St Paul's Senior Community

F 0804

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the Facility failed to provide appetizing food at palatable temperatures for 3 of 5 residents (Resident R1, Resident R2, Resident R5) reviewed for food and nutrition services in the sample of 5.Findings Include:1- Resident R1's Face Sheet documents he was admitted to the facility on [DATE REDACTED] with diagnoses including gastric ulcer, end stage renal disease, and muscle wasting and atrophy.Resident R1's 8/15/25 Diet Order documents liberal renal precautions; no orange juice or bananas; limit potatoes and tomatoes; provide double protein portions three times daily; restrict fluid to 1500 mL (milliliter) in 24 hours.Resident R1's Minimum Data Set (MDS) dated [DATE REDACTED] documented Resident R1 was cognitively intact.On 9/4/25 at 9:20 AM, Resident R1 stated the food is not good and is always cold.2-Resident R2's Face Sheet documents Resident R2 was admitted to the facility on [DATE REDACTED] with diagnoses including stage 3 sacral pressure ulcer, burns involving 50-59% of body surface, dependence on renal dialysis, and muscle wasting and atrophy.Resident R2's 8/12/25 Diet Order documents renal diet with no orange juice, oranges, bananas, or milk; limit tomatoes and potatoes to one meal per day.Resident R2's MDS dated [DATE REDACTED] documented Resident R2 was cognitively intact.On 9/4/25 at 9:45 AM, Resident R2 stated the food is awful about half

the time. It usually arrives late and is cold.3-Resident R5's Face Sheet documents Resident R5 was admitted to the facility on [DATE REDACTED] with diagnoses including unspecified pressure ulcer of sacral region, muscle wasting and atrophy, and need for assistance with personal care.Resident R5's 11/14/24 Diet Order documents pureed diet with double portions and mechanical soft preferences, per Speech Language Pathologist (SLP).Resident R5's MDS dated [DATE REDACTED] documented Resident R5 was moderately cognitively impaired.The Facility's 6/11/25 Grievance by Resident R5 documents Resident R5 concerned that food quality is not good.On 9/4/25 at 3:10 PM, Resident R5 stated the food is still lousy most of the time.On 9/4/25 at 12:40 PM, obtained temperatures from a sample meal from the Two South Kitchenette using a metal calibrated thermometer after the last resident tray was served. The gravy was in a pan on the counter and had no method for maintaining the temperature during meal service. The gravy temperature was 105 F (Fahrenheit). V13, Assistant Dietary Manager, stated that needs to be kept in

the warmer. The Facility's Resident Council Meeting Minutes dated 6/27/25 documents food is cold as an issue/concern The Facility's Resident Council Meeting Minutes dated 8/29/25 documents food cold as an issue/concern.On 9/4/25 at 3:57 PM, V1, Regional Director of Operations/Interim Administrator, stated she expects staff to serve food at acceptable temperatures as described in the Facility policy.The Facility's Undated Monitoring Food Temperatures for Meal Service Policy documents, Food temperatures of hot foods on room trays at the point of service are preferred to be 120 F or greater to promote palatability for

the resident.

Residents Affected - Few

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/05/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

St Paul's Senior Community

1021 West E Street Belleville, IL 62220

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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and record review, the Facility failed to ensure always available alternative options were available for 2 of 5 residents (Resident R2, Resident R5) reviewed for food and nutrition services in the sample of 5.1-Resident R2's Face Sheet documents Resident R2 was admitted to the facility on [DATE REDACTED] with diagnoses including stage 3 sacral pressure ulcer, burns involving 50-59% of body surface, dependence on renal dialysis, and muscle wasting and atrophy.Resident R2's 8/12/25 Diet Order documents renal diet; no orange juice, oranges, bananas, or milk; limit tomatoes and potatoes to one meal per day.Resident R2's MDS dated [DATE REDACTED] documented Resident R2 was cognitively intact.

On 9/4/25 at 9:45 AM, Resident R2 stated the Facility has an alternative menu, but is always told they do not have

the items he requests.2-Resident R5's Face Sheet documents Resident R5 was admitted to the facility on [DATE REDACTED] with diagnoses including unspecified pressure ulcer of sacral region, muscle wasting and atrophy, and need for assistance with personal care.Resident R5's 11/14/24 Physician Order documents pureed diet with double portions and mechanical soft preferences, per Speech Language Pathologist (SLP).Resident R5's MDS dated [DATE REDACTED] documented Resident R5 was moderately cognitively impaired.Resident R5's 6/11/25 Grievance documents the Facility is always out of food items.On 9/4/25 at 3:10 PM, Resident R5 stated he does not like the food, but does not ask for alternates because he knows is not going to get it. They always tell him they don't have it.On 9/4/25 at 10:17 AM, V8, Dietary Manager, stated they run out of some alternative items like chicken strips and French fries.On 9/4/25 at 3:57 PM, V1, Regional Director of Operations/Interim Administrator, stated the alternative menu is available from 7:00 AM to 7:00 PM. There will be isolated instances where certain foods are not available from time to time, but in general, the alternative options should be available to residents.On 9/4/25 at 2:28 PM, requested Facility policy regarding alternative menus from V1.On 9/5/25 at 10:00 AM, no policy was received from the Facility.The Facility's Alternative Menu documents two pages of food choices, including chicken tenders, French fries, and various soups and sandwiches.

Event ID:

Facility ID:

If continuation sheet