Health inspection·August 1, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete the other dining room and not the main dining room. On 7/31/25 at 11:33 AM, V2 Assistant Administrator stated she talked to R2 this week and R2 did ask her if I heard about what happened over the weekend. V2 stated she told R2 she would investigate it. V2 stated she talked to V4 who told her she was called this weekend. V4 stated on Friday R2 said she would sit in the dining room/TV room then she got called Saturday because R2 said she didn't want to sit there.On 7/31/25 at 2:12 PM, V9 CNA stated R2 was put in the TV room for breakfast. V5 said R2 had to sit in there and R2 got upset. I didn't see everything but could hear what was going on. V5 said they were told that she is to sit in there. R2 told V5 she talked to the DON, and she could sit in the dining room if she wants to. V5 was being stern, and she was rude to R2. V5 told R2 that it wasn't her job, and she didn't know why this happened. V5 said she could talk to them on Monday. V5 wasn't yelling at R2. This happened on Saturday. I could hear her crying and she was really upset. They were all ignoring her. The nurse and CNAs ignored her. This was right before breakfast was brought out. I went and moved her from the TV room to the smaller tv room on the women's hall.The facility's Residents' Rights policy (11/2018) showed, your rights to dignity and respect: you have the right to make your own decisions. Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life.The Face Sheet Dated 7/31/25 for R2 showed diagnoses including bipolar disorder, chronic obstructive pulmonary disease, type 2 diabetes mellitus, hypothyroidism, necrotizing fasciitis, acute respiratory failure with hypercapnia, primary insomnia, body mass index 70 or greater, intermittent explosive disorder, hypertension, polycystic ovarian syndrome, attention deficit hyperactivity disorder, predominantly inattentive type, other obesity due to excess calories, rheumatoid arthritis, critical illness myopathy, abnormal posture, gastroesophageal reflux disease, type 2 diabetes mellitus with hyperglycemia, blepharitis, vitamin D deficiency, long term use of anticoagulants, anxiety disorder, deep vein thrombosis, major depressive disorder, borderline personality disorder, neuromuscular dysfunction of the bladder, inflammation of vagina and vulva, and psoriasis.The Minimum Data Set, dated [DATE] for R2 showed no cognitive impairment. Event ID: Facility ID: 145418 If continuation sheet Page 2 of 6 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 08/01/2025 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)

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 interviews and record review, the facility's direct care staff failed to notify the abuse coordinator of an injury of unknown origin for one of four residents (R1) reviewed for abuse in a sample of eight.The findings include:R1's face sheet indicated an initial admission date of 03/01/2011 with a past medical history not limited to: paranoid schizophrenia, bipolar disorder, major depressive disorder, mood affective disorder, anxiety, anemia, pruritis, history of shock therapy, and long term (current) use of anticoagulants.R1's care plan indicated but not limited to: risk for injury related to limited dexterity and cognitive impairment and risk for falls with date initiated of 10/02/2023.R1's Minimum Data Set (MDS) section C for cognitive patterns dated 04/13/2025 indicated severe cognitive impairment. R1's skin condition report with effective date of 07/26/2025 submitted by V7 (Licensed Practical Nurse) documented bruising to R1's rear right thigh, chin, front left shoulder, and right front lower leg that were purple in color and a new/change in skin condition.Review of facility reported incidents revealed an initial report for R1 related to a bruise of unknown origin with an incident date of 07/26/2025 that was submitted to Illinois Department of Public Health (IDPH) on 07/28/2025. R1's abuse/neglect screen dated 07/28/2025 indicated R1 is at risk for abuse and/or neglect.R1's hospital after visit summary dated 07/28/2025 indicated R1 was seen by V13 (Medical Doctor) in the emergency department and was diagnosed with chronic iron deficiency anemia, posttraumatic hematoma (localized collection of blood) of right lower extremity, contusion of chin (bruise) and schizoaffective disorder.On 07/31/2025 at 09:55 AM, observed R1 propel herself in a wheelchair out of her room on the A wing. Observed a dark purple colored bruise that measured approximately three centimeters in length and width to the area under R1's chin. R1 was exhibiting verbal outbursts and looking for her babies. R1 was unable to indicate how the bruise occurred. Further assessment was not able to be completed due to R1's behaviors.On 07/31/2025 at 10:03 AM V2 (Administrator in Training) said R1 is currently on 1:1 supervision with staff due to falls. At 10:05 AM, V16 (Licensed Practical Nurse) said R1 is on 1:1 supervision due to a recent change in condition and bruising. On 07/31/2025 at 11:18 AM, V1 (Administrator) said she is the abuse coordinator and reports abuse, allegations to IDPH initially within two hours, then a final report within five days. V1 then said an injury of unknown origin in not investigated as abuse initially, but the facility would submit a report to IDPH in the same timeframe as abuse and would initiate an investigation. On 07/31/2025 at 12:20 PM, V3 (Director of Nursing) said she was first notified about R1's bruising on the morning of 07/28/2025 (Monday). V3 added that she was not informed by staff regarding any incidents involving R1 over the past weekend. V3 said she then assessed R1 and observed dark purple discoloration to R1's chin and neck, right inner and upper thigh, right shin and calf areas, and a hematoma to the right shin. V3 then said due to R1's condition and her inability to explain the cause, R1 was transferred to a local emergency room for further evaluation. At 12:40 PM, V3 indicated that during course of her investigation into R1's bruising, it was determined that staff had observed bruising on R1 on 07/26/2025 but did not report the injury to the supervisor on duty/call. V3 added that staff should have reported the initial bruising to on-call supervisor and administrator, should have been reported to IDPH when discovered.On 07/31/2025 at 01:14 PM, V7 (LPN) said she was informed by the aides on 07/26/2025 of R1's bruising and upon her assessment, V7 observed bruising to R1's chin and throat area that were purple in color. V7 then said she informed V4 (ADON) about R1's bruising that same morning (07/26/2025) and again on the morning of 07/28/2025 (Monday) regarding the worsening and other bruises to R1.On 07/31/2025 at 03:09 PM, V14 (Certified Nursing Assistant) said on 07/26/2025 (Saturday) at around 05:00 AM, she noticed a dark spot under R1's chin that looked deep dark purple in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145418 If continuation sheet Page 3 of 6 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 08/01/2025 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)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete color. V14 said when she changed R1's clothes, she saw a light purple colored bruise on her right shoulder and on her belly, she saw a light purple-blueish colored bruise and small dots to her stomach area. V14 indicated that she informed V7 of her findings.On 07/31/2025 at 03:27 PM, V15 (Certified Nursing Assistant) said she first saw bruising on R1 on 07/26/2025 (Saturday) at around 07:30-07:45 AM. V15 then said the bruising to R1's chin, right and left shins and sides of both legs were purple in color, the right leg was dark purple, and the left was light purple in color. V15 said she reported the bruising to V7 shortly after seeing them. On 07/31/2025 at 03:38 PM, V4 (Assistant Director of Nursing) said she was not informed by V7 on Saturday (07/26/2025) about R1's bruising and was first made aware on the morning of 07/28/2025.On 07/31/2025, facility provided documentation for a facility in-service presented on 07/28/2025 which indicated that all injuries noted during transfers, showers, dressing, etc. must be reported to the nurse, any and all new injuries noted to a resident , including but not limited to bruising, skin tears, lacerations and burns must be documented in a skin-other assessment.if staff cannot ascertain a cause of injury, staff must immediately notify the nursing manager on call; significant injuries of unknown origin are reportable to IDPH (Illinois Department of Public Health) within 2 hours of discovery. Abuse policy with effective date of 09/2024 reads in part: 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 the immediate supervisor who must then report it to the administrator.Any allegation of abuse or any incident that results in serious bodily injury will be reported to the Department of Public Health immediately, but not more than two hours after the allegation of abuse. Any incident that does not involve abuse and does result in serious bodily injury shall be reported within 24 hours. The nursing staff is additionally responsible for reporting on a facility incident report the appearance of suspicious bruises, lacerations, or other abnormalities as they occur. Upon report of such occurrences, the nursing supervisor is responsible for assessing the resident, reviewing the documentation and reporting to the administrator or the person designated to act on behalf of the administrator in the administrator's absence.An injury should be classified as an injury of unknown source when both of the following conditions are met: the source of the injury was not observed by any person or the source of the injury could not be explained by the resident and the injury is suspicious because of the extent of the injury or the location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma) or the number of injuries observed at one particular point in time or the incidence of injuries over time. If classified as an injury of unknown source, the person gathering facts will document the injury, the location and time it was observed, any treatment given and notification of the resident's physician, responsible party. The Department of Public Health will be notified. Timeframes for reporting and investigating abuse will be followed.Incident and Accident policy last approved 10/2024 reads in part: the incident/accident report is completed for all unexplained bruising or abrasion, all accidents or incidents where there is injury or the potential to result in injury, allegations of theft and abuse registered by residents, visitors or other, and resident to resident altercations.The director of nursing, assistant director of nursing, or nursing supervisor must notify the following if an actual injury occurs: the Illinois Department of Public Health via email, fax, or phone within twenty-four (24) hours of the occurrence. Event ID: Facility ID: 145418 If continuation sheet Page 4 of 6 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 08/01/2025 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)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the safety of a resident by not adequately assessing a resident for risk of falls, not assessing a resident for injury after a fall, and not properly transferring a resident off the floor after a fall incident for one of three residents (R1) reviewed for falls in the sample of eight.The findings include:R1's face sheet indicated initial admission date of 03/01/2011 with a past medical history not limited to: paranoid schizophrenia, bipolar disorder, major depressive disorder, mood affective disorder, anxiety, anemia, pruritis, history of shock therapy, and long term (current) use of anticoagulants.R1's care plan indicated but not limited to: risk for injury related to limited dexterity and cognitive impairment and, is a risk for falls both with date initiated of 10/02/2023; requires use of psychotropic medications (antidepressant, antipsychotic, anti-anxiety) to manage mood and/or behavior issues, date initiated 04/07/2024. R1's Minimum Data Set (MDS) section C for cognitive patterns dated 04/13/2025 indicated severe cognitive impairment.R1's fall risk assessment dated [DATE] documented that R1 is not at risk for falls.Incident Follow Up note with effective date of 07/29/2025 at 04:00 PM that was created by V3 (Director of Nursing) on 07/31/2025 at 08:52 AM documented, via phone interview with (V10 Agency Nurse) on duty 07/27/2025, [Interdisciplinary Team] has ascertained that resident had been noted sitting on the floor next to her bed that night. Nurse did not believe resident to have actually sustained a fall, but to have scooted/sat from her bed as she is prone to do, so full body assessment and fall documentation were not completed at that time. Nurse has been thoroughly educated on assessment and reporting/notification expectations.On 07/31/2025 at 09:55 AM, observed R1 propel herself in a wheelchair out of her room on the A wing. Observed a dark purple colored bruise that measured approximately three centimeters in length and width to the area under R1's chin. R1 was exhibiting verbal outbursts and looking for her babies. R1 was unable to indicate how the bruise occurred. Further assessment was not able to be completed due to R1's behaviors.On 07/31/2025 at 10:03 AM V2 (Administrator in Training) said R1 is currently on 1:1 supervision with staff due to falls.On 07/31/2025, facility provided corrective action forms for V11 and V12 (Certified Nursing Assistants) that indicated a written warning was given due to a improper transfer on 07/27/2025 when both aides lifted resident (R1) from the floor without using a mechanical lift or gait belt and additional in-servicing was provided via phone on 07/29/2025. In-service log on resident safe transfers dated 07/29/2025 was also provided for V10 (Agency Nurse), V11 and V12. V3 provided documentation related to a facility in-service presented on 07/28/2025 which indicated but not limited to.residents must be assessed fully if noted on the floor at any time, unless having been witnessed purposely and safely placing themselves there or known to have been purposely and safely assisted there by staff if care planned to be so.On 07/31/2025 at 12:20 PM, V3 (DON) said during course of investigation for R1's bruising, it was noted that on 07/27/2025, R1 was found sitting on the floor next to her bed. V10 and V11 got her up by the underarms and the back of her pants, and no gait belt was used. V3 added that V10 didn't think to document the incident as a fall because she believed R1 scooted herself to the floor. V3 also said that V10 did not do a full assessment after staff found R1 on the floor so it was unknown whether R1 had sustained any other injury post fall incident. On 07/31/2025 at 12:58 PM, V11 said she was with another resident on 07/27/2025 at around 8:00 PM when V10 came to get her and told V11 that R1 had fallen, and V10 needed help getting R1 off the floor. V11 said when she entered R1's room, she saw her sitting on the floor next to the bed. V11 then said she and V10 picked [R1] up off the ground with our arms under her arms and grabbing the back of her pants. V11 added that the did not put a gait belt on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145418 If continuation sheet Page 5 of 6 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 08/01/2025 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)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete her but should have. V11 said they put R1 in her bed, then she and V10 left the room and that's why V11 assumed V10 already assessed R1 because she left when V11 left the room. V11 also said that she would normally use a mechanical lift when transferring a resident off the floor after a fall that was discussed at the fall training two months ago where staff were educated on using a mechanical lift, and use of a gait belt when not using a lift.On 07/31/2025 at 01:34 PM, V12 said she was with a resident across the hall from R1's room on 07/27/2025 when she heard R1's roommate said R1 had fallen on the floor around 08:30-09:00 PM. V12 went into R1's room and saw her sitting on the floor next to the bed and wanted help getting up. V12 said she went to get the nurse (V10) to help get R1 up. V12 then said she and V10 put their arms under R1's arms and tried to get her up off the floor but V12 couldn't get [her] side up so V12 went to get V11 to assist V10. V12 then said they got her off the floor by pulling her under the arms and by the back of her pants. V12 added that they no gait belt was applied to R1 at any time but they should have. On 07/31/2025 at 02:45 PM, R9 (R1's roommate) said R1 fell to the floor last weekend so she went out in the hall and told staff. On 07/31/2025 at 12:49 PM and 08/01/2025 at 09:09 AM, called V10 (Agency Nurse with no answer. Detailed message and call back number were both left. No call-backs received from V10.On 08/01/2025, requested fall policy and procedures. V1 indicated facility does not have a fall protocol policy then indicated facility has a prevention policy.Fall Prevention Program policy last approved 10/2024 reads in part: to assure the safety of all residents in the facility when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. Quality Assurance Programs will monitor the program to assure ongoing effectiveness.Transfers-Manual Gait Belt and Mechanical Lifts policy last approved 04/2025 reads in part: in order to protect the safety and well-being of the staff and residents, and to promote quality care, this facility will use mechanical lifting devices for the lifting and movement of residents.use of a gait belt for all physical assist transfers is mandatory. Event ID: Facility ID: 145418 If continuation sheet Page 6 of 6