St Paul's Senior Community

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, interview and record review, the facility failed to ensure 2 of 4 residents (Resident R3, Resident R5) reviewed for resident rights were treated with dignity and respect by allowing staff to use personal cell phones excessively during work hours in the sample of 5. Findings include:On 11/21/25 at 2:19 PM, V6, Certified Nursing Assistant (CNA), was sitting at a table in the 1 South Dining Room looking at a cell phone.On 11/22/25 at 5:20 AM, V15, Licensed Practical Nurse (LPN), was sitting at the 1 South Nurse's Station looking at a cell phone.On 11/22/25 at 5:25 AM, V16, CNA, was sitting at a table in the 1 South Dining Room looking at a cell phone.1-Resident R3's Face Sheet documents Resident R3 was admitted to the facility on [DATE REDACTED] with diagnoses including age related physical debility and muscle wasting and atrophy.Resident R3's Minimum Data Set (MDS) dated [DATE REDACTED] documented Resident R3 was moderately cognitively impaired.On 11/21/25 at 11:00 AM, Resident R3 stated staff are frequently on their cell phones at work.2-Resident R5's Face Sheet documents Resident R5 was admitted to

the facility on [DATE REDACTED] with diagnoses including hemiplegia and need for assistance with personal care. Resident R5's MDS dated [DATE REDACTED] documented Resident R5 was moderately cognitively impaired.Resident R5's Grievance dated 9/26/25 documents, Cell phone use during meals and in general, as a complaint.On 11/21/25 at 3:10 PM, V2, Director of Nursing (DON), stated it is in the Employee Handbook that staff are not to be on cell phones

during work hours.On 11/25/25 at 8:20, AM, V3, Assistant Director of Nursing (ADON), stated there is a no nonsense policy regarding cell phone use for which staff are not allowed to use their cell phones unless

they are on break or off the unit.The Facility's Undated Employee Handbook documents, Unless approved for Community business, the possession or use of cellular phones, pagers, and other portable communication devices is strictly prohibited while on duty except during your scheduled rest and meal periods. Use of these devices will be restricted to the break room or outside of the Community. While you are on duty, these devices will be stowed in your locker, purse/backpack, or vehicle. If the purse/backpack is stowed in a work area, these devices must be in an off position.The Facility's Resident Rights Policy: dated 12/2024 documents, Each resident residing in this community has the right and will be afforded the right to

a dignified existence, self-determination, and communication with and access to persons and services inside and outside the community without interference, coercion, discrimination or reprisal.

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

11/25/2025

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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review, the Facility failed to follow its approved menu for 2 of 4 residents (Resident R2, Resident R3) reviewed for dietary services in the sample of 5. Findings include:1-Resident R2's Face Sheet documents Resident R2 was admitted to the facility on [DATE REDACTED] with diagnoses including Alzheimer's disease.Resident R2's Diet Order dated 10/16/25 documents Resident R2 is on a mechanical soft diet.The Facility's Mechanical Soft Menu for 11/21/25 documents ground sausage links will be served at Breakfast.Resident R2's 11/21/25 Meal Ticket for Breakfast documents ground sausage will be served. On 11/21/25 at 8:51 AM, V5, Dietary Aid, began plating food for breakfast service.On 11/21/25 at 9:05 AM, V3, Assistant Director of Nursing (ADON), served Resident R2 breakfast in the 1-South Dining Room. There were cubes of a white colored meat on the plate that were approximately one-half inch in size.On 11/21/25 at 9:07 AM, V5 stated she would not know what kind of meat was on Resident R2's plate.On 11/21/25 at 9:10 AM, V6, Certified Nursing Assistant (CNA), was feeding Resident R2. She stated the meat looked like ham or diced up turkey. V7, Housekeeping Director, was standing nearby and stated, That's baked ham.On 11/21/25 at 10:23 AM, V10, Assistant Dietary Manager, stated Resident R2 got turkey on his breakfast tray. The sausage that was supposed to be served was on the food truck that had not come in yet, so she just chopped up some turkey for him.2-Resident R3's Face Sheet documents Resident R3 was admitted to the facility on [DATE REDACTED] with diagnoses including age related physical debility and muscle wasting and atrophy.Resident R3's Minimum Data Set (MDS) dated [DATE REDACTED] documented Resident R3 was moderately cognitively impaired.Resident R3's Diet Order dated 2/21/25 documents Resident R3 is on a controlled carbohydrate, no added salt diet.On 11/21/25 at 11:00 AM, Resident R3 stated the facility does not always serve what is listed on the menu.On 11/25/24 at 8:27 AM, V2, Director of Nursing (DON), stated menus should be followed as prescribed. The Facility's Guidelines for Menu Planning from the 2012 Long Term Care Diet Manual does not address adhering to prescribed menus.

Event ID:

Facility ID:

If continuation sheet

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

11/25/2025

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 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 and record review, the Facility failed to provide meals at palatable temperatures for 1 of 4 residents (Resident R3) reviewed for food and nutritional services in the sample of 5.Findings include:1-Resident R3's Face Sheet documents Resident R3 was admitted to the facility on [DATE REDACTED] with diagnoses including age related physical debility and muscle wasting and atrophy.Resident R3's Minimum Data Set (MDS) dated [DATE REDACTED] documented Resident R3 was moderately cognitively impaired.Resident R3's Diet Order dated 2/21/25 documents Resident R3 is on a carbohydrate controlled, no added salt diet.On 11/21/25 at 11:00 AM, Resident R3 stated sometimes the food is served cold.The Facility's Resident Council Meeting Minutes dated 10/24/25 document cold food as an issue/concern.On 11/25/25 at 8:27 AM, V2, Director of Nursing (DON), stated the food should consistently be served hot.The Facility's Undated Monitoring Food Temperatures for Meal Service Policy documents food temperatures will be monitored daily to prevent foodborne illness and ensure foods are served at palatable temperatures.

Residents Affected - Few

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

Event ID:

Facility ID:

If continuation sheet