Inspection·December 9, 2022

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete applied a needle tip to the end. V7 then dialed the dose regulator on the end of the insulin pen to 15 units. V7 took the insulin pen into R27's room and injected R27 with the insulin into R27's left abdomen. V7 exited R27's room and proceeded down the hall to continue passing residents' medications. On 12/7/22 at 2:15p.m. V2 ( Director of Nurses/DON) stated that she expects nurses to notify a physician if a resident's blood glucose level is higher than the physician's highest parameters for blood glucose levels on the sliding scale insulin orders. Event ID: Facility ID: 145793 If continuation sheet Page 2 of 17 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 145793 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Renaissance Care Center 1675 East Ash Street Canton, IL 61520 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to ensure pressure relief boots were on a resident's feet and a resident's feet were floated in bed as ordered by the physician and documented in the care plan for one of four residents (R34) reviewed for pressure ulcers in a sample of 24. Residents Affected - Few Findings include: R34's physician's orders (POS) dated 10/12/22 documents R34 was ordered to wear pressure relieving boots only while in bed on each shift. R34's Wound Physician's note dated 11/30/22 documents R34 has a stage 4 pressure ulcer to the right heel. This same wound note documents R34 has pressure relieving boots as part of R34's pressure ulcer prevention interventions. R34's care plan intervention dated 7/22/22 documents for staff to float R34's heels while R34 is in bed. In addition, R34's care plan intervention dated 10/13/22 instructs for R34 to wear pressure relief boots to both lower extremities while in bed. On 12/7/22 at 9:53a.m. V2 (Director of Nurses) entered R34's room to assess R34's right heel stage 4 pressure ulcer. R34 was lying in bed with blankets over R34's feet. V2 pulled back R34's covers which demonstrated that R34 did not have pressure relief boots on either lower extremity and that neither of R34's heels were being floated off the bed. One of R34's pressure relief boots was on the shelf against the wall across from the foot of R34's bed. The other pressure relief boot was lying on the other bed in R34's room. V2 pointed to R34's pressure relief boots and verified R34 was not wearing them while in bed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145793 If continuation sheet Page 3 of 17 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 145793 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Renaissance Care Center 1675 East Ash Street Canton, IL 61520 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 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pain management for one of one resident (R41) reviewed for pain management in the sample of 24. This failure resulted in R41, who is a resident on hospice services with the diagnoses of malignant neoplasm of her right lung, cervix, trachea, and adrenal gland, refusing to get out of bed and reposition because of R41's extreme pain with any kind of movement. Residents Affected - Few Findings include: The facility's Management of Pain policy, dated 5/29/18, documents, Our mission is to facilitate independence, promote resident comfort and preserve resident dignity. The purpose of this policy is to accomplish that mission through an effective pain management program, providing our residents the means to receive necessary comfort, exercise greater independence, and enhance dignity and life involvement. We will achieve these goals through: Promptly and accurately assessing and diagnosing pain; Encouraging residents to self-report pain; Increasing comfort and reducing depression and anxiety in residents; Monitoring treatment efficacy and side effects; Preventing and minimizing anticipated pain when possible; Using pain medication judiciously to balance the resident's desired level of pain relief with the avoidance of unacceptable adverse consequences. For the purpose of this policy, pain is defined as 'whatever the experiencing person says it is, existing whenever the experiencing person says it does.' Procedure: Residents and families will be asked to periodically measure satisfaction related to pain and its management. Physician Communication and Involvement-Pain will be assessed and managed in a timely fashion, especially if it is of recent onset. The physician will be notified of resident's complaint of pain when not relieved by medication as ordered by the physician. Thorough communication with the physician will ensure an appropriate pain management plan. On 12/06/22 at 02:17 PM, R41 was alert and oriented lying-in bed on her right side. R41 stated she has lots of pain from her lung cancer, kidney stones, and my leg issues. A few nights ago, the nurse (V9 Licensed Practical Nurse) would not give me my pain medicine for some reason. I put my light on around 11:00 p.m. and asked her for a pain pill. She told me I couldn't get it just yet because I still had an hour before I was due. I was ok with this no big deal. So, an hour went by she told me the same thing again. 1 am went by, 2 am went by 3 am went by, 4 am went by, 5 am went by and she never brought me pain medication. She was in the room at 6 am finally and I asked her where my pill was. She told me I was sleeping when she came in. If I was sleeping it wasn't very good. I was in so much pain all I could do was doze off not actually sleep. She treated me like a dog. I'm in pain and I asked for a pain pill, but she says I don't even look like I'm in pain. If I get off my routine of pain medication it throws it completely off, and then I have to start all over again to try and get it under somewhat control. Unable to contact nurse. R41 was unable to reference a date. R41's MDS (Minimum Data Set), dated 10/23/22, documents that R41 scored a 13 on her BIMS (Brief Interview for Mental Status) assessment signifying that R41 is cognitively intact. A facility Grievance/Complaint form, dated 12/6/22, documents, (R41) stated that (V9) did not give her PRN (as needed) pain meds over the weekend. Resident could not give exact time or date. The form also documents, Follow Up Action Taken: Upon investigation, interviewed V9. She stated on 12/5/22 at 3:00 a.m., R41 asked for a pain pill. V9 stated when she brought the pain pill to R41, she was sleeping at that time. V9 attempted to wake R41 by calling her name. R41 did not wake up. Approximately at 5:30 a.m., V9 stated CNAs (Certified Nursing Assistant) informed her R41 was asking for a pain (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145793 If continuation sheet Page 4 of 17 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 145793 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Renaissance Care Center 1675 East Ash Street Canton, IL 61520 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 0697 Level of Harm - Actual harm pill. At that time V9 stated she was in another resident's room that was having an emergency. V9 instructed the CNAs to let R41 know she would be down with her pain medicine as soon as she was done helping the resident that was having the emergency. V9 then stated informed the oncoming nurse at 6:00 a.m. that the resident asked for pain medicine. R41 received pain medicine at 6:05 a.m. Residents Affected - Few R41's Controlled Drug Receipt/Record Disposition Form, dated 11/30-12/7/22, documents that R41 received Norco 10/325 mg one tablet on 12/4/22 at 8:10 p.m., and the next dose was not administered until 12/5/22 at 6:05 a.m. R41's Physician's orders, dated 12/7/22, documents that R41 has the following orders: Morphine Sulfate Solution 100 mg (milligrams)/5 ml (milliliters). Give 0.25 ml orally every six hours as needed for mild pain; Norco 10-325 mg one tablet by mouth every four hours as needed for pain. R41's Care plan, dated 4/19/22, documents, I have altered respiratory status related to Lung Cancer. Intervention: Use pain management as appropriate. Monitor/document side effects and effectiveness. R41's History and Physical, dated 10/16/22, documents, Chief Complaint: Pain. History of Present Illness: R41 complains of diffuse pain and achiness especially in her back but seems to be generalized. She has known metastatic lung cancer. Not currently undergoing active treatment. Impression and Plan: Chronic pain. R41's Pain Assessment, dated 10/23/22, documents that R41 has frequent severe pain, and that she complains of pain daily. R41's Significant change MDS, dated [DATE], documents in Section J Health Conditions that R41 has frequent severe pain R41's Medicare Daily Progress note, dated 10/23/2022 at 11:33 a.m., documents, R41 refused to be repositioned in bed or get up for meals. R41 has been deciding if she wants hospice or not and R41 has decided that she does not want to treat lung cancer and prefers to have hospice services. R41's medical record has no documentation of physician follow up. R41's Medicare Daily Progress note, dated 10/26/2022 at 09:56 a.m., documents, As needed pain medications given with effectiveness noted, R41 states that she is still having pain. R41 refused to get up for AM meal. R41 is able to feed self but requires set up assistance. R41 has poor appetite and fluid intake and has been educated on coming to dining room but still refuses. R41 refused to go to appointment for renal scan. R41 has decided on hospice and hospice will be here today to evaluate R41. Staff offered to reposition R41 and R41 refused. R41's record documents she was admitted to Hospice on 10/27. R41's Nurses' note, dated 10/27/22 at 9:41 a.m., documents, R41 refuses to get up for meals despite staff encouragement. Staff offered to reposition R41, and she refused. R41 prefers to lay on right side despite being educated on skin breakdown. R41's Nurses' note, dated 10/27/2022 at 12:42 p.m., documents, R41 is admitted to hospice. New order to discontinue Norco 7.5 mg/325 mg every 4 hours as needed. Start Norco 10 mg/325 mg every 4 hours as needed. R41's Care plan, dated 10/28/22, documents, Terminal illness-admit to hospice due to Cancer (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145793 If continuation sheet Page 5 of 17 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 145793 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Renaissance Care Center 1675 East Ash Street Canton, IL 61520 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 0697 Level of Harm - Actual harm Residents Affected - Few diagnosis. Goal: Myself and my family's will be maintained, and I will be comfortable without observable indications of pain and/or other physical, mental, or psychological symptoms thru staff monitoring and intervention. Intervention: Provide Pain/Discomfort medications per physician order. Monitor effectiveness and side effects. Report changes in pain, uncontrolled pain, and adverse effects of medications to the physician. R41's Nurses' note, dated 10/28/22 at 9:35 a.m., documents, Refuses to get up for meals. R41 has poor appetite. R41's Hospice admission Orders, dated 10/28/33, documents that R41's primary diagnosis for admission to hospice is malignant neoplasm of R41's right lung. The orders also document R41's related diagnoses are malignant neoplasm of the adrenal gland, trachea, and cervix. R41's Nurses' note, dated 10/30/22 at 12:47 p.m., documents, R41 states pain is all over. R41's Behavior Note, dated 11/1/22 at 2:24 a.m., documents, No behaviors noted or reported from change in pain and anxiety meds. Continues asking for pain meds on same schedule as before. R41's Nurses' note, dated 11/3/22 at 8:28 p.m., documents, Maintaining comfort as much as possible. R41's Behavior note, dated 11/3/2022 at 02:30 a.m., documents, R41 received a 10-325 Norco at 01:00 a.m. and rang her call light at 02:30 a.m. asking for another pain pill. R41 stated, 'she would not tell anyone if I gave her another one early.' R41 was told that we would not be administering anything early to her. R41 has been increasing her requests for pain pills and at denials she continues to ask for other medications that have been discontinued or not available to her like Diazepam and oxycodone-acetaminophen. R41's Behavior note was signed by V9. R41's Behavior note, dated 11/3/2022 at 4:00 a.m., documents, R41 request another pain pill at 03:50 a.m. I told her it has been less than 4 hours since her last pill and this is her 3rd request since being administered a pain pill at 01:00 a.m. She stated, 'it was okay to give it to her early since it's only like 10 minutes early.' I told her it was more than an hour early and I would not be issuing her medications early. I also explained due to the increasing requests and attempts at bargaining for more pills we have to chart all of the attempt times as well and would not be going against the orders to give them early. When entering her room to answer the call light she was asleep and woke up when turned the call light off. R41's Behavior note was signed by V9. R41's Medical record has no documentation of R41's physician or hospice being notified of R41's requesting pain medication, on 11/3/22, prior to being scheduled due to pain not being controlled. On 12/08/22 at 9:54 AM, V2 (Director of Nursing) confirmed that V9 should have notified the physician or hospice of R41's increased pain, but V9 did not do that. R41's Nurses' notes, dated 11/6/22 at 6:29 p.m., documents, Appears in no pain. However, the note also documents, Requesting Norco when available. R41's Nurses' note, dated 11/8/22 at 10:48 a.m., documents, R41 refuses to get up for meals. R41's Nurses' notes, dated 11/9/22 at 9:16 a.m., document, R41 refused to get up for meal. R41's Nurses' notes, dated 11/11/22 at 6:26 p.m., documents, Comfort maintained as much as possible. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145793 If continuation sheet Page 6 of 17 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 145793 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Renaissance Care Center 1675 East Ash Street Canton, IL 61520 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 0697 Level of Harm - Actual harm R41's Nurses' note, dated 11/13/2022 at 09:21 a.m., documents, Resident refuses to get up for meals. She is a total staff assist for transfers, ADLs (activities of daily living), and tray set up. She is hospice status. Her pain is controlled with as needed pain medications. However, R4's Nurses' notes also documents, Resident refuses to be repositioned. Stating 'if I move, I hurt.' Staff will continue with current plan of care. Residents Affected - Few R41's MAR (Medication Administration Record), dated 11/22, documents that R41's tolerable pain is a 4 (on a pain scale of 0-10). R41's Pain assessments document that 17 out of 30 days, R41's pain level exceeded her tolerable pain rating it from a 5-10 (on a pain scale of 0-10). The MAR also documents that R41 is being administered Norco 10-325mg on an average of daily two to four times a day with the exception of five days when R41 requested it one time during the day. In addition to the Norco, R41 was started on Morphine as needed 11/3/22, and R41 requested the Morphine (11/3-11/30/22) one time a day nine days and twice a day four days. On 12/08/22 at 12:08 PM, V8 (Certified Nursing Assistant) stated, (R41) complains a lot of being in pain. She doesn't show facial expressions of pain, but I'm not in her body so I don't know what she is feeling. When we provide incontinent care to R41, R41 cry's out and will be saying, 'Oh that hurts' the whole time especially if we have to roll her to her left side. On 12/08/22 at 9:54 AM, V2 (Director of Nursing) stat (R41) does have frequent pain. On 12/08/22 at 10:43 AM, V5 (MDS-Minimum Data Set Coordinator) stated, (R41) frequently requests a change in her pain medication or an increase. V5 also confirmed that a person can build up a tolerance to pain medication, and that R41 has active cancer. On 12/08/22 at 11:00 AM, V6 (Hospice Registered Nurse) was assessing R41. R41 stated, My pain is just all over. I'd say it's a 7 (scale of 0-10) right now. It's stabbing and aching. The main places it hurts are my kidneys and my lungs. My cancer is primarily in my lungs. I don't get out of bed because I hurt too much. I can't even move to roll over let alone get out of bed the pain is so bad. I can only lay in one position to help with the pain. My heart has also been fluttering and beating fast more lately. While R41 was speaking she was constantly fidgeting and facial grimacing throughout the conversation. V6 explained to (R41), Your pain is a vicious cycle. You hurt then you start getting anxious. If your pain isn't controlled, you get even more anxious and your pain keeps going up because your body is getting anxious and worked up. V6 also stated, I feel like (R41) would benefit from changing her Norco to something like Methadone because I feel that her body may have built up a tolerance and she needs a constant schedule to keep ahead of her pain. (R41) has lung cancer and has had multiple fractures so she for sure has pain. On 12/09/22 at 10:15 a.m., V1 (Administrator) stated that (R41) is on hospice for her diagnosis of cancer, but she feels that (R41) is just a pain medication seeker because she is always wanting more pain medications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145793 If continuation sheet Page 7 of 17 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 145793 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Renaissance Care Center 1675 East Ash Street Canton, IL 61520 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Based on observation, interview and record review the facility failed to ensure licensed nursing staff had the necessary skill set to identify and address a resident's change in condition, properly disinfect a blood glucose monitor between uses, and prime the needle tip of an insulin pen before use. These failures affected six of six residents (R27, R8, R5, R18, R39, R12) reviewed for nursing services in a sample of 24. Findings include: A Charge Nurse (LPN/Licensed Practical Nurse) policy/Job Description (undated) states, The duties of this position include, but are not limited to the following: 1. Follows established policies and procedures of the nursing department and contributes to change when necessary. 2. Responsible for unit's assigned personnel to assure quality care is provided, and Is accountable for administration of medications and treatments as prescribed by the attending physician and recording of such in the health record. An Insulin injections policy dated as revised 11/15/14 gives as its purpose, To provide guidelines to Licensed nursing staff for performing insulin injections effectively and safely. In addition, this policy states, If using a FlexPen small amounts of air may collect in the cartridge during normal use. To avoid injecting air and ensure proper dosing: A. Turn the dose selector to 2 units. B. Hold your FlexPen with the needle pointing up, and tap the cartridge gently a few times, which moves the air bubbles to the top. C. Press the push-button all the way in until the dose is back to 0. A drop of insulin should appear at the tip of the needle. D. If no drop appears repeat. A Physician Notification of Resident Change of Condition/ When to call 911 policy dated as revised 5/9/19 gives as its purpose, To provide guidelines for facility staff to follow to ensure that there is appropriate notification of any change in a resident's condition, and proper decisioning when to contact 911 for emergency discharge to hospital. In addition, this policy gives examples of when a nurse should notify a physician with changes in resident's condition including, Glucometer reading >300 or <70, and are symptomatic unless specific parameters given by physician, and If the change in condition is assessed as not serious/life threatening the Charge Nurse should notify the physician of the condition and request orders. A Glucose Meter Cleaning Policy dated 8/1/13 states, Clean and disinfect glucose meter appropriately using EPA (Environmental Protection Agency) approved cleaner after each use. A blood glucose machine manufacturer's User Instruction Manual (undated) under Cleaning and Disinfection Guidelines states there are two options for disinfecting the machine between uses, Cleaning and disinfecting can be completed by using a commercially available EPA registered disinfectant detergent or germicide wipe, or dilute 1mL of household bleach (5-6% sodium hypochlorite solution) in 9mL of water to achieve a 1:10 dilution (final concentration of 0.5%-0.6% sodium hypochlorite). The solution can then be used to dampen a paper towel (do not saturate the towel). Then use the dampened paper towel to thoroughly wipe down the meter. R27's list of current diagnoses includes Type 2 Diabetes Mellitus. R27's physician's orders sheet (POS) dated 8/11/22 documents R27 was ordered NovoLog FlexPen (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145793 If continuation sheet Page 8 of 17 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 145793 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Renaissance Care Center 1675 East Ash Street Canton, IL 61520 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Solution Pen-injector 100UNIT/ML (milliliters) Inject as per sliding scale: if (blood glucose reading is) 151 200mg/dL (milligrams per deciliters) = 3u (units); 201 - 250 = 6u; 251 - 300 = 9u; 301 - 350 = 12u; 351 - 400 = 15u, injected before meals. On 12/6/22 at 11:20a.m. V7 (Licensed Practical Nurse) was performing residents' blood glucose monitoring and administering residents' medications. V7 removed a blood glucose monitor, a blood glucose test strip, and a lancet from the medication cart and entered R27's room. V7 proceeded to puncture R27's finger using the lancet then placed a drop of blood onto the test strip which V7 had inserted into the blood glucose monitor. The blood glucose monitor showed that R27's blood glucose level was 518 mg/dl. V7 removed the test strip from the blood glucose monitor and exited R27's room. V7 stated she did not have any bleach wipes to disinfect the blood glucose monitor and that she would have to use an alcohol swab instead. V7 proceeded to tear open a small packet containing a gauze swab moistened with alcohol and then used the swab to cleanse the outer surface of the blood glucose machine. V7 referred to R27's physician's orders to determine how much insulin was prescribed for R27's blood glucose of 518mg/dL. V7 stated that R27 receives sliding scale Novolog insulin using a prefilled insulin pen. V7 stated that R27's sliding scale insulin orders instruct nurses how much insulin to administer based on how high R27's blood glucose is before meals. V7 stated that even though R27's blood glucose reading is very high at 518mg/dL, R27's sliding scale insulin orders only show a maximum insulin dose of 15 units to be administered when R27's blood glucose reading is between 351-400mg/dL. V7 stated she would not need to call R27's physician because R27's physician did not leave orders for what the nurse should do in the event R27's blood glucose was above the highest limit of 400mg/dL and 15 units of Novolog insulin. V7 stated she would simply give the highest dose of insulin ordered on the sliding scale which was 15 units. V7 removed R27's Novolog insulin pen from the medication cart and applied a needle tip to the end. V7 then dialed the dose regulator on the end of the insulin pen to 15 units. V7 stated she did not need to prime the insulin pen's needle tip with a small amount of the insulin prior to injecting R27. V7 took the insulin pen into R27's room and injected R27 with the insulin into R27's left abdomen. V7 exited R27's room and proceeded down the hall to continue passing residents' medications. At 11:43a.m. V7 stopped in front of R8 and R5's room to monitor both residents' blood glucose levels and administer medications. Without disinfecting the blood glucose monitor used to test R27's blood, V7 took the monitor, a test strip and a lancet into R8 and R5's room. V7 proceeded to use the lancet to puncture R8's finger and applied a drop of R8's blood to the test strip inserted into the blood glucose machine. Once V7 finished with R8's blood glucose monitoring, V7 removed the test strip from the machine and proceeded to wipe it with an alcohol swab pad. V7 reentered R8 and R5's room and proceeded to use the same blood glucose monitor to test for R5's blood glucose reading. V7 exited R5's room, wiped the blood glucose monitor with an alcohol swab and pushed the medication cart down the hall to R18's room. At 12:02p.m. V7 entered R18's room, used a lancet to puncture the end of R18's finger and apply a drop of blood to the test strip inserted into the blood glucose monitor. Once V7 was finished testing R18's blood, V7 removed the test strip from the blood glucose monitor and wiped the machine using an alcohol swab. At 12:10p.m. V7 entered R39's room and used the same blood glucose monitor to test R39's blood glucose level. Afterwards, V7 again wiped the blood glucose monitor with an alcohol swab. At 12:39p.m. V7 entered R12's room and used the same blood glucose monitor to test R12's blood glucose level. Once V7 was finished, she again cleansed the monitor using an alcohol swab. On 12/8/22 at 10:48a.m. V2 (Director of Nurses) stated that she expects licensed nursing staff to have the competency/knowledge to ensure an insulin FlexPen needle tip is primed before injecting the resident with insulin, be knowledgeable on how to effectively disinfect a blood glucose monitor (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145793 If continuation sheet Page 9 of 17 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 145793 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Renaissance Care Center 1675 East Ash Street Canton, IL 61520 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 0726 between uses, and be able to determine when to call a physician for a change in condition such as when a blood glucose level is elevated above the highest range on the physician's orders for sliding scale insulin. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145793 If continuation sheet Page 10 of 17 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 145793 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Renaissance Care Center 1675 East Ash Street Canton, IL 61520 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to document diagnoses and behaviors to warrant the use of an antipsychotic and perform gradual dose reductions (GDRs) for two of five residents (R28, R35) reviewed for psychotropics in the sample of 24. Findings include: The facility's Psychotropic Medications Protocol Chemical Restraints policy, dated 8/15/18, documents, Residents shall only be given antipsychotic drugs when clinically indicated according to appropriate diagnosis and physician's order. Residents who receive antipsychotic/psychoactive medications shall have gradual dose reductions attempted in accordance with state and federal regulation and behavior interventions reviewed, unless clinically contraindicated. 1. R28's Physician's order, dated 12/7/22, document that R28 has an order to receive Zyprexa (antipsychotic) 2.5 mg (milligrams) by mouth at bedtime for the diagnosis of refractory depression. R28's Care plan, dated 12/24/21, documents, I use psychotropic medications (Zyprexa) related to refractory depression. On 12/07/22 at 08:23 AM, R28 was lying in bed alert not displaying any behaviors. R28's Nurses' note, dated 12/24/2021 at 03:31 a.m., documents, In bed resting. Doctor's office returned call last night with new order to add Zyprexa 2.5 mg daily for refractory depression. His family was concerned he was depressed and not wanting to do his therapy. They were afraid he was just giving up. Spoke with R28 to encourage him to put in effort and let him know we would call the doctor. Staff will continue to work with R28 to move forward with his therapy and spend time with family. R28's Pharmacy Note to Attending Physician/Prescriber, dated 6/6/22, documents, This resident (R28) is diagnosed with Dementia and is receiving the antipsychotic Zyprexa 2.5 mg daily. Please consider reducing the dose of antipsychotic, with the eventual goal of discontinuation, while monitoring to re-emergency of target and/or withdrawal symptoms. The Pharmacy note has no documentation of a physician response to the pharmacist's recommendation. R28's Pharmacy Note to Attending Physician/Prescriber, dated 8/4/22, documents, As a reminder, per CMS (Centers for Medicare and Medicaid Services) guidelines, this patient (R28) is due for GDR for the following medication to ensure that he/she is using the lowest possible effective/optimal dose: Zyprexa 2.5 mg at bedtime. The Pharmacy note has no documentation of a physician response to the pharmacist's recommendation. R28's Psychiatrist Note, dated 10/20/22, documents, Staff reported that he was not wanting to come out or get up out of bed. R28 takes Zyprexa. Review of System: General: Dementia. Psychiatric: Depression. R28's Behavior/Intervention Monthly Flow Record, dated 12/22, documents that R28 is being monitored for the behaviors of easily agitated and refusing to get out of bed into recliner or wheelchair. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145793 If continuation sheet Page 11 of 17 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 145793 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Renaissance Care Center 1675 East Ash Street Canton, IL 61520 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few R28's current medical record has no documentation of a GDR attempt of R28's Zyprexa since it was started on 12/23/21. On 12/08/22 at 9:54 AM, V2 (Director of Nursing) stated, (R28) is on an antipsychotic for refractory depression. His behaviors are refusing cares, inappropriately touching staff, and easily agitated. I don't think he's had many behaviors that I'm aware of. V2 confirmed that R28 has not had a reduction in Zyprexa since it was started. On 12/08/22 at 10:35 AM, V3 (Social Services Director) stated, (R28's) behaviors do not put him or others at risk for harm. On 12/08/22 at 12:08 PM, V8 (Certified Nursing Assistant) stated, (R28) basically just gets agitated when he wants to refuse cares, and he doesn't like to get out of bed. He doesn't do anything that would put himself or others at risk for harm. 2. On 12/07/22 at 08:36 AM, R35 was alert smiling and conversing appropriately with no behaviors observed. R35's Initial Psychotropic Drug Assessment, dated 6/26/20, documents that R35 was admitted to the facility on [DATE] receiving Zyprexa 20 mg by mouth daily for the diagnosis of Major Depressive Disorder. R35's Physician's orders, dated 12/7/22, document that R35 had an order to receive Zyprexa 15 mg by mouth at bedtime for depression. R35's Care plan, dated 1/11/22, documents, I exhibit the behavior of crying/tearful. I take medication to help relieve symptoms. Concerns may be related to diagnosis of Major depression. R35's Care plan, dated 1/11/22, documents, I use psychotropic medications (olanzapine, benztropine) related to major depressive disorder. R35's Pharmacy Notes to Attending Physician/Prescriber, dated 7/6/22 and 8/4/22, document, As a reminder, per CMS (Centers for Medicare and Medicaid Services) guidelines, this patient (R35) is due for GDR for the following medication to ensure that he/she is using the lowest possible effective/optimal dose: Olanzapine 15 mg at bedtime. The Pharmacy note has no documentation of a physician response to the pharmacist's recommendation. R35's Behavioral Care Solutions note, dated 10/31/22, documents, Denied agitation, anxiety, depression. no observed delusions and tremors. Staff has not observed behaviors. Review of System: General: Dementia. Psychiatric: Depression. R35's Behavior Note, dated 10/25/22 and 10/27/22, document, No behaviors noted or reported from decrease in Zyprexa. R35's Behavior Note, dated 11/2/22, documents, No behaviors noted this shift continues increased Zyprexa due to failed reduction. R35's Interdisciplinary Team Note, dated 11/7/2022 at 11:41 a.m., documents, Zyprexa 15 mg at bedtime for crying, tearful, refusing care and treatment and getting out of bed. Last medication change (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145793 If continuation sheet Page 12 of 17 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 145793 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Renaissance Care Center 1675 East Ash Street Canton, IL 61520 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 10/26/22. Current behaviors noted this review. Action: attempted to GDR Zyprexa to 7.5 mg on 10/22/22. R35 did not tolerate and was increased back to 15 mg on 10/26/22. R35's Behavior/Intervention Monthly Flow Record, dated 10/22, documents that R35 is being monitored for crying/tearful, refusing cares/treatments/getting out of bed, and difficulty sleeping. The flow record also has no documentation of behaviors occurring or increasing during the month of October to warrant the failed GDR attempt. On 12/08/22 at 12:08 PM, V8 stated, (R35) is the sweetest woman ever. She has days that she may say she is in a grouchy mood, but she doesn't really have any behaviors. Especially nothing that would put herself or others at risk for harm. On 12/08/22 at 09:54 AM, V2 (Director of Nursing) stated, (R35) is on an antipsychotic for the behaviors of refusing cares/treatments/getting out of bed. We do not have a diagnosis for her antipsychotic. The doctor just ordered it but did not give a diagnosis. She was admitted with the Zyprexa with severe episodes of major depressive episodes without psychotic features. We attempted to decrease her to 7.5 mg in October, but it failed so we increased it back up because of or crying, tearful, refusing care and treatment and getting out of bed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145793 If continuation sheet Page 13 of 17 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 145793 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Renaissance Care Center 1675 East Ash Street Canton, IL 61520 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 - Potential for minimal harm Based on interview and record review, the facility failed to state in the arbitration agreement that,the agreement can be rescinded within 30 days of signing it and that it is not required to sign an agreement for binding arbitration as a condition of admission. They also failed to explain the arbitration agreement in a manner that the resident and their representative understands or acknowledge if the resident and their representative understood the agreement. This had the potential to affect all 52 residents residing in the facility. Residents Affected - Many Findings include: The facility's Arbitration Agreement between Facility and Resident documents This arbitration may be revoked by written notice delivered by Resident to this facility within three (3) business days of signature. There is no documentation in the arbitration agreement that it is not required to sign the agreement for binding arbitration as a condition of admission. It also does not define what arbitration is in language that the resident or their representative can understand. R23's Arbitration Agreement between Facility and Resident, dated 8/12/22, documents that V11 signed the binding arbitration. On 12/8/22 at 2:02 PM, V11 (R23's Family Member) stated that she knew arbitration was something legal but was not aware she was signing away the rights to litigation if needed. The arbitration agreement was not explained to her and she thought all of the papers had to be signed for R23 to be admitted to the facility. R27's Arbitration Agreement between Facility and Resident, dated 10/11/21, documents that V12 (R27's Family Member) signed the binding arbitration. On 12/7/22 at 1:15 PM, V12 stated, I signed a lot of papers for (R27's) admission. No one explained anything to me about what the arbitration paper meant. I signed whatever they put in front of me. I had no idea I was giving up our legal rights. R35's Arbitration Agreement between Facility and Resident, dated 6/23/20, documents that V13 (R35's Family Member) signed the binding arbitration. On 12/9/22 at 8:05 AM, V13 (R35's Family Member) stated that someone went through the admission packet with her, but she was not aware she was signing R35's legal rights away. V13 also stated that she thought that arbitration meant an independent person would represent R35 and help with any legal issues. On 12/6/22 at 11:38 AM, V1 (Administrator) stated that everyone signs the arbitration page when they are admitted . It is a part of the admission packet and V10 (Receptionist) goes over the admission packet with the residents or residents' family upon admission. On 12/8/22 at 9:25 AM, V10 (Receptionist) stated that the contract includes the arbitration papers. V10 stated I explain all the papers. The arbitration agreement is for anything they (resident/resident representative) want to argue or are unhappy with about the resident's care. For instance, if they have a complaint about the food or showers, they are to get ahold of a nurse or Social Services. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145793 If continuation sheet Page 14 of 17 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 145793 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Renaissance Care Center 1675 East Ash Street Canton, IL 61520 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 Level of Harm - Potential for minimal harm V10 also stated that the arbitration agreement had nothing to do with anything legal or at least that was her understanding and that is how she explained the agreement to the residents' families. The facility's CMS (Centers for Medicare and Medicaid Services) Form 672 dated 12/6/22 and signed by V5 (MDS/Minimum Data Set Coordinator) documents 52 residents reside within the facility. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145793 If continuation sheet Page 15 of 17 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 145793 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Renaissance Care Center 1675 East Ash Street Canton, IL 61520 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to disinfect blood glucose meter with a disinfectant agent according to manufacturer's guidelines. This had the potential to affect 10 residents (R5, R8, R9, R20, R25, R30, R31, R40, R41, R43) who receive scheduled blood glucose monitoring. Residents Affected - Some Findings include: The facility's Glucose Meter Cleaning policy, dated 8/1/13, documents, Purpose: To ensure proper cleaning of Glucose meter after each use. Procedure: Obtain glucose reading according to facility guidelines. Clean and disinfect glucose meter appropriately using EPA approved cleaner after each use. Allow glucose meter to thoroughly dry prior to using it on another resident. The facility's Glucose Monitor manual documents, Cleaning & Disinfecting Guidelines: Contact with blood presents a potential infection risk. We suggest cleaning and disinfecting the meter between patient use. Option 1: Cleaning and disinfecting can be completed by using a commercially available EPA-registered disinfectant detergent or germicide wipe. To use a wipe, remove from the container and follow product label instructions to disinfect the meter. Option 2: To clean the outside of the blood glucose meter, use a lint-free cloth dampened with soapy water or isopropyl alcohol (70-80%). To disinfect the meter, dilute 1 mL (milliliter) of household bleach (5-6% sodium hypochlorite solution) in 9 mL of water to achieve a 1:10 dilution (final concentration of 0.5-0.6% sodium hypochlorite). The solution can then be used to dampen a paper towel (do not saturate the towel). Then use the dampened paper towel to thoroughly wipe down the meter. Please note there are commercially available 1:10 bleach wipes from a variety of manufacturers. On 12/6/22 at 11:20 a.m. V7 (Licensed Practical Nurse) was performing residents' blood glucose monitoring and administering residents' medications. V7 removed a blood glucose monitor, a blood glucose test strip, and a lancet from the medication cart and entered R27's room. V7 proceeded to puncture R27's finger using the lancet then placed a drop of blood onto the test strip which V7 had inserted into the blood glucose monitor. The blood glucose monitor showed that R27's blood glucose level was 518 mg/dl. V7 removed the test strip from the blood glucose monitor and exited R27's room. V7 stated she did not have any bleach wipes to disinfect the blood glucose monitor and that she would have to use an alcohol swab instead. V7 proceeded to tear open a small packet containing a gauze swab moistened with alcohol and then used the swab to cleanse the outer surface of the blood glucose machine. Once V7 was finished administering R27's medication, V7 exited R27's room and proceeded down the hall to continue testing residents' blood glucose levels and passing residents' medications. At 11:43a.m. V7 stopped in front of R8 and R5's room to monitor both residents' blood glucose levels and administer medications. Without disinfecting the blood glucose monitor used to test R27's blood, V7 took the monitor, a test strip and a lancet into R8 and R5's room. V7 proceeded to use the lancet to puncture R8's finger and applied a drop of R8's blood to the test strip inserted into the blood glucose machine. Once V7 finished with R8's blood glucose monitoring, V7 removed the test strip from the monitor and proceeded to wipe it with an alcohol swab. V7 reentered R8 and R5's room and proceeded to test R5's blood glucose level using the same machine used to test for R5's blood glucose reading. V7 exited R5's room, wiped the blood glucose monitor with an alcohol swab and pushed the medication cart down the hall to R18's room. At 12:02p.m. V7 entered R18's room, used a lancet to puncture the end of R18's finger and apply a drop of blood to the test strip inserted into the blood glucose monitor. Once V7 was finished testing R18's blood, V7 removed the test strip from the blood glucose monitor and wiped the monitor using an alcohol swab. At 12:10p.m. V7 entered R39's room and used the same (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145793 If continuation sheet Page 16 of 17 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 145793 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Renaissance Care Center 1675 East Ash Street Canton, IL 61520 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some blood glucose monitor to test R39's blood glucose level. Afterwards, V7 again wiped the blood glucose monitor with an alcohol swab. At 12:39p.m. V7 entered R12's room and used the same blood glucose monitor to test R12's blood glucose level. Once V7 was finished, she again cleansed the machine using only an alcohol swab. On 12/07/22 at 08:11 AM, V4 (Registered Nurse) applied gloves and performed a blood glucose check on R31. V4 walked back out to the medication cart and set the glucose monitor on the top of the medication cart, without sanitizing it. V4 stated, I think we have disinfecting wipes on this cart. I've done two blood glucose checks prior to (R31's), and I cleansed them with the disinfecting wipes. V4 began opening drawers on her medication cart, and was unable to find the disinfectant wipes. Then, V4 checked her storage rooms at her nurses' station and was unable to find the wipes as well. At 8:40 a.m., V4 presented a package of disinfectant wipes, and stated, These are the wipes that we use to clean the glucose monitor. I used these wipes to clean the glucose monitor twice before R31's blood glucose check, and I will use them for the others I have left. I was told we can use these or alcohol swabs to clean them. The facility disinfecting wipes packaging had no documentation of the wipe disinfecting against blood-borne pathogens. On 12/07/22 at 3:00 PM, V2 (Director of Nursing) provided the facility blood glucose meter user manual and the alcohol swabs and stated that it documents to clean the machine with alcohol wipes. V2 also stated, the wipes we use do the same thing as the alcohol swabs. On 12/8/22 at 10:48a.m. V2 (Director of Nurses) stated that she expects licensed nursing staff to be knowledgeable on how to effectively disinfect a blood glucose monitor between uses. On 12/08/22 at 12:08 PM, V4 stated, I'm working this hallway today. I have blood glucose checks that I've done today on this hall as well. I don't have any of the disinfectant wipes that I showed you on this cart. So, I've been using alcohol swabs to clean the glucose meter. On 12/8/22, V1 (Administrator) provided an Order Listing report, dated 12/8/22, that documented the following residents received blood glucose monitoring at least daily: R5, R8, R9, R20, R25, R30, R31, R40, R41, R43. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145793 If continuation sheet Page 17 of 17