Avenues At Royal Oak
AVENUES AT ROYAL OAK in KEWANEE, IL — inspection on February 27, 2026.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
ready to clock out and heard yelling.
She went to the dining room. V12 called R3 a b**** and R3 called
12:40 PM, V2 (Assistant Administrator) said she was walking out the building when staff reported
slurs and V12 responded verbally back.
She directed V12 to go into the kitchen and was suspended during the investigation. On 2/27/26 at 12:38 PM, V1 said R3 was using racial slurs. R3 called V12 the n word and cotton picker. V12 responded extremely inappropriately and responded verbally to R3. At the end of the investigation, V12 was terminated. V12's Interview statement dated 2/9/26 shows I was in the kitchen (R3) started yelling N****.I came out of the kitchen and asked, What's your problem.
Then (R3) kept cursing at me. I did get upset and started cussing back at him because he has been calling us N*.
The facility's Abuse and Reporting Policy dated 12/25 states, The facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of good and services by staff or mistreatment.physical abuse is the infliction of injury on a resident that occurs other than by accidental means.Verbal abuse includes the use of oral, written or gestured communication.
145418 02/27/2026
Avenues at Royal Oak 605 East Church Street Kewanee, IL 61443
bed-hold policies.
interview and record review the facility failed to safely discharge a resident for1 of 3 residents (R6)
has diagnoses that include diabetes and bipolar disorder. R6 was discharged last 1/30/26.
The same face sheet documents discharged to-Nursing Home unknown.R6's facility assessment dated [DATE] show R6 has no cognitive impairment.R6's vital summary shows R6 weighs 426 pounds (lbs.)On 2/27/26 at 10:10 AM, V5 (Social Service) said R6 was transferred to another Nursing Home that took bariatric residents (approximately 145 miles away) from this facility. As far as I know R6 was still at the facility up to this time. V5 said she had not called the facility to check on R6 since the time of transfer. V5 said she provided the receiving Nursing Home R6's information but cannot recall who she spoke to at the facility. V5 also confirmed she did not document this information in R6's medical records.On 2/27/26 at V15 (Administrator of the Nursing Home R6 was referred to) said R6 was never a resident in their facility.On 2/27/26 at 11: 36 AM, R6 said the time she was transferred to another Nursing Home, (1/30/26) the receiving Nursing Home said they were not ready for her and that they did not have the bed and wheelchair that would fit her. R6 said it was by that time very late, so she was brought to a hospital. At this time, she was in a different facility (not the facility she was supposed to transfer to).On 2/27/26 at 10:30 AM V14 (R6's family) said when R6 got to the Nursing Home where she was supposed to be transferred to, the Nursing Home did not have the bariatric bed or bariatric wheelchair for R6. R6 got so anxious and had palpitations so she was sent to the emergency room (ER).
The hospital found a different Nursing Home that would take R6 and have the medical equipment she needed (not the Nursing Home she was referred to.)On 2/27/26 at 1:41 PM, V16 (License Practical Nurse) said she was the Nurse that discharged R6 on 1/30/26. V16 said she sent with R6 her discharged medications but did not provide any additional discharge papers to R6 because she was not instructed to do that. On 2/27/26 at 12:48 PM, V3 (Director of Nursing-DON) said when discharging a resident including a transfer to another Nursing Home, the discharging Nurse should have provided discharge instructions that included (but not limited to) list of meds and instructions, list of medical equipment that the resident need and a copy kept in the medical record to ensure continuity of care and resident's safety.The Facility Policy on Notice of Transfer and discharge date d 12/20/25 documents: When the facility transfers or discharges a resident, the facility must ensure that the transfer or discharge is documented in the residence medical record, appropriate information is communicated to the receiving healthcare institution.
Discharge from the facility will include review of all necessary items to maintain the individual's highest practicable well-being, this includes necessary DME (durable medical equipment) and provision of medication prescriptions, appointments and treatments.