Inspection·February 28, 2025

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 interview and record review the facility failed to protect a high risk resident from physical abuse for one of three residents (R1) reviewed for abuse in a sample of three. Residents Affected - Few Findings include: The facility's Abuse Prevention and Reporting policy, revised 09/2024, documents that the facility affirms the right of our resident it be free from abuse, neglect, exploitation, misappropriation, of property, deprivation of goods and services by staff or mistreatment. A resident to resident altercation should be reviewed as potential situation of abuse. Resident to resident altercations that include any willful action that results in physical injury, mental anguish or pain must be reported in accordance with regulations. R1's electronic medical record documents the following diagnosis: bipolar, anxiety, depression, attention deficit hyperactivity disorder, traumatic brain injury, insomnia, and pseudobulbar affect. R1's Abuse/Neglect Screening, dated 1/27/25, documents a score of 6, indicating R1 is a high risk for abuse. R1's current care plan documents that R1 is at high risk for abuse/neglect as noted from the Abuse Screening. R1's goal is to be free from abuse/neglect through the next review. R1's abuse intervention documents to provide a safe and secure environment. R2's current electronic medical record documents the following diagnosis: traumatic brain injury, paranoid personality, moderate intellectual disabilities, major depression, insomnia, alcohol abuse, and bipolar personality. R1's Progress Notes, dated 1/10/25, documents that R1 was sitting at a table in the dining room, when R2 approached R1 and made contact with his open hand to R1's face. R1 and R2 were separated and assessed. Neither R1 nor R2 had any injuries. R2's Progress Notes, dated 1/10/25, documents that R2 approached R1 during a verbal altercation and made contact with R1's hand to R2's face. R1 told R2 I bet you won't hit me. R2 then made contact with R1's face. Both parties were immediately separated and assessed. No injuries were noted. All parties were notified of the incident and interventions were put into place. The facility's Final Abuse Investigation Report, dated 1/17/25, documents that on 1/10/25 there was a resident to resident altercation between R1 and R2. Both residents were immediately separated and (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 2 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 02/28/2025 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)