough money in the trust fund account to
give the residents any money today either. We (the facility) used to do banking hours on Tuesdays and
Thursdays, now its whenever we
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145418
If continuation sheet
Page 2 of 9
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
12/20/2024
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 0567
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
receive a check for the trust fund account which has only been once a week. Last week we (the facility) did
bank on Friday. I have not been told why we are unable to get more money for the trust fund account.
On 12/17/24 at 11:40 AM V3/BOM stated, We (the facility) did bank with the residents on Tuesday's and
Thursday's. That is no longer happening since November 1st, 2024, when the facility changed ownership.
We only have been doing banking one time a week and it depends on the day and when we receive the
check. We have not had enough funds to give the resident's the money they request so we limited giving
them ten dollars per week. I know one week we were only able to give the resident's four dollars.
On 12/17/24 at 12:05 PM V1/Administrator stated, The disbursement of cash to the resident's changes
since our new company took over and the new company didn't account for the 130 resident that reside at
the facility. We are still trying to get it all straightened out.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145418
If continuation sheet
Page 3 of 9
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
12/20/2024
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.
Based on interview and record review the facility failed to report an allegation of employee to resident
sexual abuse to the State Agency and to Law Enforcement of one resident (R1) of three residents reviewed
for abuse.
Findings include:
Facility Policy/Abuse Prevention and Reporting dated 09/2024 documents:
The purpose of this policy is to assure that the facility is doing all that is within its control to prevent
occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services
by staff and mistreatment of residents.
This will be done by:
Filing accurate and timely investigative reports.
Sexual Abuse is non-consensual sexual contact of any type with a resident.
Sexual Abuse includes, but is not limited to:
Unwanted intimate touching of any kind especially of breasts or perineal area.\
Generally, sexual contact is nonconsensual if the resident either:
Lacks ability to consent and/or does not want the contact to occur.
Internal Reporting Requirements and Identification of Allegations:
Upon learning of the report, the administrator or a designee shall initiate an incident investigation.
Any allegation of abuse or any incident that results in serious bodily harm or injury will be reported to the
State Agency immediately, but not more than two hours after the allegation of abuse.
External Reporting/Initial Reporting of Allegations:
When an allegation of abuse, exploitation, neglect, mistreatment or misappropriation of resident property
has occurred, the resident's representative and State Agency's Regional Office shall be informed by
telephone or fax. Public Health shall be informed that an occurrence of potential abuse, neglect,
exploitation, mistreatment or misappropriation of resident property has been reported and is being
investigated.
Informing Law Enforcement:
The facility shall also contact local law enforcement authorities in the following situations:
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145418
If continuation sheet
Page 4 of 9
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
12/20/2024
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
Sexual Abuse of a resident by a staff member, another resident, or visitor.
Level of Harm - Minimal harm
or potential for actual harm
The term immediately as it is used in this policy in relation to reporting abuse, neglect exploitation,
mistreatment, misappropriation of resident property, and suspicion of a crime shall be defined as, following
management of the immediate risk to the resident or resident involved or not later than two hours after
forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than
24 hours if the events that cause suspicion do not result in serious bodily injury.
Residents Affected - Few
On 12/17/24 at R1 stated V21, LPN (Licensed Practical Nurse) came into my room wanting to do a room
search for missing hand sanitizer. R1 stated he told V21 that he had to go to the bathroom and went into
the bathroom, pulled his pants down to his knees and sat on the toilet. R1 stated V21 came into the
bathroom and patted down his pants while he was sitting on the toilet and inappropriately touched his groin
area. R1 stated I was telling her to get out. I reported it to the Ombudsman and to the State. All the nurses
know what happened.
Progress Note dated 12/14/24 at 4:57pm indicates V21, LPN (Licensed Practical Nurse) found the hand
sanitizer missing from the medication cart. Note indicates R1 has a history of ingesting hand sanitizer. Note
indicates (V21) entered (R1) room to see if the hand sanitizer was in there and it wasn't. (R1) denied having
the hand sanitizer and the room was searched. Hand sanitizer was not found.
On 12/19/24 at 3:20pm V2, DON (Director of Nursing) confirmed the following written statements were
obtained and submitted to her on 12/14/24 following the above incident:
V21, Agency LPN This nurse left the dining area and came back to my medication cart and noticed the
hand sanitizer was missing off the cart. This nurse went to (R1) bedroom and asked (R1) if he had seen the
hand sanitizer. (R1) stated 'No, you can search my room.' (R1) went into the restroom. This nurse and (V19,
CNA) searched the room. Hand sanitizer was not found.
V18, CNA (Certified Nurse Assistant) 12/14/24 at 5pm I asked (R1) why he wasn't coming to out to the
evening meal and (R1) stated 'Because the nurse (V21) grabbed my shit.' Later I overheard (R1) talking to
(V20, Family) who was telling (R1) that (V21) would be suspended.
V19, CNA indicated (V21, Nurse) told me that the sanitizer was missing off her cart. (R1) refused to let
(V21) search his room then ran into the bathroom so (V21) and I searched (R1's) room and then (V21)
knocked and entered (R1's) bathroom and lightly patted (R1's) pants pockets. At no time was (R1)
unclothed nor were any other parts touched.
On 12/18/24 at 2:30pm V18, CNA stated I went to ask (R1) if he was coming to dinner, his room smelled
very strongly of hand sanitizer. (R1) said he used the sanitizer on the nurses' cart. I was in the hallway
when (V21, LPN) and (V19, CNA) went into search (R1) room. Afterwards (R1) was on the phone with
(V20, Family). (R1) was upset and said (V21, LPN) grabbed him in his private area. I thought (V19 and V21)
had it under control so I didn't report it to anyone else.
On 12/18/24 at 1:15pm V20, Family stated that R1 called her the evening of 12/14/24 to report that he had
been touched inappropriately during a search for hand sanitizer. V20 stated she then contacted V17,
Admissions Liaison and reported the incident to V17. V20 stated she received a phone text at 7:02pm
indicating that V21, LPN had been walked out of the facility by V2, DON.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145418
If continuation sheet
Page 5 of 9
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
12/20/2024
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
On 12/18/24 at 1:45pm V17, Admissions Liaison stated that on 12/14/24 she received a phone call from
V20, Family, who was upset and reported that a nurse (V21) had burst into the bathroom when R1 was
sitting on the toilet, searched his pants and also searched under (R1's) scrotum. V17 stated she told V20 to
call the State Agency and report the incident. V17 stated I then immediately called and reported what I'd
been told to (V1, Interim Administrator). (V1) told me (V2, DON) was coming to the facility to remove the
employee (V21). I did specifically tell (V1) that (R1) said (V21) inappropriately touched (R1's) genitals. I felt
that was unacceptable.
On 12/18/24 at 1:25pm V6, Social Service Director stated she received a call from V9, Ombudsman between 8 and 830am on 12/17/24 to report R1's allegation against V21, LPN that occurred on 12/14/24.
V6 stated she then immediately called V1 and then called V2, DON.
On 12/19/24 at 11:30am V9, Ombudsman confirmed reporting R1's allegation of being inappropriately
touched by V21 to V6 on the morning of 12/17/24.
ON 12/18/24 at 2:30pm V2, DON stated she received a call the night of 12/14/24 from V1, Administrator
and was told to get statements related to an incident that occurred with R1 and to report back to V1.
V2 stated she went to talk to R1 about ingesting the hand sanitizer to determine how much he ingested in
order to call Poison Control. V2 stated she was focused on the medical aspect of ingesting hand sanitizer at
the time.
V2 stated she called V1 back and V1 told me it was a behavioral issue. V2 stated I thought since none of
the statements indicated inappropriate touching, it was just behavioral.
On 12/17/24 and on 12/19/24 V1, Interim Administrator stated she initially completed a grievance and not
an actual reported allegation of sexual abuse because she wasn't aware of R1's allegations of abuse until
reported by a State Surveyor at approximately 1:45pm on 12/17/24. V1 did confirm receiving a phone call
from V17 on 12/14/24 and did receive a report on V2's interviews with staff on 12/14/24.
Preliminary 24-hour Abuse Investigation Report indicates:
The facility has received a report of Sexual Abuse of a resident by an employee. The Report identifies R1
as the resident allegedly abused.
On 12/19/24 at 1:44pm The State Regional Office confirmed receipt of the facilities/R1's Initial Abuse
Investigation Report on 12/17/24 at 2pm.
Incident/Sexual Abuse allegation was made R1 at approximately 5pm on 12/14/24. This allegation was
reported to V18, CNA and V17, Admissions Liaison on 12/14/24. V17 stated that she informed V1, Interim
Administrator of the nature of the allegation on 12/14/24.
Report to the State Regional Office was not made until 12/17/24 at 2pm. No evidence was provided
indicating Law Enforcement was notified.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145418
If continuation sheet
Page 6 of 9
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
12/20/2024
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 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) after an allegation of
employee to resident sexual abuse was reported for three residents reviewed for abuse.
Residents Affected - Few
Findings include:
Facility Policy/Abuse Prevention and Reporting dated 09/2024 documents:
The purpose of this policy is to assure that the facility is doing all that is within its control to prevent
occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services
by staff and mistreatment of residents.
This will be done by:
Immediately protecting residents involved in identified reports of possible abuse, neglect, exploitation,
mistreatment and misappropriation of property.
Protection of Residents:
The facility will take steps to prevent potential abuse while the investigation is underway.
Employees of the facility who have been accused of abuse, neglect, exploitation, mistreatment or
misappropriation of resdient property will be removed from resdient contact immediately.
The employee shall not be permitted to return to work until the results of the investigation have been
reviewed by the administrator and it is determined that any allegation of abuse, neglect, exploitation,
mistreatment or misappropriation of resdient property is unsubstantiated.
On 12/17/24 at R1 stated V21, LPN (Licensed Practical Nurse) came into his room wanting to do a room
search for missing hand sanitizer (12/14/24). R1 stated he told V21 that he had to go to the bathroom and
went into the bathroom, pulled his pants down to his knees and sat on the toilet. R1 stated V21 came into
the bathroom and patted down his pants while he was sitting on the toilet and inappropriately touched his
groin area. R1 stated I was telling her to get out. I reported it to the Ombudsman and to the State. All the
nurses know what happened. R1 stated V21 was walked out of the facility that night, but then came back
and was his nurse the next day.
Progress Note dated 12/14/24 at 4:57pm indicates V21, LPN (Licensed Practical Nurse) found the hand
sanitizer missing from the medication cart. Note indicates R1 has a history of ingesting hand sanitizer. Note
indicates (V21) entered (R1) room to see if the hand sanitizer was in there and it wasn't. (R1) denied having
the hand sanitizer and the room was searched. Hand sanitizer was not found.
On 12/18/24 at 2:30pm V18, CNA stated I went to ask (R1) if he was coming to dinner, his room smelled
very strongly of hand sanitizer. (R1) said he used the sanitizer on the nurses cart. I was in the hallway when
(V21, LPN) and (V19, CNA) went into search (R1) room. Afterwards (R1) was on the phone with (V20,
Family). (R1) was upset and said (V21, LPN) grabbed him in his private area.
On 12/18/24 at 1:15pm V20, Family stated that R1 called her the evening of 12/14/24 to report that he had
been touched inappropriately during a search for hand sanitizer. V20 stated she then
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145418
If continuation sheet
Page 7 of 9
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
12/20/2024
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 0610
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
contacted V17, Admissions Liaison and reported the incident to V17. V20 stated she received a phone text
at 7:02pm indicating that V21, LPN had been walked out of the facility by V2, DON.
On 12/18/24 at 1:45pm V17, Admissions Liaison stated that on 12/14/24 she received a phone call from
V20, Family, who was upset and reported that a nurse (V21) had burst into the bathroom when R1 was
sitting on the toilet, searched his pants and also searched under (R1's) scrotum. V17 stated she told V20 to
call the State Agency and report the incident. V17 stated I then immediately called and reported what I'd
been told to (V1, Interim Administrator). (V1) told me (V2,DON) was coming to the facility to remove the
employee (V21). I did specifically tell (V1) that (R1) said (V21) inappropriately touched (R1's) genitals. I felt
that was unacceptable.
On 12/18/24 at 2:30pm V2, DON stated she received a call the night of 12/14/24 from V1, Administrator
and was told to get statements related to an incident that occurred with R1 and to report back to V1. V2
stated that she did ensure V21 left the facility after the incident. V2 stated nurses are supposed to keep
hand sanitizer locked up on the unit.
V2 stated that V21 did return to work at the facility the following day (12/15/24) and was R1's assigned
nurse (on 12/15/24).
V2 stated that was a scheduling mistake and shouldn't have been allowed to return. V2 stated V21 is no
longer allowed to work at the facility.
Time/Shift Details Report dated 12/14/24 indicates V21 started work on that date at 6am and left the facility
at 6:12pm.
Time/Shift Details Report dated 12/15/24 indicates V21 started work on that date at 5:59am and left the
facility at 6:10pm.
Incident/Sexual Abuse allegation was made by R1 at approximately 5pm on 12/14/24. This allegation was
reported to V18, CNA and V17, Admissions Liaison on 12/14/24. V17 stated that she informed V1, Interim
Administrator of the nature of the allegation on 12/14/24. V21 was escorted out of the facility on 12/14/24,
however was allowed to return and was R1's assigned nurse on 12/15/24.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145418
If continuation sheet
Page 8 of 9
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
12/20/2024
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 0804
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, record review and interview the facility failed to monitor food temperatures to ensure
food was served at a palatable temperature. This failure has the potential to affect all residents that reside
at the facility.
Residents Affected - Many
Findings include:
A facility policy last revised 09/2023 and titled Monitoring Food Temperatures for Meal Service documents,
Food temperatures will be monitored to prevent foodborne illness and ensure foods are served at palatable
temperatures. Procedure: 1. Prior to serving a meal, food temperatures will be taken and and documented
for all hot and cold foods to ensure proper serving temperatures. Any food item not found at the correct
holding/serving temperature will not be served but will undergo the appropriate corrective action listed
below. 2 The temperature for each food item will be recorded on the Food Temperature Log. Foods that
required a a corrective action (such as reheating) will have the new temperature recorded with a notation of
the corrective action intervention.
Resident Council Meeting notes dated November 21, 2024, document, The food is way better and served
hot, but some of the residents said food was still not hot when they received it.
Resident Council Meeting notes dated October 17, 2024, document, Chicken wrap needs to be warm and
soup needs to be warmer.
Resident Council Meeting notes dated September 19, 2024, document, Cold food getting served.
Facility Food temperature logs were not completed for the evening meal for December 4, 2024, through
December 28, 2024. Food temperature log holding temperatures were not documented on any day or meal
between 11/13/24 and 12/18/24 for B and C Halls.
On 12/17/24 at 11:00 AM R3 stated, The food is terrible and cold. When I asked the staff to reheat it, they
refused and said it had to be eaten that way because they wouldn't warm it while they were passing trays.
On 12/17/24 at 12:00 PM, R5 had just had a tray served. V10, Assistant Dietary Manager, used a
thermometer to check the temperature of R5's food items. R5's mashed potatoes registered 108 degrees
Fahrenheit and carrots at 110 degrees Fahrenheit. R5 stated, This is actually warm, it is usually cold,
especially the evening meal.
On 12/18/24 at 12:19 PM V12/Dietary Manager stated that she obtains food temperatures on all food
before it goes out to the residents but The problem that doesn't get addressed is CNAs take some time to
come to serve the trays.
On 12/18/24 at 1:30 PM V12 stated there is a problem with staff obtaining temperatures, but not
documenting. V12 confirmed there are several days with no documentation. V12 further stated that on the
evening shift, CNAs are busy on the halls and food is often delayed in being served, especially on the
weekends, which is why the food is served cold.
A facility roster dated 12/17/24 document there are 132 residents living in the facility. All residents receive
meal trays.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145418
If continuation sheet
Page 9 of 9
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
4 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.
F567 - The resident has a right to manage his or her financial affairs
Honor the resident's right to manage his or her financial affairs.
F609 - The facility must develop and implement written policies and procedures that:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
F610 - In response to allegations of abuse, neglect, exploitation, or mistreatment, the
Respond appropriately to all alleged violations.
F804 - Food and drink
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
FAQ · About this visit
Common questions about this visit
What happened during the December 20, 2024 survey of AVENUES AT ROYAL OAK?
This was a inspection survey of AVENUES AT ROYAL OAK on December 20, 2024. The surveyor cited 4 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at AVENUES AT ROYAL OAK on December 20, 2024?
Yes, 4 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to manage his or her financial affairs."
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
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.