Health inspection·February 9, 2026

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to properly maintain the mechanical lift slings for one of three residents (R1) reviewed for falls in a sample of three. This failure resulted in R1 being emergently transferred to the ER (Emergency Room), receiving medical treatment for an acute intertrochanteric right femur fracture. Findings Include:The facility's Hydraulic Lift (Total Body) policy dated 12/10/2025 documents, Purpose: To provide nursing staff with proper guidelines for use of a hydraulic lift. Policy: All nursing staff will be trained on the proper use of the Hydraulic Mechanical Lifts that are used within the facility, to ensure safe transfer for residents. Mechanical Lift will be used as ordered and per nursing judgment. Responsibility: It is the responsibility of the Director of Nurses to ensure that all nursing staff have received proper training on the Mechanical lift prior to using it. It is the responsibility of all nursing staff to ensure that policies and procedures are followed when using a Mechanical lift. Positioning sling for resident in seated position: 16. Prior to lifting an individual, make sure that the straps of the sling are securely placed on the hooks of the carry bar.The facility's Full Body Sling Instruction Manual does not date documents. WARNING: Carefully inspect the sling before each use for wear and damage to seams, fabric, straps, and strap loops. Torn, cut, frayed, or broken slings can fail, resulting in serious personal injury to the user. Use only slings that are in good condition. Discard and destroy old, unusable slings. Washing Instructions: 1. Machine wash warm or cold, a. Maximum washing temperature 185 F (85 C), b. Wash at 160 F (71 C) for 3 minutes, c. Wash at 145 F (63 C) for 10 minutes, d. Air dry, or tumble dry at cool or very low temperature, e. Do not tumble dry at high temperature. 2. Use a non-enzyme detergent. 3. Do not use bleach. 4. Do not wash with other colors. WARNING: After each laundering (in accordance with instructions on the sling), inspect sling(s) for wear, tears, and loose stitching. Bleached, torn, cut, frayed, or broken slings are unsafe and could result in injury. Discard immediately.The facility's Guideline for Identifying Deteriorated Slings not dated documents, Accelerated Deterioration from Bleach, High Temperature Wash or Drying Slings, especially loop straps that have been damaged from being laundered in unsuitable conditions (bleach, high heat wash or dry) may appear to be in good condition but the actual tensile strength of the material may be compromised and pose a safety risk and should not be used for lifting a patient or resident. Proactive Medical slings have been designed and tested for laundry wash conditions of 170F (Fahrenheit) degrees and air dry or dry at low temperature. The slings should never be bleached. Commercial washers and dryers are not recommended. Care instructions on the sling label should always be followed. Laundry equipment should be properly maintained and repaired when necessary. Causes of Deterioration Due to Laundry Conditions: 1. Chemical degradation (bleach, peroxide, chlorine, and other disinfectants). This can occur if bleach was used in high amounts or high-concentration bleach was used during the wash cycle. Washing at higher temperatures will make the fabric more susceptible to attack by the chemical. Page 1 of 3 145793 145793 02/09/2026 Renaissance Care Center 1675 East Ash Street Canton, IL 61520

F 0689 Level of Harm - Actual harm Residents Affected - Few Insufficient flush, rinse, or neutralizing of the chemicals from fabric, followed by subsequent drying at high temperature will again intensify chemical action and increase the degree of deterioration to the sling fabric. 2. Temperature or high heat damage. This can occur if the slings are left in the dryer for too long or dried at excessive heat. The Slings are made from plastic fibers and do not absorb as much water and require less drying time than other laundry of natural fiber and fabric. 3. Mechanical/Wash Action can contribute to the accelerated deterioration of the slings, especially if they have been subjected to the above conditions. Slings should be washed using a gentle cycle to minimize excessive agitation and internal fiber abrasion.R1's admission Record dated 12/9/2026 documents, Multiple Sclerosis, Nondisplaced Intertrochanteric Fracture of Right Femur.R1's Care Plan dated 12/9/2026 documents, I have an ADL (Activities of Daily Living) Self Care Performance Deficit related to impaired mobility related to MS (Multiple Sclerosis), and muscle weakness. Revision on: 09/21/2020. TRANSFER: R1 requires Mechanical Aid, (Mechanical Lift) for transfers; Assists x 2 (two people must assist with transferring). Date Initiated: 08/02/2022. Revision on: 03/18/2024.R1's MDS (Minimum Data Set) dated 10/4/2025 section GG documents, Functional Limitation in Range of Motion, Upper extremity, 0 (no impairment) and Lower Extremity 2 (impairment on both sides).R1's MDS dated [DATE] section GG documents, Functional Limitation in Range of Motion, Upper extremity 0 (no impairment) and Lower Extremity 1 (impairment on one side).R1's Emergency History of Present Illness dated 12/9/2025 documents, R1 presents to the emergency department by ambulance for right hip and right arm pain. R1 was being transferred via (mechanical lift) at the nursing home when the mechanical lift sling broke causing R1 to fall onto the bed. R1 denies hitting her head or neck pain. X-ray demonstrates an acute intertrochanteric right femur fracture. Normal humerus X-ray. Orthopedic surgery was consulted. R1 admitted to MS (medical surgical floor) for further treatment.The facility's QA (questions and answers) meeting dated 12/2025 documents, Upon investigation, it was identified that the Housekeeping Supervisor had been responsible for managing (mechanical lift) sling rotation and tracking. When the supervisor resigned from the position, this responsibility was not formally transitioned. The incoming supervisor was not made aware of the established sling rotation and monitoring procedure, resulting in a lapse in oversight. Root Cause Analysis: The root cause was identified as a failure to formally assign and communicate responsibility for Mechanical lift sling rotation and expiration tracking during the supervisory transition, resulting in a lack of consistent monitoring.On 2/9/2026 at 9:00 AM, R1 was in the dining room, in her high-back wheelchair, with a mechanical lift sling underneath her. R1 stated she does not remember her fall. R1 stated that when she is transferred with the mechanical lift, there are two people transferring her. R1 stated she feels safe. R1 stated she does not have any concerns. R1 stated she is pretty sure that she has not had any falls. R1 stated she does have pain in her right hip when being moved around a lot.On 2/9/2026 at 11:00 AM, V3 (Environmental Supervisor) stated that before R1's fall in December, the laundry aides would bleach mechanical lift slings and wash them with sheets. V3 stated she also puts the mechanical lift slings in the dryer and is not sure what the temperature was.On 2/9/2026 at 11:30 AM, V4 (Maintenance) stated the washer temperature goes between 105 degrees Fahrenheit to 110 degrees Fahrenheit. V4 also stated the dryer heat is 177 degrees Fahrenheit.On 2/9/2026 at 10:05 AM, V5 (Laundry Aide) stated that when it comes to washing mechanical lift slings, she is supposed to separate them from everything else in the laundry and only wash mechanical lift slings together on the personals setting. V5 was not sure what the temperature was when washing on the personals setting. V5 stated that once the mechanical lift slings are washed, they go into the dryer that has only one setting. V5 was unsure what temperature the dryer setting was on. V5 stated that once the mechanical lift slings are dry, she is to 145793 Page 2 of 3 145793 02/09/2026 Renaissance Care Center 1675 East Ash Street Canton, IL 61520

F 0689 Level of Harm - Actual harm Residents Affected - Few check them for any damage or fraying of thread on the straps and throughout the sling seams before sending them to each hall for use.On 2/9/2026 at 1:52 PM, V8 (Certified Nurse Assistant) stated she was getting R1 up for dinner on 12/9/2025 using the mechanical lift, and when she looked at the mechanical lift sling before using it on R1, the sling did not look frayed. V8 stated once R1 was up in the air in the mechanical lift, V9 (Certified Nurse Assistant) was guiding R1 into her wheelchair. At that point, V8 stated the right bottom strap on the mechanical lift sling broke, and all V8 saw as R1 falling to the ground. V8 stated that once the management staff came in and looked at the mechanical lift sling, the management staff determined that the straps were dry rotted.On 2/9/2026 at 2:00 PM, V9 (Certified Nurse Assistant) stated that on 12/9/2025, she was with V8 (Certified Nurse Assistant) in R1's room, assisting R1 out of bed and into R1's wheelchair with the mechanical lift. V9 stated that once R1 had her mechanical lift sling underneath her, all four straps attached to the mechanical lift, and seemed fine. V8 started to lift R1 using the remote on the mechanical lift from her bed to her wheelchair. V9 stated she was guiding R1 and positioning R1 to be placed in her wheelchair when R1's bottom right mechanical lift strap broke. V9 stated R1 fell out of the mechanical lift sling, hit the side of the bed, and landed on her right side. V9 stated that once the management staff looked at the mechanical lift sling, the management staff determined the broken strap was dry rotted.On 12/9/2026 at 2:22 PM, V10 (Registered Nurse) stated that on 12/9/2025, V9 (Certified Nurse Assistant) came to get her to tell her R1 had fallen out of her mechanical lift during transferring her from the bed to her wheelchair. V10 stated that when she came into R1's room, R1 was lying horizontally on her right side, lying across the mechanical lift legs, and R1's neck was cranked to the side close to the nightstand. V10 stated it was determined that R1's mechanical lift sling strap had broken, and that was why she fell out of the sling and onto the floor.On 12/9/2026 at 3:32 PM, V2 (Director of Nursing) stated that after R1's fall, it was determined that the mechanical lift sling straps were dry-rotted and that the mechanical lift slings were being improperly washed and dried. 145793 Page 3 of 3