Inspection·March 27, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect one of three residents (R2) from physical abuse by another resident, in a sample of seven. FINDINGS INCLUDE: The facility policy, Abuse Prevention and Reporting, dated (approved) 09/2024 directs staff, 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. Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Physical abuse is the infliction of injury on a resident that occurs other than by accidental means that requires medical attention. Physical abuse includes hitting, slapping, pinching, kicking and controlling behavior through corporal punishment. The facility Report to State Office, dated 3/8/2025 at 6:00 A.M. and signed by V1/Administrator documents,(R3) alleges (he) was struck by another resident (R2). Injuries: 2 CM (Centimeter) laceration to left forearm. Residents were immediately separated. Laceration assessed and treated by nurse. Responsible party, MD (Medical Doctor), Police and Ombudsman notified. The facility form dated 3/10/2025 and signed by R3 documents, (R3) states that he was sitting in his wheelchair and (R2) threw something across the room then went over and hit (R3) with his crutches. The facility form dated 3/10/2025 and signed by R2 documents, (R2) stated that he got into his chair and went over to (R3) and hit him three times with his crutch. (R2) stated he did it because (R3) was making snoring noises the night before when (R2) was trying to play his game. The facility Original Allegation: Peer to Peer form, dated (final) 3/11/2025 documents, Review of facility investigation documents, (R2) is a [AGE] year old resident with diagnosis to include Chronic Diastolic Heart Failure, COPD (Chronic Obstructive Pulmonary Disease), Nonrheumatic Aortic Valve Insufficiency, Alcohol Abuse, Essential Hypertension, Acquired Absence of Right Leg Above Knee, Rheumatic Tricuspid Insufficiency, Chronic Kidney Failure Stage 3 and Major Depressive Disorder. (R3) is a [AGE] year old resident with diagnosis to include Paranoid Schizophrenia, COPD, Depression, Intellectual Disabilities and Anxiety Disorder. It was reported to (V2/Administrator) an altercation between (R2) and (R3) while in their room. (R2 and R3) were immediately separated and assessed. Responsible parties, Physician, Law Enforcement and Ombudsman notified. (R3) noted to have a 5 CM (Centimeter) X .5 CM abrasion to left forearm. Area cleansed and dressed per MD (Medical Doctor) orders. No psychological changes noted to either (R2 or R3). Investigation initiated. Resident interviews were (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 3 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 03/27/2025 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)