Health inspection·November 16, 2023

F 0623 Level of Harm - Potential for minimal harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete On 11/14/23, at 10:30 am, V6 (R50's Spouse) stated, (R50) has been sent to the hospital a couple times, and I do not remember receiving anything in writing on the hospitalization. On 11/14/23 at 2:00 pm, V1 (Administrator) stated, I cannot provide you with any written documentation that representatives were given written notification for any of our Resident hospital transfers because I cannot find anything in any of our Resident medical records, or even any nursing progress notes on them either. Written notifications of hospital transfers have not been getting done. Event ID: Facility ID: 145793 If continuation sheet Page 2 of 14 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 11/16/2023 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)

F 0625 Level of Harm - Potential for minimal harm Residents Affected - Many Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. Based on record review and interview the Facility failed to notify the Resident/Resident Representative, in writing of the Facility Bed Hold Policy. This failure has the potential to affect all 52 Residents residing in the Facility. Findings include: Facility Application for Medicare and Medicaid Report (CMS/Central Management Services Form 671), dated 11/14/23, documents 52 Residents residing in the Facility. Facility Discharge/Transfer Policy, revised 5/29/18, documents: the purpose is to provide the Facility with guideline for appropriate discharge and transfer procedures; it is the responsibility of all staff to ensure that transfer and discharge are appropriate; when the Facility transfers or discharges Resident under any circumstances appropriate documentation shall be made in the Resident's clinical record; and before the Facility transfers a Resident to a hospital, the Facility must provide written information to the Resident/Family Member/Legal Representative that specifies the duration of the Facilities bed to hold policy and the Facilities policies regarding bed hold periods; the Resident/Responsible Party will be given the Resident Rights Regarding Bed Holds; and will be given a copy of the jointly signed and dated Bed Hold form and a copy will be placed in the Resident's medical record until the Resident is re-admitted ; and if the Resident's hospital visit should for any reason exceed 24 hours, then the State of Resident's Rights Regarding Bed Hold shall be provided to the Resident/family Member/Legal Representative. R4's Census List, dated 11/16/23, documents Hospital Discharge/Unpaid Leave dates of 2/22/23, 3/29/23, 6/14/23, 8/26/23 and 9/15/23. R9's Census List, dated 11/16/23, documents Hospital Discharge/Unpaid Leave dates of 2/28/23, 6/16/23, 8/13/23 and 9/21/23. R17's Census List, dated 11/16/23, documents a Hospital Discharge/Unpaid Leave date of 8/8/23. R27's Census List, dated 11/16/23, documents a Hospital Discharge/Unpaid Leave date of 8/29/23. R34's Census List, dated 11/16/23, documents a Hospital Discharge/Unpaid Leave date of 11/7/23. R50's Census List, dated 11/16/23, documents Hospital Discharge/Unpaid Leave dates of 6/24/23 and 8/1/23. On 11/14/23, at 10:30 am, V6 (R50's Spouse) stated, (R50) has been sent to the hospital a couple times, and I do not remember receiving anything in writing on the bed hold policy. On 11/16/23 at 2:00 pm, the Facility could not provide written notification documentation of the Resident/Family Member/Legal Representative for Bed Hold Policy for hospital transfers/discharges. On 11/14/23 at 2:00 pm, V1 (Administrator) stated, I cannot provide you with any written documentation that representatives were given to written notification of Bed Holds for any of our Resident hospital transfers, for the last year, because I cannot find anything in any of our Resident medical (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145793 If continuation sheet Page 3 of 14 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 11/16/2023 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)

F 0625 Level of Harm - Potential for minimal harm records, or even any nursing progress notes on them either. I looked back, when I was trying to find any documentation for this, and I noticed that we got 'cited' for this exact issue back in 2019 on a survey. When we got that citation, our plan of correction was that our Marketing Director, at that time, started going to the hospital and getting the Bed Hold's signed in person, but she is no longer employed here, so it has not been getting done since. We are not doing them for anyone (written notification of bed hold policy). Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145793 If continuation sheet Page 4 of 14 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 11/16/2023 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)

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Based on observation, interview and record review the facility failed to provide procedures, protocols, and training for the use of a manual feeding tube declogging device and failed to follow physician orders for feeding tube site wound treatment for one resident (R9) of two residents reviewed for feeding tubes in the sample of 34. Findings include: Manufacturer Instructions (insert) for Use of (declogging device) dated 2021 documents: Intended use: The intended use of the declogger is to clear clogs from enteral feeding tubes and thereby reduce the occurrence of feeding tube replacement procedures. Indications for use: The declogger is indicated for use only in clearing occlusions and/or clogs in feeding tubes (G/Gastrostomy, J/Jejunostomy, and/or PEG/Percutaneous Endoscopic Gastrostomy style) in sizes from 14Fr (French) 22Fr. User instructions indicate there are five different sizes of decloggers and that both the size (diameter) and length of the feeding tube should be known to use the appropriate size declogger. Protocol/Policy for use of the declogger: The declogger should be used every week to maintain unimpeded flow of an enteral formula. The declogger device will also be used to achieve patency of a tube that has become clogged with semi-solid formula. The declogger should be disposed of after single use. The following protocol should be followed according to the desired need. Blocked Jejunostomy tube 1. Determine the size of the gastric or jejunostomy tube. CAUTION: Verify that the tube has not been modified i.e., shortened. 2. Select appropriate size of declogger device that corresponds to the size of the tube. 4. Insert the declogging device to reach the blockage and slowly rotate two times in a clockwise direction then reverse and rotate two-times in a counterclockwise direction while removing it. Do not attempt to force the declogging device through the entire blockage. 5. Repeat the entire process until the stop disk of the declogging device is reached without difficulty. 6. Flush tube with 30-60cc's (cubic centimeters) of water. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145793 If continuation sheet Page 5 of 14 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 11/16/2023 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)

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few CAUTION: If the declogging device becomes imbedded in the blockage and cannot be easily dislodged, the enteral feeding tube will need to be replaced. DO NOT attempt to physically remove the declogging device. WARNINGS: If the declogging device becomes imbedded in the blockage and cannot be easily dislodged, the entire feeding tube will need to be changed. DO NOT attempt to physically remove the declogging device. Cross Contamination Risk: Do not reuse the declogging device as this may spread contamination from one patient to another patient. Residual Risk: Risk associated with the use of this product has been reduced as far as possible, but the product cannot completely eliminate potential patient or user harm arising from the following: Harm from mechanical hazards Harm from misuse, or user error Harm from unanticipated origins. Facility Policy/Enteral Tube Feeding dated 9/30/21 documents: When a G-tube becomes displaced, plugged, damaged, or comes completely out it may be replaced or declogged unless contraindicated. Observe the insertion site frequently and report any signs and symptoms of skin breakdown or infection to nurse immediately. Protect skin from further breakdown with appropriate interventions. No policy, protocol/procedure for use of a physical declogging device was presented. Nurse Note dated 11/11/23 at 8:09am indicates R9 was sent to the hospital for J-tube dislodgement after R9's J-tube was found lying beside R9 in her bed with the bulb intact. Note indicates R9's J-tube was reinserted to maintain patency of the stoma. Note indicates R9's J-tube was last surgically replaced on 9/22/23. Note dated 11/11/23 at 9:33am indicates R9 returned to the facility and per hospital staff R9's J-tube was reinserted, however no paperwork was provided by the hospital to confirm tube placement. Note dated 11/11/23 at 12:56pm indicates that while attempting to flush R9's J-tube and start R9's feeding, the nurse was unable to aspirate or flush fluids. Note indicates nurse then attempted to utilize declogger but met with resistance past where declogging device could be visualized. Note indicates hospital physician was contacted and stated to use G-tube until R9 could be scheduled for surgery to replace the J-tube. On 11/16/23 at 1:00pm V5, RN (Registered Nurse) stated that she had to go to another unit (not part of the Skilled Nursing/Long Term Care Unit) to obtain the declogging device that she used to try to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145793 If continuation sheet Page 6 of 14 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 11/16/2023 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)

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few declog R9's J-tube on 11/11/23. V5 stated that she just used the size of declogger that the nurse on the other unit gave her to use and that she did not know the size of R9's G or J tubes The sizes of the tube are on the actual tubes. At that time, it was noted that the size of R9's G-tube was 24 Fr with a 7-10ml (milliliter) balloon, and the J-tube was a 22 Fr with a 7-10ml balloon. R9's feeding tubes did not indicate the length of the tubes - only the size (diameter). Neither the size or the length of R9's enteral tubes were found in R9's physician orders or care plan. On 11/16/23 at 2:00pm V7, NP (Nurse Practitioner) stated she is not that familiar with an enteral tube declogging device and wouldn't use one unless she had some training. V7 stated the manufacturer instructions should be followed. On 11/16/23 at 2:50pm V2, DON (Director of Nursing) stated that she was trained by a floor nurse on how to use a declogging device. V2 stated she has never provided any training or instruction to the nurses on how to use the declogger and there is no specific policy, procedure, or protocol for their use. On 11/16/23 at 1:10pm V5, RN was changing the stoma dressings on R9's two feeding tube sites which included a G-tube (on upper abdomen) and J-tube (mid abdomen). Both stoma sites had crusted reddish-brown discharge under and around the skin-side flange. Neither sites had a dressing in place. At that time V5 stated that she usually removes the old dressing, cleans the site, and replaces with a new dressing There should be a dressing. R9's current Physician Order Summary Report indicates Cleanse G/J tube site with soap and water every shift and as needed. Apply dressing as needed every 8 hours and as needed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145793 If continuation sheet Page 7 of 14 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 11/16/2023 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)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review the facility failed to provide humidified oxygen, physician ordered oxygen flow rates and failed to date oxygen humidifier bottles for six residents (R6, R14, R15, R17, R19, R42) of seven residents reviewed for oxygen therapy in the sample of 34. Residents Affected - Some Findings include: On 11/15/23 between 1:30pm and 1:45pm the following residents with current orders for oxygen administration were seen with V4, RN (Registered Nurse): 1) R6 was in bed receiving oxygen via a nasal cannula at flow rate of 4 liters per minute. R6's nasal cannula was attached to the oxygen concentrator that did not have a humidification bottle. R6's Current Physician Order Report Summary indicates Change nasal cannula tubing every Sunday evening and humidification every Sunday night shift for maintenance. Replace all oxygen equipment per facility policy. Report also indicates (R6) may use oxygen at 2-4 liters to maintain SPO2 (oxygen saturation) greater than 93% (order date 11/3/23). 2) R14 was in bed receiving oxygen via a nasal cannula at flow rate of 2.5 liters per minute. R14's nasal cannula was attached to the oxygen concentrator humidification bottle that was undated and completely empty. At that time V4, RN confirmed R14's oxygen humidification bottle was empty and stated (The bottle) is not dated - that's even worse. R14's Current Physician Order Report Summary indicates May use oxygen at 2-4 liters to maintain SPO2 (oxygen saturation) greater than 93% (order date 11/4/22). 3) R15 was in bed receiving oxygen via a nasal cannula at flow rate of 2.5 liters per minute. R15's nasal cannula was attached to the oxygen concentrator humidification bottle that was undated and completely empty. R15's Current Physician Order Report Summary indicates Oxygen at 2 liters per nasal cannula as needed (order date 11/1/20). R15's current care plan indicates Give oxygen as ordered by the physician. 4) R17 was seen in her room in a recliner chair at multiple times throughout the day on 11/14/23 and 11/15/23. All observations found R17 receiving oxygen at 3.5 liters via nasal cannula. R17's nasal cannula was attached to an oxygen humidification bottle that was empty and dated 10 (October) - the day of the month was smudged and unreadable. On 11/15/23 at 1:35pm V4, RN confirmed R17's humidification bottle was dry and last dated sometime in October. Current Physician Order Summary Report indicates R17 May use 2-4 liters to maintain SPO2 (oxygen (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145793 If continuation sheet Page 8 of 14 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 11/16/2023 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)

F 0695 saturation) >93% (date initiated 8/12/23). Level of Harm - Minimal harm or potential for actual harm Current Care Plan - focus area CHF (Congestive Heart Failure) and CAD (Coronary Artery Disease) indicates R17 utilizes oxygen therapy per physician orders. Residents Affected - Some R17's Care Plan did not include a specific focus area for oxygen/respiratory therapy. 5) R19 was in bed receiving oxygen via a nasal cannula at flow rate of 1 liter per minute. R19's nasal cannula was attached to the oxygen concentrator humidification bottle that was undated and contained a very small amount (approximately 1 inch) of cloudy water. At that time V4, RN stated the water in the bottle should not be cloudy and needs to be replaced. Also at that time, R19 asked what the oxygen flow rate indicated on her concentrator - V4 responded 1 liter. R19 responded I'm supposed to be on 2 liters. Current Physician Order Summary Report indicates R19 May use 2-4 liters to maintain SPO2 (oxygen saturation) >93% (date initiated 4/12/23). R19's current care plan indicates Give oxygen as ordered by the physician. 6) R42 was in bed receiving oxygen via a nasal cannula at flow rate of 2 liters per minute. R15's nasal cannula was attached to the oxygen concentrator humidification bottle that was undated and completely empty. Current Physician Order Summary Report indicates R42 May use 2-4 liters to maintain SPO2 (oxygen saturation) >93% (date initiated 6/30/23). R42's current care plan indicates Oxygen therapy per physician orders. Replace oxygen and nebulizer tubing and humidification weekly. On 11/15/23 at 1:45pm V4, RN stated she has worked for the facility for one year and didn't know if oxygen orders need to include humidification or if all residents should have humidification. On 11/15/23 at 2:45pm V4, RN stated if a resident is receiving oxygen at 2 liters or under, humidification can be used for comfort. If flow rate is 2 liters or greater - should have humidification. Facility Policy/Oxygen Administration dated 2/8/21 documents: It is the responsibility of the Charge Nurse to ensure that residents who have an order for oxygen are receiving the proper amount via the proper way, per physician order. Procedure: Adjust the delivery device so that it is comfortable, and the proper flow of oxygen is being administered. Label (pre-filled) humidifier with date and time opened. For re-usable humidifiers: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145793 If continuation sheet Page 9 of 14 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 11/16/2023 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)

F 0695 Fill with sterile distilled or sterile ionized water to fill line. Level of Harm - Minimal harm or potential for actual harm Attach humidifiers to flow meter by screwing nut onto flow meter. Set flow meter to the rate ordered by the physician. Residents Affected - Some Label humidifier with date and time opened. Precaution: Constant flow of oxygen can cause drying and thickening of normal secretions resulting in laryngeal ulceration. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145793 If continuation sheet Page 10 of 14 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 11/16/2023 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)

F 0882 Level of Harm - Minimal harm or potential for actual harm Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. Based on interview and record review the facility failed to ensure the designated Infection Preventionist was certified. This failure has the potential to affect all 52 residents residing in the facility. Residents Affected - Many Findings include: The facility's undated Infection Control Specialist Job Description documents, Under the direct supervision of the Director of Nursing, within scope of practice, the Infection Control Specialist will track, analyze, and look for trends in infection . 10. Will maintain current knowledge of CDC (Centers for Disease Control) guidelines, and appropriate procedures. 11. Will be responsible for completing infection control log on a daily basis, analyzing, and looking for trends on a monthly basis and completion of monthly infection control report. Is responsible for surveillance, identification, prevention, control and reporting of infections. Qualifications include Education/experience in nursing administration, infection control standards, and/or geriatric nursing is desirable. Will have knowledge on current infection control procedures and practices. The facility's undated Director of Nursing Job Description documents Under the supervision of the Nursing Home Administrator, the Director of Nursing is responsible for the overall operation of the nursing department 24 hours a day, 7 days a week. Essential Position Functions: 6. Cooperate with the Administrator in the planning of staff development programs that will enhance staff knowledge in providing quality resident care . 9. Maintain professional competence through continuing education . 11. Stay current with the Illinois Department of Public Health and Public Aid directives and ensure department's compliance with such directives . 12. Ensure that the nursing department's is in compliance with State Code Requirements . 21. Ensure that the nursing staff is aware of their responsibilities. On 11/15/23 at 8:30 AM, Signage was posted to the front entrance door that documents the facility is currently in a COVID-19 outbreak. During the facility tour there were no residents being isolated for COVID-19. The facility Infection Control binder does not include any documentation for infections for the months of October or November and does not indicate there are currently any residents positive for COVID-19 or in contact or droplet isolation. On 11/15/23 at 10:36 AM, V3 ICP (Infection Control Preventionist) stated she works part time at the facility as the ICP and the facility just came out of a COVID-19 outbreak and there are currently no residents or staff testing positive. V3 ICP stated she is requiring all staff to wear a N95 mask while working in the facility until the facility has two weeks of no positive COVID tests as the last positive resident came out of isolation on 11/14/23. V3 ICP stated she completed each of the Infection Control Preventionist modules and provided copies of completed Modules 1 through 15 that document successfully completed for each. V3 ICP stated she only remembers taking a test at the end of each Module and does not recall taking another exam after completing all the Modules. On 11/15/23 at 2:30 PM, V1 Administrator confirmed the only documents she has for V3 ICP having taken the Infection Control Preventionist program was the completion of the Modules and was unable to provide a Certification of completion of the 19-hour program or exam completion. V3 ICP should have taken the Infection Control exam for certification. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145793 If continuation sheet Page 11 of 14 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 11/16/2023 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)

F 0882 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete On 11/16/23 at 3:30 PM V3 ICP stated she managed to get back into the training course and was currently taking the exam. As of this date and time V3 ICP was unable to provide the Certification for the Infection Control Preventionist Course documenting the completion of the 19-hour program or the exam completion. V3 ICP stated again, I cannot say definitively that I took the exam or not. The Long-Term Care Facility Application for Medicare and Medicaid, CMS (Central Management Services) Form 671, signed and dated on 11/14/23 by V1 Administrator documents there are 52 residents currently residing in the facility. Event ID: Facility ID: 145793 If continuation sheet Page 12 of 14 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 11/16/2023 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)

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to administer the pneumonia vaccine for two (R2 and R50) of five residents reviewed for immunizations in the sample of 34. Residents Affected - Few Findings include: The facility's Pneumo (pneumococcal) Vaccination policy and procedure, dated 10/16/09, documents According to the National Institutes of Health, everyone [AGE] years of age and older should get the pneumococcal vaccine as well as younger people with certain qualifiers. All facility staff will follow the facility policies on Pneumo Vaccinations. All residents will be offered the Pneumo vaccine every 5 years per Center for Disease Control Guidelines recommendations. It is the responsibility of the DON (Director of Nursing)/Designee to ensure that all residents receive the Pneumo Vaccine and proper documentation is done every 5 years. The facility's undated Pneumonia Shot (pneumococcal vaccine) resident education form documents Who should get the pneumococcal vaccine? People age [AGE] or older; People with a chronic illness such as advanced breast cancer, heart or lung disease, or diabetes; People with a weak immune system due to illness and/or the effects of chemotherapy; Residents of nursing homes and other long-term care facilities. The facility's Pneumococcal Vaccine Resident Consent Form includes education and place for signature and date of acceptance or decline of the vaccine. 1. The current Physician Orders for R2, documents May Administer Pneumococcal vaccine every 5 years if not contraindicated. The Immunization Record for R2 documents R2 received the influenza vaccine on 9/28/23 and the pneumococcal vaccine is documented as Immunization Required. The Pneumococcal Vaccine Resident Consent Form for R2, signed and dated 6/25/23, documents R2's consent to receive the Pneumococcal Vaccine. 2. The current Physician Orders for R50, documents May administer Pneumococcal Vaccine every 5 years if not contraindicated. The Immunization Record for R50 documents R50 received the influenza vaccine on 9/25/23 and the pneumococcal vaccine is documented as Immunization Required. The Pneumococcal Vaccine Resident Consent Form for R50, signed and dated 9/4/23, documents R50's consent to receive the Pneumococcal Vaccine. On 11/16/23 at 1:30 pm, V2 DON (Director of Nursing) stated flu vaccines are given during flu season, but the Pneumococcal vaccines can be given at any time. V2 DON stated V3 ICP (Infection Control Preventionist) oversees the facility's immunizations. On 11/15/23 at 12:48 pm, V3 ICP confirmed consent was obtained for R2 on 6/25/23 and R50 on 9/4/23. V3 ICP stated she does not give the Pneumococcal vaccines until the flu vaccinations are given and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145793 If continuation sheet Page 13 of 14 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 11/16/2023 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)

F 0883 only orders the pneumonia vaccine when she has enough residents who have consented. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145793 If continuation sheet Page 14 of 14