Renaissance Care Center

Inspectors wroteBased 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: [...]

Inspectors wroteBased on interview and record review, the facility failed to prevent misappropriation of controlled substance medications for five of six residents (R1, R2, R3, R4, and R5) reviewed for misappropriation of resident medications in a sample of six.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview, and record review the facility failed to cover a urinary drainage catheter bag with a privacy bag for two of 15 residents (R4, R48) reviewed for dignity in the sample of 38.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on interview and record review the facility failed to ensure that one resident (R1) is free from abuse in a sample of three residents reviewed for abuse. This failure caused R1 to be visibly soiled through outer clothes and to have an odor. Findings Include: The Facility's Abuse Reporting policy dated 8/11/2017 documents This facility will not tolerate resident abuse or mistreatment by anyone, including staff members, other residents, consultants, volunteers, and staff of other agencies, resident representative, legal guardians, friends or other individuals. The Abuse Reporting policy documents For the purposes of this policy, and to assist staff members in recognizing abuse, the following definitions shall pertain: Abuse: [...]

Inspectors wroteBased on interview the facility failed to ensure that one resident (R1) was free from physical restraint in a sample of three residents reviewed for abuse. Findings Include: The Facility's Physical Restraint policy dated 9/23/15 does not define situations that could be considered a physical restraint. The policy does document that the use of physical restraints shall be limited to situations necessary to maximize a resident's physical, mental and psychosocial wellbeing. Physical restraints shall be considered only after all alternatives to physical restraint usage has been documented as being ineffective in accomplishing a resident's care goals. The [NAME] Webster Dictionary defines a restraint as a device that restricts movement. R1's current care plan dated 12/26/2022 documents I will push myself out of my wheelchair at times. [...]

Inspectors wroteBased on interview and record review the facility failed to follow procedures when documenting medication for four residents (R1, R2, R3, and R5) of six residents reviewed for medication in the sample of eleven.

Inspectors wroteBased on interview and record review the facility failed to prevent significant medication administration errors for 3 residents (R1, R2, and R5) of 6 residents reviewed for medication administration in the sample of 11.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on record review and interview the facility failed to notify the Resident or Resident Representative, in writing of Transfers/Discharges to the Hospital. This failure has the potential to affect all 52 Residents residing in the Facility.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pain management for one of one resident (R41) reviewed for pain management in the sample of 24. This failure resulted in R41, who is a resident on hospice services with the diagnoses of malignant neoplasm of her right lung, cervix, trachea, and adrenal gland, refusing to get out of bed and reposition because of R41's extreme pain with any kind of movement.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure licensed nursing staff had the necessary skill set to identify and address a resident's change in condition, properly disinfect a blood glucose monitor between uses, and prime the needle tip of an insulin pen before use. These failures affected six of six residents (R27, R8, R5, R18, R39, R12) reviewed for nursing services in a sample of 24.

Inspectors wroteBased on observation, interview, and record review, the facility failed to disinfect blood glucose meter with a disinfectant agent according to manufacturer's guidelines. This had the potential to affect 10 residents (R5, R8, R9, R20, R25, R30, R31, R40, R41, R43) who receive scheduled blood glucose monitoring.

Inspectors wroteBased on observation, interview, and record review the facility failed to notify a physician of an elevated blood glucose level for one of one resident (R27) reviewed for notification of changes in a sample of 24.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure pressure relief boots were on a resident's feet and a resident's feet were floated in bed as ordered by the physician and documented in the care plan for one of four residents (R34) reviewed for pressure ulcers in a sample of 24.

Inspectors wroteBased on observation, interview, and record review, the facility failed to document diagnoses and behaviors to warrant the use of an antipsychotic and perform gradual dose reductions (GDRs) for two of five residents (R28, R35) reviewed for psychotropics in the sample of 24.

Inspectors wroteBased on interview and record review, the facility failed to state in the arbitration agreement that,the agreement can be rescinded within 30 days of signing it and that it is not required to sign an agreement for binding arbitration as a condition of admission. They also failed to explain the arbitration agreement in a manner that the resident and their representative understands or acknowledge if the resident and their representative understood the agreement. This had the potential to affect all 52 residents residing in the facility.