Inspection·September 16, 2025

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm Based 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.Findings include: The facility's Call Light Policy, dated 10/2024, documents Purpose: To respond to residents' requests needs in a timely and courteous manner. Guidelines: Resident call lights will be answered in a timely manner. 1. All residents that have the ability to use a call light shall have the nurse call light system available at all times and within easy accessibility to the resident at the bedside or other reasonable accessible location.R63's Care Plan dated 9/24/24, documents, (R63) is usually unable to perform ADLS (Activities of Daily Livings) without weight bearing/hands on assist of one to two care givers or dependent for cares related to history of Stroke. This same plan of care documents R63 requires staff assistance with all ADLS and extensive assistance with two staff members and mechanical lift for transfers.On 9/14/2025 at 9:21 AM R63 was sitting in a high back wheelchair in his room at the end of his bed. R63 was yelling help. R63 stated he was needing a staff member to help move him. R63's call light was lying out of reach on R63's bedside table in his room.On 9/14/25 at 9:24 AM V10/Certified Nursing Assistant verified R63's call light was not within reach and should have been since R63 is unable to self-propel his wheelchair to reach his call light. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145418 If continuation sheet Page 2 of 8 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 09/16/2025 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 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.R62's Smoking Progress Note dated 7/30/2025 and signed by V13 (Activity Director), documents (R62) does use tobacco. (R62) does not use an electronic cigarette or vaping device. (R62) is not interested in receiving information regarding smoking cessation. No problem with general awareness and orientation, including ability to understand the facility safe smoking policy. No concerns with general behaviors and interpersonal interaction. No problem noted to move around, general mobility. No concerns noted with potential for causing injury to self or others from smoking in unauthorized areas or careless use of smoking materials. No concerns with history of hazardous behavior (example: smoking in unauthorized areas or careless use of smoke materials, sustaining burns, fire starting). No concerns with begging, borrowing, trading items or panhandles for smoking materials. (R62) has a history of less than one pack per day. No concerns with potential for safely following the facility smoking policy. Recommendation - (R62) requires a smoking apron; is not able to store smoking materials.On 9/14/2025 at 9:00 AM R62 stated, I can do things by myself. I want to smoke cigarettes and this place makes me vape. I don't want to vape. R62 stated he likes to buy his own tobacco and cigarette cartridges and make his own, but the facility will not let him. R62 stated he is forced to buy vapes, they are expensive, and he does not want to use his money on vapes in order to smoke when he is fully capable to smoke cigarettes.On 9/16/2025 at 12:20 PM, V13 (Activities Director) stated R62 is not capable of rolling his own cigarettes. V13 stated R62 has attempted, and staff must help him. V13 stated R62 cannot load the empty cartridge on the machine and cannot pinch and roll the end without shaking and getting frustrated. V13 reported they have always helped R62 roll cigarettes if he needed it with no problem but then V1/Administrator instructed all activities staff to not help roll residents cigarettes because we are not getting paid to roll cigarettes, if residents cannot roll themselves, they need to buy their own cigarettes or vape.On 9/16/2025 at 12:25 PM, V14 (A Wing Activity Aide) stated I have helped (R62) several times roll his own cigarettes, and he cannot place the cigarette cartridge on the machine. I have no problem helping him but now I am not allowed to.On 9/16/2025 at 1:20 PM, R62 was in the main dining room, R62 loaded tobacco into cigarette machine, placed empty cigarette cartridge on machine, started the machine, loaded the cigarette cartridge, and pinched and twisted the end of the cigarette to seal the tobacco without difficulty. V13 (Activity Director) was also observing and verified R62 had no difficulty in rolling his own cigarettes. Event ID: Facility ID: 145418 If continuation sheet Page 3 of 8 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 09/16/2025 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based 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. Findings include: The facility's Cleaning-Sanitizing Bathing Equipment and Toilet Seats Policy revised 1/2018 documents housekeeping personnel are responsible for at least daily cleaning of bathing equipment, wipe down or scrub all surfaces with a soft brush, cleaning cloth or sponge and sanitizing agent to assure removal of organic matter and then completely rinse with clean water. The facility's Housekeeper Supervisor policy revised 7/2023 documents the primary purpose of the Housekeeper Supervisor is to perform the day-to-day activities of the Housekeeping Department in accordance with current federal, state, and local standards, guidelines and regulations governing our facility, and as may be directed by the Administrator, and Director of Environmental Services, to assure that our facility is maintained in a clean, safe, and comfortable manner. The Housekeeping Supervisor is responsible for ensuring work/cleaning schedules are followed, clean, wash sanitize, and polish fixtures, ledges, room heating/cooling units, bathrooms, clean floors including sweeping, mopping, stripping, waxing, buffing, and disinfecting. The facility's Maintenance Director Job Description revised 12/2022 documents to repair facility/resident property as necessary. In the event of inability to repair coordinate with outside vendors to make repair or replace as cost effectively as possible. Also ensure services that are provided by outside vendors are properly completed/supervised in accordance with contracts/work orders. Ensure supplies and equipment are maintained to provide a safe comfortable environment. The facility's Resident Roster dated 9/14/25, provided by V1 (Administrator) documents 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 reside in A wing. On 09/14/2025 from 8:30 AM to 3:00 PM, during random observations of A Wing: Hallway floors had visible dirt and debris. Paint was peeling and chipping on the walls in multiple resident rooms. Multiple resident bathrooms had black fuzzy discoloration along the walls behind toilets and sinks. Baseboards were peeling away from the walls and laying on the bathroom floors. The dining room floor was sticky and covered with dried liquid, food particles, and dirt. Several bathroom toilets were leaking water at the base of the toilet, with standing water present on the floors. Bath blankets were wrapped around the base of toilets that were leaking water. On 9/15/25 at 10:00 AM, R1 stated in a resident council meeting that A wing is very dirty and in disrepair, closet doors are falling off and drawers are sticking, paint is peeling, and the toilets never work. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145418 If continuation sheet Page 4 of 8 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 09/16/2025 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 9/15/2025 at 1:01 PM, V6 (Maintenance Director) stated We replace screens often on the toilets, and I'm not sure why toilets leak so frequently. There are lots of plumbing issues because the plumbing is old and needs replaced. We plan to start painting rooms and bathrooms at some point. There is black mold from water damage in the bathrooms and housekeeping should be washing walls in the bathrooms. On 9/15/2025 at 1:30 PM, V7 (Housekeeping Supervisor) stated We use a hospital grade cleaning solution to spray on mold on walls. We put the solution in a spray bottle, spray it on, leave it for five–six minutes, then spray it off. The staff used to be good at using it, but they haven't been using it for a while. The facility is cutting five staff members' hours—and told staff it's due to budget cuts. I have a checklist that is supposed to be completed, but sometimes the staff turn them back in and sometimes they don't. I am aware there is black mold in many bathrooms. The floors in the A Wing dining room are terrible—they look awful. On 9/15/25 at 2:15 PM, V7 stated that she has done a walk-through of A wing and has found mold in every bathroom. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145418 If continuation sheet Page 5 of 8 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 09/16/2025 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 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based 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.Findings include:The facility's Facility Assessment Tool, dated 9/11/2025, documents the facility will provide a Registered Nurse (RN) eight and a half hours per day as needed to accommodate RN staffing hours.The facility's (state agency) Notice of Staffing Violations, received date 8/18/25, documents the facility's January 1st- March 31st, 2025, quarter for payroll-based journal was shortfall for RN coverage on 55 days.The facility's nursing staff schedule for September 2025, documents on Saturday 9/6/25 and Sunday 9/7/25 the facility did not have eight hours of an RN working in the facility.On 9/16/2025 at 1:00 PM, V2 (Director of Nursing) confirmed the facility does not have an RN on certain days for a minimum of eight hours. V2 stated On the dates that we don't have an RN on the schedule or the daily staffing sheet; it is because we don't have an RN. We have that issue and have been cited by the (state agency) for low RN coverage. I used to have agency RNs that we could utilize, and they (corporate) won't let us use agency RNs anymore. So now we have some days that are short RN coverage for the 8 hours a day.The facility's Long-Term Care Facility Application for Medicare and Medicaid form dated 9/14/25 and signed by V1 (Administrator), documents 128 residents currently reside within the facility. Event ID: Facility ID: 145418 If continuation sheet Page 6 of 8 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 09/16/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.Findings include:The facility's Ceiling and Fans Policy, un-dated, documents Frequency: All fans should be cleaned quarterly or more often, if needed, by maintenance. Purpose: To ensure a clean work environment. The facility's Storage Policy, undated, documents Policy: Food should be stored properly and used within the appropriate time period to ensure safe and high-quality food is served. Purpose: Food safety. Procedure: The Use-by Guidelines-Posted should be used to determine a use-b date when labeling opened or unopened food that must be used within a certain time frame. Foods with a manufacturer's use-by date should still require and opened-on date once the item is opened. Expired food items should be disposed of.The facility's Staff Hygiene/Hair Nets Policy, dated 9/2024, documents Purpose: To establish standards for employee dress, personal hygiene, and hand hygiene practices. 2. Dress code will include at least the following. Specific uniform criteria and colors will be at the discretion of the Food Service Supervisor: e. Beards are to be trimmed and covered with face mask or [NAME] (beard net).The facility's Cooling Foods-Hot Foods and Ambient Foods Policy, undated, documents Policy: Hot food items should be cooled from 135 degrees Fahrenheit to 70 degrees Fahrenheit within two hours and to 41 degrees Fahrenheit or lower within an additional four hours. Ambient Food items should be cooled to 41 degrees Fahrenheit or lower within four hours. Purpose: Proper cooling of foods eliminates the most common cause of foodborne illnesses. Procedure: 10. Use a clean, sanitized, and calibrate thermometer to monitor temperatures and record on the cooling log at the appropriate intervals.On 9/14/25 at 8:27 AM a kitchen tour was conducted with V3/Dietary Manager. During breakfast preparation, two fans were noted blowing towards the breakfast steam table. The fans had an accumulation of thick, stringy dust and debris on their exteriors and blades. V3/Dietary Manager verified the presence of the debris and could not recall the last time the fans were cleaned. On 9/14/25 at 8:31 AM the walk-in refrigerator was found to contain three pans of food dated 9/12/25: two covered pans of pork loin and one of ground beef. V3/Dietary Manager verified these items were cooked two days prior for a meal on the current inspection day. In addition, an unlabeled 2-quart container of brownish/purple soft substance, identified by V3 as peanut butter and jelly mixture, was also observed. V3 stated the 2-quart container should have been properly labeled with its contents and preparation date. The facility's cool-down logs, covering the period of August 25, 2025, through September 12, 2025, do not document that cool down temperature records were completed for two large pans of pork loin and one large pan of ground beef, all dated September 12, 2025. On 9/14/25 at 8:33 AM, V3/Dietary Manager confirmed that these cool down log entries were missing and should have been recorded.On 9/14/25 at 8:35 AM, an open bag of pork patties was found in the freezer without a date or label. V3 verified the open bag of pork patties should have been properly labeled and dated when opened. On 9/14/25 at 8:36 AM V4/Cook with long facial hair was observed serving breakfast without a beard net. V3/Dietary Manager verified V4 was not wearing a beard net while serving breakfast and it is required. The facility's CMS (Centers for Medicare and Medicaid Services) Long Term Care Facility Application for Medicare and Medicaid Form 671 dated 9/14/25 and signed by V1/Administrator documents 128 residents currently reside within the facility. Event ID: Facility ID: 145418 If continuation sheet Page 7 of 8 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 09/16/2025 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 0847 Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. Level of Harm - Minimal harm or potential for actual harm Based 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.Findings include:The facility's undated Arbitration Agreement documents, Arbitration is an alternative means of resolving a dispute in place of court litigation. Binding Arbitration mean that both parties must comply with the arbitration decision, and that decision cannot be appeal. This agreement binds all parties, including, without limitation, any spouse, children or heirs of the resident, whose claims arise out of injuries, death because of alleged negligence, or wrongful act, but not intentional injury, and services rendered for any condition and arising out of the diagnosis, treatment, or care of the resident.The facility's CMS (Centers for Medicare and Medicaid Services) Long Term Care Facility Application for Medicare and Medicaid Form 671 dated 9/14/25 and signed by V1/Administrator documents 128 residents currently reside within the facility.R95's Contract Between Resident and (the facility) dated 8/11/25, documents that R95 signed the binding arbitration agreement.On 9/15/25 at 11:00 AM, R95 stated she does not recall anyone explaining what an arbitration agreement is, and R95 would not of signed this document if she knew.R43's Contract Between Resident and (the facility) dated 8/15/25, documents that R43 signed the binding arbitration agreement.On 9/14/25 at 11:10 AM, R43 stated that she does not remember V8 (Business Office Manager) explaining what an Arbitration Agreement was and if R43 had known she would not have signed the document.On 9/15/2025 at 10:00 AM, during resident council meeting, R1, R5, R21, R26, R43, and R115 did not recall signing the arbitration agreement or that anyone explained to them or their representative what it was, and all stated they would not have signed the arbitration agreement if they understood what it was.09/14/2025 10:45 AM, V8 (Business Office Manager) stated that V8 goes over all the information in the admission contract with residents and their families. V8 stated that arbitration agreement means if anything happens or comes up, the resident and family doesn't have to do anything, V8 takes care of it. When asked what V8 explains to residents and their families that the arbitration agreement is V8 stated, I tell them if Medicare or Medicaid doesn't pay something then we help take care of it. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145418 If continuation sheet Page 8 of 8