Inspection·January 9, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm R48's Physicians Order documents to provide catheter care every shift for urinary catheter (dated 11/16/24). On 1/7/25 at 10:15 AM, R48's urinary drainage catheter bag was hanging on the side of R48's bed. The urinary drainage catheter bag was visible from the hallway with yellow colored urine in the bag. Residents Affected - Few On 1/8/25 at 3:06 PM, V2/Director of Nursing verified that the urinary drainage catheter bags should be covered whenever visible to the hallway to promote dignity. FORM CMS-2567 (02/99) Previous Versions Obsolete 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 01/09/2025 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 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to complete Criminal History Background Checks within 24-hour of admission, Illinois Sex Offender Registry checks prior to admission, and Illinois Department of Corrections Sex Registry Checks prior to admission as instructed by the facility's Abuse Policy for five of five residents (R107, R108, R109, R110, R157) reviewed for Abuse Prevention in the sample of 38. Residents Affected - Some Findings include: The Abuse Prevention Program Policy dated 8/11/17 documents Policy It is the policy of this facility to prevent resident abuse, neglect, exploitation, mistreatment, and misappropriation of resident property. The following procedures shall be implemented when an employee or agent becomes aware of abuse or neglect of a resident, or of an allegation of suspected abuse or neglect of a resident by a 3rd (third) party. II. Pre-admission Screening of Potential Residents: This facility shall check the criminal history background on any resident seeking admission to the facility in order to identify previous criminal convictions. Prior to the admission of a new resident to the facility, this facility will: Check for the resident's name on the Illinois Sex Offender registration. Check for the resident's name on the Illinois Department of Corrections sex registrant search page. Within 24 hours after admission of a new resident to the facility, this facility will: Initiate a Criminal History Background Check according to the Facility Identified Offender Policy and Procedure. 1. R107's admission Record documents R107 was admitted on [DATE]. R107's Criminal History Background check, Illinois Sex Offender Registry, and Illinois Department of Corrections Registry document being completed on 1-6-25 (three days after R107's admission). 2. R108's admission Record documents R108 was admitted on [DATE]. R108's Criminal History Background check, Illinois Sex Offender Registry, and Illinois Department of Corrections Registry document being completed on 1-6-25 (three days after R108's admission). 3. R109's admission Record documents R109 was admitted on [DATE]. R109's Criminal History Background check, Illinois Sex Offender Registry, and Illinois Department of Corrections Registry document being completed on 12-30-24 (three days after R109's admission). 4. R110's admission Record documents R110 was admitted on [DATE]. R110's Criminal History Background check, Illinois Sex Offender Registry, and Illinois Department of Corrections Registry document being completed on 12-23-24 (three days after R110's admission). 5. R157's admission Record documents R157 was admitted on [DATE]. R157's Illinois Sex Offender Registry and Illinois Department of Corrections Registry document being completed on 1-7-25 (five days after R157's admission). On 1-8-25 at 11:30 AM V8 (Admission's Coordinator) stated R107-R110's and R157's Criminal History Background Checks, Illinois Sex Offender Registry Checks, and Illinois Department of Corrections (continued on next page) 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 01/09/2025 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 0607 Level of Harm - Minimal harm or potential for actual harm Registry Checks were not completed prior to admission or within 24 hours of admission. V8 stated, Me and (V9/Vice President of Operations) are responsible to do the resident background checks, however me and (V9) were off when (R107-R110 and R157) were admitted , so their background checks did not get done within 24 hours of their admission. Residents Affected - Some 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 01/09/2025 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to implement a restorative range of motion program and include the restorative program within the resident's care plan for one of one resident (R20) reviewed for limitations in range of motion in the sample of 38. Findings include: The Restorative Program/Range of Motion policy dated 8/3/13 documents Purpose: To provide resident with limited range of motion and appropriate treatment and services to increase or prevent further decrease in range of motion. Policy: All residents will be assessed on admission and quarterly, or more often as a change of condition warrants, for risk factors for development of contractures. A program will be developed based on the resident's unique risk factors and involving formalized therapy and/or restorative nursing, as applicable. This program will be reflected in the interdisciplinary care plan and will be systematically and consistently followed. The facility protocol for ROM (Range of Motion) is ten repetitions daily, seven days a week for prevention of contractures. All residents who have been assessed and found to require range of motion exercises will have services provided by staff. Responsibility: It is the responsibility of the CNA (Certified Nursing Assistant)/Restorative Aide to perform exercises as identified. It is the responsibility of the Care Plan Coordinator for addressing on the care plan. Procedure: 1. Resident to be assessed following to determine need for range of motion. 2. Address ROM on care plan and identify extremities to be exercised. 3 Communicate to CNA's who require ROM. Explain procedure to resident including what areas will be exercised. 5. Perform range of motion including finger and toes of extremities to be exercised. 6. Provide resident with 10 (ten) repetitions as per resident's tolerance. Never continue past the point of resistance or pain. Take caution not to over tire the resident. 8. When possible, encourage the resident to assist with the exercise. R20's MDS (Minimum Data Set) assessment dated [DATE] documents R20 is cognitively intact and has limitations in range of motion to both sides of the lower extremities. R20's Restorative Program dated 12-29-23 documents, Perform active range of motion exercises daily to (R20's) upper bilateral extremities using verbal cues and hand on assistance of one staff as needed. On 01/07/25 at 9:31 AM R20 was sitting up in bed. R20 had two bilateral above the knee amputations and could not lift his arms up above his waist. R20 stated, I do not get range of motion exercises by staff. I cannot raise my arms up. I have really bad arthritis to my left shoulder. I would like for the staff to do exercises. On 01/07/25 at 9:45 AM both V5 (CNA/Certified Nursing Assistant) and V6 (CNA) were transferring R20 from the bed to the wheelchair using a mechanical lift. V5 and V6 both stated they do not do range of motion exercises with R20. On 1-9-24 at 11:10 AM V17 (Restorative Aide) stated, (R20's) restorative program documents (R20) should get hand over assistance of staff to do range of motion exercises every day. I usually try to do (R20's) range of motion once a week with (R20) and the CNAs are supposed to do the other days. I personally have not been able to do range of motion exercises with (R20) in quite a while. 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 01/09/2025 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview the facility failed to ensure physician ordered daily weights were obtained for a resident with Congestive Heart Failure for one of one resident (R31) reviewed for hydration in the sample of 38. Residents Affected - Few Findings include: The Weights policy dated 9/1/19 documents Purpose: To define the process for obtaining weights on all residents in the facility. It is the responsibility of the C.N.A. (Certified Nursing Assistant)/Designee to obtain weights monthly, and as ordered. The nurse management team is responsible for monitoring to ensure that all weights are obtained in a timely manner. Procedure: 6. D.O.N. (Director of Nursing)/Designee will maintain a log and follow-up to ensure timely completion of weights and proper notification of weight variances. R31's current Physician Order Sheet, dated 1/08/25, document the following order, Daily weight every day due to CHF (Congestive Heart Failure). This order has a start date of 10/24/2024. R31's current Care Plan documents, Focus: I have Congestive Heart Failure. Goal: I will be free of peripheral edema through the next review date. Intervention: 10-24-24 Daily Weight. R31's Weights and Vitals Summary Logs dated 10-24-24 through 1-8-25 document R31 has not been weighed daily as ordered by the physician on ten days within this timeframe. On 01/07/25 at 12:15 PM V2 (Director of Nursing) verified R31 has not been weighed daily as ordered for ten days within the timeframe of 10-24-24 through 1-8-25. 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 01/09/2025 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to assess a resident for the risk of entrapment and medical needs, obtain a physician's order prior to use, and obtain a consent prior to the use of side rails/assist rails for seven of seven residents (R2, R20, R28, R31, R48, R49, R107) reviewed for side rail use in the sample of 38. Findings include: The Side Rails Policy dated 10/9/19 documents Purpose: To provide guidelines assessment and use of side rails. Policy: The use of bed rails as restraints is prohibited unless they are necessary to treat a resident's medical symptoms. All residents who utilize rails will have a side rail screening completed. Responsibility: It is the responsibility of the Care Plan Coordinator/Rehab Nurse to assess the need for side rails, and document and care plan accordingly. Procedure: 1. If a resident requests side rails, a Side Rail Assessment Form must be completed and Side Rail Assessment for Risk of Entrapment. A physician order must be obtained when using side rails. The order must indicate the number of side rails to be used and the medically related reason. If used for mobility, then this must be indicated in the order. (Use) Side Rail Assessment Form. (Use) Side Rail Consent Form. (Use) Side Rail Assessment for Risk of Entrapment. 1.R20's admission Record documents R20 is a [AGE] year-old that was admitted to the facility on [DATE] with the diagnoses of Chronic Respiratory Failure, Chronic Obstructive Pulmonary Disease, Congestive Heart Failure, Type II Diabetes Mellitus, Hypotension, and Acquired Absence of the Left and Right Legs Above the Knee. R20's Fall assessment dated [DATE] documents R20 is a moderate risk for falls, is totally incontinent of bowel and bladder, is receiving more than two medications that put R20 at risk for falls and is unable to independently come to a standing position. R20's current Physician's Order Sheets document R20 utilizes ½ side rails for mobility and safety. R20's Medical Record does not include a consent or an assessment of R20's ½ side rails for appropriate use or risks for entrapment. On 01/07/25 at 9:31 AM R20 was lying in bed with 1/2 side rails in the raised position to both upper sides of R20's bed. 2. R28's admission Record documents R28 is an [AGE] year-old that was admitted to the facility on [DATE] with the diagnoses of Diabetes Mellitus, Anxiety Disorder, Insomnia, and Chronic Obstructive Pulmonary Disease. R28's current Physician's Order Sheets document R28 utilizes a right-side bed cane (assist rail) for bed mobility. R28's Fall assessment dated [DATE] documents R28 is a high risk for falls, is totally incontinent (continued on next page) 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 01/09/2025 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some of bowel and bladder, is confined to a chair and disorientated, is unable to independently come to a standing position, requires hands-on assistance to move from place-to-place, and has decreased in muscle coordination. R28's Medical Record does not include an assessment of R28's 1/8 sized assist rail for appropriate use and risks for entrapment or a consent for the use of R28's assist rail. On 01/08/25 at 9:00 AM R28 was sitting up in bed with an 1/8 sized assist rail in the raised position to the right upper side of R28's bed. 3. R31's admission Record documents R31 is a [AGE] year-old that was admitted to the facility on [DATE] with the diagnoses of Morbid Obesity, Depression, Anxiety Disorder, and Chronic Obstructive Pulmonary Disease. R31's Fall assessment dated [DATE] documents R31 is a moderate risk for falls, is frequently incontinent of bowel and bladder, and is receiving more than two medications that put R31 at risk for falls. R31's Medical Record does not include an assessment of R31's 1/8 sized assist rail for appropriate use and risks for entrapment, a consent for the use, or a physician's order for the use of R31's assist rail. On 01/08/25 at 9:05 AM R31 was sitting up in bed with an 1/8 sized assist rail in the raised position to the right upper side R31's bed. 4. R107's admission Record documents R107 is a [AGE] year-old that was admitted to the facility on [DATE] with the diagnoses of Anxiety Disorder, Insomnia, Acute and Chronic Respiratory Failure with Hypoxia, Fibromyalgia, Chronic Obstructive Pulmonary Disease, and Bipolar Disorder. R107's Brief Interview for Mental Status dated 1-8-25 documents R107 is severely cognitively impaired. R107's Fall assessment dated [DATE] documents R107 is a high risk for falls, is frequently incontinent of bowel and bladder, is receiving more than two medications that put R107 at risk for falls, is confined to a chair and disorientated, is unable to independently come to a standing position, exhibits loss of balance while standing, and has decreased muscle coordination. R107's Medical Record does not include an assessment of R107's 1/8 sized assist rail for appropriate use and risks for entrapment, a consent for the use, or a physician's order for the use of R107's assist rail. On 01/08/25 at 09:18 AM R107 was lying in bed with an 1/8 sized assist rail in the raised position to the right upper side of R107's bed. 5. R2's current computerized medical record, documents R2 was admitted to the facility on [DATE] with diagnoses which included Paraplegia, Methicillin Resistant Staphylococcus Aureus Infection as the cause of Diseases Classified Elsewhere, Encounter for Attention to Colostomy, Encounter for Attention to Other Artificial Openings of Urinary Tract. (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 01/09/2025 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 0700 Level of Harm - Minimal harm or potential for actual harm R2's Fall assessment dated [DATE] documents R2 is a low risk for falls, is occasionally incontinent of bowel/bladder, and is confined to a chair and oriented. R2's Medical Record does not include an assessment of R2's 1/8 sized assist rail for appropriate use and risks for entrapment, a consent for use, or a physician's order for the use of R2's assist rail. Residents Affected - Some On 1/9/25 at 9:45 AM, R2 was lying in bed with an 1/8 sized assist rail on the left side of R2's bed. 6. R48's current computerized medical record, documents R48 was admitted to the facility on [DATE] with diagnoses which included Seizures, Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms, Down Syndrome, Retention of Urine, Spondylosis with Myelopathy, Cervical Region, Fusion of Spine, Cervical Region, and Urinary Tract Infection. R48's MDS (Minimum Data Set) assessment dated [DATE] documents a BIMS (Brief Interview for Mental Status) Score of 2/15, indicating (severe cognitive impairment). R48's Fall assessment dated [DATE] documents R48 is a high risk for falls, has had multiple falls, is totally incontinent of bowel and bladder and is unable to independently come to a standing position. R48's Medical Record does not include an assessment of R48's 1/8 sized assist rail for appropriate use and risks for entrapment, a consent for use, or a physician's order for the use of R48's assist rail. On 1/7/25 at 10:15 AM, R48 was lying in bed with an 1/8 sized assist rail on each side of R48's bed. 7. R49's current computerized medical record, documents R49 was admitted to the facility on [DATE] with diagnoses which included Infarction due to Unspecified Occlusion or Stenosis of Right Middle Cerebral Artery, Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side, Dysphasia, and Metabolic Encephalopathy. R49's MDS assessment dated [DATE] documents a BIMS Score of 13/15, indicating (cognition intact). This MDS also documents that R49 has an impairment on one side of her upper and lower extremity, is dependent on staff for activities of daily living, and requires substantial assistance for bed mobility and transfers. R49's Fall assessment dated [DATE] documents R49 is a high risk for falls, is occasionally incontinent of bowel and bladder, is receiving two medications that put R49 at risk for falls, and is unable to independently come to a standing position. R49's Medical Record does not include an assessment of R49's 1/8 sized assist rail for appropriate use and risks for entrapment, a consent for use, or a physician's order for the use of R49's assist rail. On 1/8/25 at 9:37 AM, R49 was lying in bed with an 1/8 sized assist rail on both sides of R49's bed. (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 01/09/2025 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 0700 Level of Harm - Minimal harm or potential for actual harm On 01/07/25 at 12:15 PM V2 (Director of Nursing) stated, We (the facility) have never completed a side rail or assist rail assessment for any residents that use them. I do not think the facility even has an assessment form to use. (R2, R20, R28, R31, R48, R49, and R107) do not have consents for the use of their side rails and (R2, R20, R31, R48, R49, and R107) do not have physician's orders for the use of their side rails. 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 01/09/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on Observation, Interview, and Record Review the facility failed to ensure refrigerated vaccination units were stored separate from food and beverages. This failure has the potential to affect all 59 residents residing in the facility. Findings include: The facility's Storage of Medications policy, dated 4/2016, documents All medications will be safe and properly stored at all times. Medications requiring refrigeration shall be kept in a separate, securely fastened locked box within a refrigerator or locked refrigerator, at or near the nurse's station, or in a refrigerator within a locked medication room. On 1/9/25 at 11:40 AM, the facility's 100 hall medication storage fridge contained a sign on the outside of the fridge that documents Medications Only. Inside of the fridge was a plastic of container of food from outside of the facility. This dish did not contain a label and was sitting directly on top of two boxes of influenza vaccine. This same fridge contained an open bottle of (flavored hydration drink). V13 (Registered Nurse) and V19 (Licensed Practical Nurse) both confirmed that food and drinks should not be stored in the medication room refrigerator and stated that this fridge is only for medications. V13 stated This looks like chili soup, and it was probably brought in for a resident. We have agency nurses who may not have known where to put it. On 1/9/25 at 11:45 AM V16 (Infection Control Preventionist) confirmed that the influenza vaccines stored in the 100-hall medication room refrigerator can be administered to any resident in the building and stated there should not be any food or open drinks kept in that refrigerator. The facility's Long Term Care Application for Medicare and Medicaid dated 1/7/25 and signed by V1 (Administrator) documents 59 residents reside in the facility. 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 01/09/2025 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to follow Enhanced Barrier Precautions (EBP) for five residents (R2, R4, R10, R48, and R49) of six residents reviewed for EBP in the sample of 38. Residents Affected - Some Findings include: The Infection Control Policy dated 7/29/24 documents Purpose: Standard Precautions shall be used when caring for residents at all times regardless of their suspected or confirmed infection status. Transmission-Based Precautions shall be used when caring for residents who are documented or suspected to have communicable disease or infections that can be transmitted to others. The facility shall make every effort to use the least restrictive approach to managing individual with potentially communicable infections. Transmission-Based Precautions shall only be used when transmission cannot be reasonably prevented by less restrictive measures. F. Enhanced Barrier Precautions: In addition to Standard Precaution, implement Enhanced Barrier Precautions for certain residents during specific high-contact resident care activities associated with MDRO (Multidrug-Resistant Organism) transmission. A. Examples of infection requiring Enhanced Barrier Precautions include but are not limited to: (1) Patients with known MDRO infection. (2) Patients who are colonized with an infectious MDRO organism. (3) Asymptomatic patients who are suspected of/under investigation for colonization or infection with an infectious microorganism. B. Gloves and Handwashing (1) In addition to wearing gloves as outlined under Standard Precautions, wear a gown (clean, non-sterile) when entering the room. C. Gown (1) In addition to wearing a gown as outlined under Standard Precautions, wear a gown (clean, non-sterile) for all interactions that may involve contact with the resident or potentially contaminated items in the resident's environment. Remove the gown and perform hand hygiene before leaving the resident's room. (2) After removing the gown, do not allow clothing to contact potentially contaminated environmental surfaces. 1. R2's current computerized medical record, documents R2 was admitted to the facility on [DATE] with diagnoses which included Paraplegia, Methicillin Resistant Staphylococcus Aureus Infection as the cause of Diseases Classified Elsewhere, Encounter for Attention to Colostomy, Encounter for Attention to Other Artificial Openings of Urinary Tract. R2's MDS (Minimum Data Set) assessment dated [DATE] documents a BIMS (Brief Interview for Mental Status) Score of 15/15, indicating (cognition intact). R2 has an Ostomy (including urostomy, ileostomy, and colostomy), and has a surgical wound. R2's Physicians Order documents to monitor ostomy site every shift (dated 9/26/24). Treat R2's right thigh wound daily and as needed every shift for wound care (dated 10/2/24). R2's Care Plan documents that R2 has impairment to skin integrity related to Paraplegia. Treat left buttock wound three time a week and as needed until healed (dated 10/9/24). R2 has a urostomy and colostomy due to paraplegia (dated 9/30/24). The revised Enhanced Barrier Precaution/EBP List printed 1/9/24 documents that R2 is in EBP precautions for having a urostomy/colostomy. On 1/7/25 at 3:25 PM, R2 stated that the staff do not wear a gown or gloves when providing care. (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 01/09/2025 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 On 1/9/25 at 9:45 AM R2 was lying in bed on his right side with a wound dressing on R2's left hip. There was no Enhanced Barrier Precaution sign on R2's door and no Personal Protective Equipment/PPE in or by R2's room. R2 stated that a nurse uses PPE when doing wound care, but the staff do not wear a gown or gloves when providing care. 2. R4's current computerized medical record, documents R4 was admitted to the facility on [DATE] with diagnoses which included Atrophy of Kidney (Terminal), Peritoneal Abscess, and Acute Kidney Failure. R4's MDS assessment dated [DATE] documents a BIMS Score of 15/15, indicating (cognition intact). R4 has an Indwelling Urinary Catheter. R4's Physicians Order documents to provide indwelling catheter care daily every shift (dated 12/26/24). The revised EBP List printed 1/9/24 documents that R4 is in EBP precautions for having an indwelling urinary catheter. On 1/7/25 at 3:05 PM, R4 was lying in bed watching television. There was no EBP sign on R4's door and no PPE in or by R4's room. R4 stated that the staff do not wear a gown or gloves when providing care. On 1/09/25 at 9:40 AM, V16 confirmed (R4) is not listed on the facility's EBP resident list and has not been in EBP precautions but should be because (R4) has a urinary catheter. 3. R10's current computerized medical record, documents R10 was admitted to the facility on [DATE] with diagnoses which included Acute Osteomyelitis of Right Ankle and Foot, Type 2 Diabetes Mellitus with Hyperglycemia, Acute Embolism and Thrombosis of Deep Veins of Right Upper Extremity, Cellulitis of Right Upper Limb, and Acute Kidney Failure. R10's MDS assessment dated [DATE] documents a BIMS Score of 15/15, indicating (cognition intact). R10 has a Diabetic Foot Ulcer. R10's Physicians Order documents to treat right heel everyday shift for wound (dated 12/11/24). On 1/7/25 at 3:25 PM R10 was standing at her door talking to another resident. There was no EBP sign on R10's door and no PPE in or by R10's room. R10 stated that the staff do not wear a gown or gloves when providing care. 4. R48's current computerized medical record, documents R48 was admitted to the facility on [DATE] with diagnoses which included Seizures, Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms, Down Syndrome, Retention of Urine, Spondylosis with Myelopathy, Cervical Region, Fusion of Spine, Cervical Region, and Urinary Tract Infection. R48's MDS assessment dated [DATE] documents a BIMS Score of 2/15, indicating (severe cognitive impairment). R48 has a urinary indwelling catheter, has one or more unhealed pressure ulcers/injuries, and three unstageable pressure ulcers. R48's Physicians Order documents to provide catheter care every shift for urinary catheter (dated (continued on next page) 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 01/09/2025 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 11/16/24). Cleanse and treat R48's sacrum wound daily (dated 12/11/24). Treat R48's left medial foot once daily until healed (dated 1/7/25). R48's Care Plan documents that R48 has potential/actual impairment to skin integrity. Treat R48's sacrum every evening shift for wound care (dated 12/12/24). Treat R48's left medial foot everyday shift for wound (dated 1/8/25). R48 has an indwelling urinary catheter related to urinary retention. The revised Enhanced Barrier Precaution List printed 1/9/24 documents that R48 is in EBP precautions for having an indwelling urinary catheter. On 1/8/24 at 9:55 AM, there was no EBP sign on R48's door and no PPE in or by R48's room. 5. R49's current computerized medical record, documents R49 was admitted to the facility on [DATE] with diagnoses which included Infarction due to Unspecified Occlusion or Stenosis of Right Middle Cerebral Artery, Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side, Dysphasia, and Metabolic Encephalopathy. R49's MDS assessment dated [DATE] documents a BIMS Score of 13/15, indicating (cognition intact). R49 has a feeding tube, has an impairment on one side of her upper and lower extremity, R49 is dependent on staff for activities of daily living and requires substantial assistance for bed mobility and transfers. R49's Physicians Order documents that R49 requires an enteral feeding of Jevity 1.2 85 milliliters per hour from 7:00 PM to 7:00 AM and 250-milliliter flush every six hours. R49's Care Plan documents that R49 requires a feeding tube related to a stroke. The revised Enhanced Barrier Precaution List printed 1/9/24 documents that R49 is in EBP precautions for having a G-tube/Gastrostomy tube. On 1/8/25 at 9:40 AM, R49 was lying in bed on her right side with V14/Registered Nurse/RN standing next to the bed with a clear plastic bag that contained R49's soiled disposable brief. V14 stated that incontinent care was just done for R49. V14 was wearing gloves but not a gown. V14 tied the bag closed and put the bag in the trash. V14 was asked why R49 was in EBP precautions and V14 stated that she thought it was because R49 had red areas to her buttock. V14 was asked if PPE needed to be worn and V14 stated No. On 1/8/25 at 9:42 AM, V15/Certified Nursing Assistant/CNA came into R49's room with a mechanical lift to get R49 up. V15 and V14 transferred R49 from the bed to the recliner with the mechanical lift. V14 and V15 were not wearing PPE. V15 stated that once a resident is dressed PPE is not needed. On 1/08/25 at 2:50 PM, V16/Registered Nurse/Infection Control Preventionist stated the facility is implementing EBP for residents who could be at risk for infection. V16 stated When I educated everyone, I told them if anyone has a hole that shouldn't be there, such as a urinary catheter, gastric tube, venous lines or a bad wound that requires a dressing change, they are on automatic EBP because we could potentially give them something. They (staff) must wear a gown and gloves (PPE) for direct contact with the potential infectious area. I didn't realize they need to have the PPE on for transfers or other close contact. We will be implementing that moving forward. They don't have PPE in every room right now. We put the PPE in the more central areas like the linen cart so staff can use it. (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 01/09/2025 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 On 1/09/25 at 9:40 AM, V16 stated During incontinence care on 1/8/25 (for R49) the staff should have been wearing a gown during the close resident contact. 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 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 01/09/2025 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 0909 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. Based on observation, interview, and record review the facility failed to perform maintenance inspections of side rails/assist rails for entrapment zones/risks for seven of seven residents (R2, R20, R28, R31, R48, R49, R107) reviewed for side rail use in the sample of 38. Findings include: 1. On 01/07/25 at 9:31 AM R20 was lying in bed with 1/2 side rails in the raised position to both upper sides of R20's bed. R20's Medical Record does not include a maintenance inspection of R20's 1/2 side rails for entrapment zones/risks. 2. On 01/08/25 at 9:00 AM R28 was sitting up in bed with an 1/8 sized assist rail in the raised position to the right upper side of R28's bed. R28's Medical Record does not include a maintenance inspection of R28's 1/8 assist rails for entrapment zones/risks. 3. On 01/08/25 at 9:05 AM R31 was sitting up in bed with an 1/8 sized assist rail in the raised position to the right upper side of R31's bed. R31's Medical Record does not include a maintenance inspection of R31's 1/8 assit rails for entrapment zones/risks. 4. On 01/08/25 at 09:18 AM R107 was lying in bed with an 1/8 sized assist rail in the raised position to the right upper side of R107's bed. R107's Medical Record does not include a maintenance inspection of R107's 1/8 assist rails for entrapment zones/risks. 5. On 1/9/25 at 9:45 AM, R2 was lying in bed with an 1/8 sized assist rail on the left side of R2's bed. R2's Medical Record does not include a maintenance inspection of R2's 1/8 assist rail for entrapment zones/risks. 6. On 1/7/25 at 10:15 AM, R48 was lying in bed with an 1/8 sized assist rail on each side of R48's bed. R48's Medical Record does not include a maintenance inspection of R48's 1/8 assist rails for entrapment zones/risks. 7. On 1/8/25 at 9:37 AM, R49 was lying in bed with an 1/8 sized assist rail on both sides of R49's bed. R49's Medical Record does not include a maintenance inspection of R49's 1/8 assist rails for (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 01/09/2025 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 0909 entrapment zones/risks. Level of Harm - Minimal harm or potential for actual harm On 01/08/25 at 11:35 AM V18 (Maintenance Assistant) stated, I am not aware of maintenance doing any inspections of side rails or assist rails to check for areas of entrapment with the bed. I just apply the rails and fix them if they break. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145793 If continuation sheet Page 17 of 17