Avenues at Royal Oak

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents were free from abuse for 4 of 7 residents (R1, R2, R3, R4) reviewed for abuse in the sample of 7.

Inspectors wroteBased on interview and record review the facility failed to ensure residents were treated with dignity and respect by other residents. This applies to 1 of 3 residents (R4) reviewed for resident rights/dignity in the sample of 7.

Inspectors wroteBased on observation and interview the facility failed to ensure windows in resident rooms were able to be opened to allow them to get fresh air. This applies to 1 of 3 residents (R5) reviewed for clean, comfortable and homelike conditions in the sample of 7.

Inspectors wroteBased on observation, interview and record review the facility failed to supervise a resident at high risk for elopement while on a 1:1 monitoring. This failure resulted in R4 leaving the facility unauthorized, and fracturing her foot while climbing/jumping over a fence. This failure applies to 1 of 3 residents reviewed for safety and supervision. The immediate Jeopardy began on 3/14/26 when V13 Certified Nursing Assistant (CNA) allowed R4 to shut her door and remain out of her line of vision while on a 1:1 monitoring status, allowing R4 to elope out of her window. V2 Administrator in Training was notified of the Immediate Jeopardy on 4/30/26 at 9:00 AM. The surveyor confirmed by observation, interview and record review that the immediate jeopardy was removed, and the deficient practice corrected on 3/16/26, prior to the start of the survey and was therefore Past Noncompliance. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident was free from misappropriation of property for 1 of 3 residents (R1) reviewed for abuse in the sample of 5.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents were free from physical and verbal abuse. This applies to 3 of 3 residents (R1-R3) reviewed for abuse in the sample of 11.

Inspectors wroteBased on interview and record review the facility failed to safely discharge a resident for1 of 3 residents (R6) reviewed for safe discharge in the sample of 11.

Inspectors wroteBased 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: [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide eight consecutive hours of a Registered Nurse, daily. This failure has the potential to affect all 128 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure kitchen fans were kept clean and free of debris, label and date opened food items in the kitchen's refrigerator and freezer, complete and record cool down temperatures for meat that was prepared and stored in the facility's refrigerator and ensure dietary staff's facial hair was covered while in the kitchen. This failure has the potential to affect all 128 residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents and their representatives were provided a clear, accurate, and understandable explanation of the arbitration agreement during the admission process, resulting in confusion and lack of informed consent for all residents reviewed. This failure has the potential to affect all 128 residents who reside in the facility.

Inspectors wroteBased on observation, and interview, the facility failed to maintain a safe, clean, and comfortable environment for residents in A Wing, resulting in unsanitary conditions, structural disrepair, and the presence of black fuzzy discoloration on bathroom walls and standing water in multiple bathrooms for 46 of 46 residents (R1, R4, R14, R15, R16, R17, R19, R21, R22, R27, R28, R29, R31, R40, R42, R44, R45, R46, R48, R51, R52, R53, R56, R60, R62, R64, R70, R71, R73, R79, R81, R83, R84, R89, R96, R97, R103, R106, R107, R110, R113, R120, R125,R130, R131, and R132) reviewed for environment in the sample list of 74.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide privacy during gastrostomy cares/feeding for one of two residents (R27) reviewed for gastrostomy cares in a sample of 74. Findings Include:The Illinois Long Term Care Ombudsman Program Resident Rights Policy, Revised 11/18 documents, Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life. You have a right to privacy. Facility staff must respect your privacy when you are being examined or given care. R27's Physician Order sheet documents, Enteral Feeding Order, four times a day, every day. On 9/14/2025 at 12:43 PM, V11 (Registered Nurse) began gastrostomy cares to R27. R27's door was wide open, and R27's curtain was halfway closed. Various residents walked past R27's room and observed V11 performing R27's gastrostomy care. On 9/14/2025 at 1: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a call light was in reach for one of one resident (R63) reviewed for call lights in a sample of 74.

Inspectors wroteBased on observation, interview, and record review the facility failed to allow a resident their preferred smoking method for one of three residents (R62) reviewed for smoking in a sample of 74. Findings Include:The Illinois Long Term Care Ombudsman Program Resident Rights Policy, Revised 11/18 documents, Your rights to dignity and respect, you have a right to make your own choices. R62's Smoking Safety Risk assessment dated [DATE] documents R62 smokes tobacco. This same assessment also documents R62 is not cognitively impaired, able to smoke, does not show potential for causing injury to self or others from smoking in unauthorized areas or careless use of smoking materials, has no history of hazardous behavior while smoking, follows facility smoking policy, and is on supervision during smoking times. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure a residents personal preference and dignity was provided for 1 of 3 residents (R2) reviewed for resident rights in the sample of 8.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on interviews and record review, the facility failed to follow their policy and procedure for pain management by not adequately assessing, documenting or treating a resident's (R3) pain while awaiting further evaluation and treatment post fall with significant injury. This failure applied to one of four residents reviewed for pain management related to falls in a sample size of 6.

Inspectors wroteBased on interviews and record review, the facility failed to protect two vulnerable residents by not preventing resident to resident physical abuse. This failure applied to two of four residents (R2, R4) reviewed for abuse in a sample of 6 that resulted in R2 being hit on the top of the head by R1 and R4 being slapped on the hand by R5.

Inspectors wroteBased 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.

Inspectors wroteBased on interview and record review, the facility failed to perform a PASARR (Pre-admission Screening and Resident Review) rescreen after the emergence of a newly diagnosed severe mental illness for one of three residents (R2) reviewed for PASARR screening, in the sample of 7.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, record review and interview the facility failed to monitor food temperatures to ensure food was served at a palatable temperature. This failure has the potential to affect all residents that reside at the facility.

Inspectors wroteBased on record review and interview the facility failed to ensure funds were available for 100 of 100 residents (R2, R4, R5, R7-R10, R12-R104) reviewed for personal funds in a sample of 104.

Inspectors wroteBased on interview and record review the facility failed to report an allegation of employee to resident sexual abuse to the State Agency and to Law Enforcement of one resident (R1) of three residents reviewed for abuse.

Inspectors wroteBased on interview and record review the facility failed to protect one resident (R1) after an allegation of employee to resident sexual abuse was reported for three residents reviewed for abuse.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident was free from abuse for 1 of 4 residents (R9) reviewed for abuse in the sample of 9.

Inspectors wroteBased on interview and record review the facility failed to ensure allegations of abuse were immediately reported to the administrator for 1 of 4 residents (R9) reviewed for abuse in the sample of 9.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident was safely transferred with a full mechanical lift for one of four residents (R84) reviewed for falls in a sample of 45 residents This failure resulted in R84 being sent to the hospital, suffered a back contusion which required medication for back pain management and ongoing psychosocial fear of being transferred with a mechanical lift.

Inspectors wroteBased on interview and record review the facility failed to provide medications as ordered for one of four residents (R232) reviewed for medication administration, in a sample of 45.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement Enhanced Barrier Precautions and Contact Precautions throughout the facility to protect vulnerable residents and prevent the spread of multi-drug resistant organisms (MDROs). This failure has the potential to affect all 132 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure their Antibiotic Stewardship program was implemented. This failure has the potential to affect all 132 residents residing at the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Infection Preventionist was adequately implementing and performing duties that accompany the position. This failure has the potential to affect all 132 residents residing at the facility.

Inspectors wroteBased on interview, observation and record review, the facility failed to ensure resident call lights were responded to in a timely manner for eight of 43 residents (R20, R37, R54, R55, R57, R63, R66 and R109) reviewed for call lights in the sample of 45.

Inspectors wroteBased on Record Review and Interview, the facility failed to ensure residents electronic medical records and care plans matched their Physician's Order for Life-Sustaining Treatment (POLST) for Cardio-Pulmonary Resuscitation (CPR) code status for two of 32 residents (R42, R92) reviewed for Advanced Directives in the sample of 45.

Inspectors wroteBased on observation, interview and record review, the facility failed to complete and implement a baseline care plan for one of two residents (R232) reviewed for new admission care plans, in a sample of 45.

Inspectors wroteBased on Observation, Interview and Record review, the facility failed to ensure hand hygiene was performed during wound care for one of four residents (R84) reviewed for Pressure ulcers in the sample of 45. Finding Include: The Facility's Preventative Skin Care Policy, dated 3/16/2023, documents, It is the facility's policy to provide preventative skin care through repositioning and careful washing, rinsing, drying, and observation of the resident's skin condition to keep them clean, comfortable, well groomed, and free from pressure ulcers. All residents will be assessed using the Braden Pressure Ulcer Scale at the time of admission and weekly times four then will be reassessed at least quarterly and/or as needed. Any resident identified as being at high risk for potential skin breakdown shall be turned and repositioned at a minimum of every two hours. [...]

Inspectors wroteBased on interview, and record review, the facility failed to implement and follow through ROM (Range of Motion) exercises for residents with functional limited range of motion for one of five residents (R64) reviewed for limited mobility in the sample of 45.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure an indwelling urinary catheter tubing was off the floor and urinary drainage bag was covered and failed to keep indwelling urinary catheter bag below a resident's bladder for one (R92) of two residents reviewed for indwelling urinary catheters in a sample of 45.

Inspectors wroteBased on observation, interview and record review the facility failed to provide ongoing communication with the dialysis center and failed to develop a complete, comprehensive care plan for a resident receiving dialysis services for one of one resident (R233) reviewed for dialysis, in a sample of 45.

Inspectors wroteBased on Observation, Interview and Record Review, the facility failed to provide psychosocial therapies and psychiatric support services to resident with diagnosis of Adjustment Disorder and repeated emergency room visits for suicidal ideation's and depression for one of six residents (R102) reviewed for Behavioral Services in the sample of 45.

Inspectors wroteBased on observation, interview, and record review the facility failed to prevent physical abuse for two (R1 and R2) of four residents reviewed for abuse in the sample of 12.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow a physician order and have Speech Therapy services assess a resident's individual swallowing needs after a choking incident for two (R1 and R2) of three residents reviewed for accidents/incidents in a sample of three.

Inspectors wroteBased on Observation, Interview and Record Review, the facility failed to ensure Physical and Occupational Therapy services were provided to residents who have been determined to have the need for Physical and Occupational Therapy services for eleven of eleven residents (R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11) reviewed for Therapy in the sample of eleven.

Inspectors wroteBased on observation, interview, and record review the administration failed to develop behavior management policies; failed to perform resident background checks within 24 hours of admission; failed to follow the facility's Identified Offender Policy and Procedure resulting in residents with a history of qualifying identified offender criminal conviction offenses being admitted to the facility for treatment for mental health services, without having an adequate amount of staff or adequate staff training on managing mental health disorders and behaviors, without care planning or acquiring specialized needs services as documented on those residents' PASRR (Pre-admission Screening and Resident Review) Level II screenings and their pre-admission screenings; [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to implement their Abuse policy by failing to protect multiple residents from verbal, physical, and mental abuse from another resident (R2), failing to provide adequate supervision of (R2) to prevent (R2) from further abusing other residents, failing to investigate and report to the state surveying agency multiple reports of resident-to-resident abuse, failed to thoroughly investigate resident-to resident abuse allegations, and failing to notify the police of resident-to-resident abuse for three of four residents (R1, R3, and R5) reviewed for abuse in the sample of 76. [...]

Inspectors wroteBased on observation, record review, and interview the facility failed to protect residents (R1, R3, R5) from verbal, mental, and physical abuse from another resident (R2) for three of four residents (R1, R3, R5) reviewed for abuse in the sample of 76. This failure resulted in R2 spitting on R1 on multiple occasions, pouring water over R1's head, cursing at R1 on multiple occasions days before R2 physically assaulted R1 by kicking and stomping R1 in the face which resulted in R1 sustaining lacerations to the nose and left eyelid, head trauma, bruising around the left eye, a hematoma under the left eye, severe pain, and mental anguish that required emergency room care for treatment. These failures resulted in an Immediate Jeopardy.

Inspectors wroteBased on record review and interview the facility failed to document all measures the facility took to meet R2 and R11's behavioral and mental health needs that could not be met by the facility, failed to develop and implement behavioral interventions and care plans to meet those behaviors, failed to document the specific services the receiving facility will provide to meet R2 and R11's needs which could not be met by the facility, prior to discharging R2 to another long-term care facility, failed to notify R2's Physician of R2's discharge and R11's emergency discharge, and failed to allow R11 to remain in the facility while a discharge appeal was pending for two of three residents (R2 and R11) reviewed for discharge in the sample of 76. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to adequately supervise a resident while showering. The facility also failed to transfer a resident with assistance of two staff as directed by the plan of care to prevent a fall for one of three residents (R55) reviewed for falls in the sample of 76. These failures resulted in R55 sustaining a fall while in the shower room, resulting in R55 suffering a head injury, head swelling, left ankle swelling with bruising, neck pain, and a traumatic hematoma to the forehead which required hospital treatment.

Inspectors wroteBased on interview and record review the facility failed to provide a sufficient number of staff and train a sufficient number of staff to care for and meet the behavioral needs of residents with mental and psychosocial disorders. These failures have the potential to affect all 131 residents residing within the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to allow a resident to use an electronic monitoring camera for one of three residents (R10) reviewed for resident rights in the sample of 76.

Inspectors wroteBased on record review and interview the facility failed to provide a written notice of a facility initiated discharge, including the reason for discharge, the location to where the resident is discharged , the regional Ombudsman's and the agency responsible for the protection and advocacy of individuals with a mental disorder contact information, or the resident's appeal rights to the resident, the resident's POA (Power of Attorney), and the Office of State Long-Term Care Ombudsman for one of three residents (R2) reviewed for notice of discharge in a sample of 76.

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer pain medication as ordered and assess pain on a daily basis for four of four residents (R88, R117, R233, R285) reviewed for pain in the sample of 23. These failures resulted in R285 having intractable pain following a fall that resulted in a fractured rib.

Inspectors wroteBased on observation, interview, and record review the facility failed to prevent physical abuse for one (R117) of four residents reviewed for abuse in the sample of 40. This failure resulted in R117 receiving an open laceration to his left jaw requiring three sutures.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide responses, actions, and rationale taken regarding resident council concerns, grievance complaints, suggestions, and recommendations. These failures have the potential to affect all 135 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the Facility Survey Results were maintained, up to date and in a location accessibility for the Residents and visitors to review. This failure has the potential to affect all 135 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a clean, comfortable, and homelike environment. This has the potential to affect all 135 residents in the Facility.

Inspectors wroteBased on record review and interview the Facility failed to oversee, govern, and initiate programs for Quality Assurance Performance Improvement programs/plans and follow-up for the calendar year. This failure has the potential to affect all 135 residents who currently reside in the facility. Findings Include: Facility Census and Condition Report, dated 10/25/23, documents 135 Residents residing in the Facility. The Facility Administrator Job Description, undated, documents: Administrator is responsible for managing, planning, organizing, directing, coordinating and the physical management of the Facility in a way that the purpose of the Facility shall be maintained in accordance with all established practices, policies, laws and applicable State Regulations; will manage and conduct business of the Facility license and certification at all times; [...]

Inspectors wroteBased on record review and interview the Facility failed to conduct quarterly Quality Assurance/QA Performance Improvement meetings and failed to identify, monitor, and correct QA potential concerns for the last calendar year. This failure has the potential to affect all 135 residents who currently reside in the facility. Findings Include: Facility Census and Condition Report, dated 10/25/23, documents 135 Residents residing in the Facility. The Facility Administrator Job Description, undated, documents: Administrator is responsible for managing, planning, organizing, directing, coordinating and the physical management of the Facility in a way that the purpose of the Facility shall be maintained in accordance with all established practices, policies, laws and applicable State Regulations; will manage and conduct business of the Facility license and certification at all times; [...]

Inspectors wroteBased on record review and interview the facility failed to conduct quarterly Quality Assurance/QA Performance Improvement meetings and assure the required committee members were present for the last calendar year. This failure has the potential to affect all 135 residents who currently reside in the facility. Findings Include: Facility Census and Condition Report, dated 10/25/23, documents 135 Residents residing in the Facility. The Facility Administrator Job Description, undated, documents: Administrator is responsible for managing, planning, organizing, directing, coordinating and the physical management of the Facility in a way that the purpose of the Facility shall be maintained in accordance with all established practices, policies, laws and applicable State Regulations; will manage and conduct business of the Facility license and certification at all times; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to perform a care plan meeting with a resident and revise a care plan following a fall, new onset of pain, use of an antipsychotic and target behaviors, and significant weight loss for six of 29 residents (R5, R24, R49, R117, R284, R285) reviewed for care plans in the sample of 40.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide showers to a resident dependent on assistance with showering for one of one resident (R284) reviewed for ADL (Activities of Daily Living) assistance in the sample of 40.

Inspectors wroteBased on interview and record review the facility failed to document current Advance Directives and code status in the physician's orders and on the care plan for one resident (R233) of 27 residents reviewed for Advance Directives in the sample of 40.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure wrist restraints were applied according to manufacturer's safety guidelines and failed to evaluate bed rails. The facility also applied arm weights as restraints for one (R5) of two residents reviewed for physical restraints in the sample of 40.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a comprehensive assessment for the use of side rails and pain management for two of 29 residents (R233, R285) reviewed for care plans in the sample of 40.

Inspectors wroteBased on interview and record review the facility failed to identify triggers, develop a Trauma Informed Care Plan and interventions for one resident (R112) identified with PTSD (Post Traumatic Stress Disorder) of 32 residents in the sample of 40.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure narcotic pain medication was available as physician ordered for a resident with a new rib fracture for one of four residents (R285) reviewed for pain in the sample of 40.

Inspectors wroteBased on observation, interview, and record review, the facility failed to document behaviors to warrant the use of an antipsychotic and perform a GDR (Gradual Dose Reduction) for one of six residents (R24) reviewed for psychotropics in the sample of 40.

Inspectors wroteBased on interview and record review, the facility failed to ensure medical records were not falsified for one of one resident (R284) reviewed for falsified records in the sample of 40.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the Daily Nurse Staffing was posted in a clear and readable format and in a prominent place readily accessible area to residents and visitors. This failure has the potential to affect all 135 residents residing in the Facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to remove an alleged perpetrator V4 (Certified Nursing Assistant) from resident cares following staff (V4) to resident verbal abuse, failed to protect residents from an alleged abuser (V4), and failed to recognize verbal abuse for one of three residents (R1) reviewed for abuse in the sample of three. These failures resulted in V4 returning to work with all residents within the facility after verbally abusing R1, resulting in R1 feeling angry and experiencing fear. These failures have the potential to affect all 134 residents residing within the facility. These failures resulted in an Immediate Jeopardy. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to prevent verbal abuse from staff V4 (Certified Nursing Assistant) to a resident for one of three residents (R1) reviewed for abuse in the sample of three. This failure resulted in V4 yelling at R1Stop f*****g talking to me (V4). You are an ass! resulting in R1 crying and experiencing mental anguish. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 9-6-23 when the facility failed to prevent V4 from verbally abusing R1, resulting in R1 crying and experiencing mental anguish. V1 (Administrator) and V9 (Activity Director) were notified of the Immediate Jeopardy on 9-8-23 at 2:28 PM. The Immediate Jeopardy was removed on 9-8-23. On 9-13-23 the surveyor confirmed through observation, interview, and record review that the facility took actions to remove the Immediate Jeopardy. [...]

Inspectors wroteBased on record review and interview the facility failed to develop a care plan to address a resident's behaviors for one of three residents reviewed for abuse in the sample of three.