Inspection·November 7, 2023

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow its policy to notify Responsible Party of change in condition for one (R1) of three residents reviewed for notifications in a sample of three. Findings include: The facility's Responsible Party Notification of Resident Change of Condition Policy, Dated 7/8/17, documents: Purpose: To ensure that residents' responsible parties are notified of changes in conditions that occur. Residents' responsible parties will be notified of changes that occur in residents condition as warranted. It is the responsibility of all licensed personnel to notify the family or responsible parties of a change in residents' condition. 1. Primary family member or responsible party will be notified of change in residents condition. R1's diagnoses include: Dementia, Muscle Weakness, Parkinson's disease. R1's Minimum Data Set (MDS), dated [DATE], documents no score for R1's BIMS (Brief Interview of Mental Status); R1 was not able to be scored. (MDS indicates that on a scale of 0 - 15, 13 to 15 cognitively intact; 8 to 12 moderate impairment; and 0 to 7 severe impairment.) R1's Care Plan documents: I am being monitored for Covid19 per IDPH/(State) Department of Public Health and CDC/Centers for Disease Control and Prevention guidelines. Covid Positive 10/24/23. On 11/3/23 at 12:05pm, V7 Licensed Practical Nurse/LPN stated that V9 Power of Attorney/POA to R1 was not notified of R1's positive Covid test; stated that R1 tested positive on 10/24/23. (V7 LPN showed that there were no computer documentation supporting notification to V9 POA, that no staff charted that they notified V9 POA.) On 11/7/23 at 10:55am, V14 Ombudsman, stated: (V9 POA was very upset that she was not notified about (R1's) Covid. On 11/6/23 at 8:40am, V9 POA stated that she visited R1 on 10/27/23, that V8 Registered Nurse/RN met her at the door to the 200 wing and told her that there was Covid on the wing and that R1 had Covid as well; stated that the staff had not notified her prior to her arrival at this time. On 11/7/23 at 11:45am, V1 Administrator stated that (V9 POA) had not been notified about R1's Positive Covid Test, that V9 POA found out about this on 10/27/23. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 145793 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 11/07/2023 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)