Skip to main content

Inspection visit

Health inspection

AVENUES AT ROYAL OAKCMS #1454182 citations on this visit
2 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 2 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

145418 01/13/2026 Avenues at Royal Oak 605 East Church Street Kewanee, IL 61443
F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to implement it's policy and procedure to identify a potential sexual abuse allegation for one of four residents, reviewed for abuse, in a sample of six.The facility policy, Abuse Prevention and Reporting, dated (effective 12/2025) 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. 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: Orienting and training employees on how to deal with stress and difficult situations, and how to recognize and report occurrences of abuse, neglect, exploitation, and misappropriation of property. During orientation of new employees, the facility will cover at least the following topics: What constitutes abuse and Procedures for reporting incidents/allegations of abuse.The (facility) Resident Grievance form, dated 12/8/25 and signed by V10/Assistant Administrator documents, On December 8(2025) , (V10) was called and CNA (Certified Nursing Assistant/V4) stated, ‘I was trying to get into (R1's) room and (V3/Transportation Driver) was behind the door and (R1) had her shirt up and (her) bra was showing. (V3) gave (R1) a sub sandwich over a bet on football. (V10) discussed with (V3) (the) incident. (V3) states I took (R1) a sub sandwich over a bet on football. I was in (R1's) room giving her the sandwich when the other (resident/R6) was coming, because (R6) continues to try and hug me, so I stay away from (R6). At no time was (R1) inappropriate with me. I was just being nice getting her a sandwich because she didn't like supper, and I lost the bet on (the) football game. (V3) was coached on appropriate behavior, such as no betting on games with food and no bringing food items. V3 stated he understood and was just being nice. (R1) states the same story when questioned.On 01/10/2026 at 8:10 A.M., V1/Administrator stated she is aware of a situation between (R1) and V3/Transportation Aide. States V3 is her brother and on 12/8/2025, she was called at home by V2/Director of Nurses with V4/Certified Nursing Assistant in the same office, stating she had witnessed V3/Transportation Aide in (R1's) room with the door closed and when V4 attempted to go into R1's room to see what was going on and why the door was closed, she was able to partially enter the room and saw R1 with her shirt up, covering her face, exposing her bra. Once V4 was able to enter R1's room, she found V3 behind the door, facing R1. At that time, V3 raised his arms in the air and stated repeatedly, don't say anything. Don't say anything. V1/Administrator states she conferred with V9/Corporate Staff, and it was decided that V4/CNA was making trouble, and she knew V3 was V1's brother and wanted to get V3 in trouble. V1 states she did not feel the situation was potential abuse, she did not report the situation to the state agency, and she did not notify the local law enforcement agency. Residents Affected - Few Page 1 of 2 145418 145418 01/13/2026 Avenues at Royal Oak 605 East Church Street Kewanee, IL 61443
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 a potential allegation of sexual abuse, to the state agency or the local law enforcement agency for one of four resident (R1), reviewed for abuse, in sample of six.The facility policy, Abuse Prevention and Reporting, dated (effective 12/2025) 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. 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. Any allegation of abuse or any incident that results in serious bodily injury will be reported to the state agency immediately. The facility shall also contact local law enforcement authorities in the following situations: sexual abuse of a resident by a staff member.The (facility) Resident Grievance form, dated 12/8/25 and signed by V10/Assistant Administrator documents, On December 8(2025) , (V10) was called and CNA (Certified Nursing Assistant/V4) stated, ‘I was trying to get into (R1's) room and (V3/Transportation Driver) was behind the door and (R1) had her shirt up and (her) bra was showing. (V3) gave (R1) a sub sandwich over a bet on football.On 01/10/2026 at 8:10 A.M., V1/Administrator stated she is aware of a situation between (R1) and V3/Transportation Aide. States V3 is her brother and on 12/8/2025, she was called at home by V2/Director of Nurses with V4/Certified Nursing Assistant in the same office, stating she had witnessed V3/Transportation Aide in (R1's) room with the door closed and when V4 attempted to go into R1's room to see what was going on and why the door was closed, she was able to partially enter the room and saw R1 with her shirt up, covering her face, exposing her bra. Once V4 was able to enter R1's room, she found V3 behind the door, facing R1. At that time, V3 raised his arms in the air and stated repeatedly, don't say anything. Don't say anything. V1/Administrator states she conferred with V9/Corporate Staff, and it was decided that V4/CNA was making trouble, and she knew V3 was V1's brother and wanted to get V3 in trouble. V1 states she did not feel the situation was potential abuse, she did not report the situation to the state agency, and she did not notify the local law enforcement agency. 145418 Page 2 of 2

Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.

Back to top

Citations

2 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.

  • 0607GeneralS&S Dpotential for harm

    F607 - The facility must develop and implement written policies and procedures that:

    Develop and implement policies and procedures to prevent abuse, neglect, and theft.

  • 0609GeneralS&S Dpotential for harm

    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.

FAQ · About this visit

Common questions about this visit

What happened during the January 13, 2026 survey of AVENUES AT ROYAL OAK?

This was a inspection survey of AVENUES AT ROYAL OAK on January 13, 2026. The surveyor cited 2 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at AVENUES AT ROYAL OAK on January 13, 2026?

Yes, 2 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Develop and implement policies and procedures to prevent abuse, neglect, and theft."

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.

Share this reportEmail

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.