Health inspection·December 6, 2025

F 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 observation, interview, and record review the facility failed to honor resident preferences regarding menu items. This failure has the potential to affect all residents residing in the facility. The findings include:The facility's resident roster provided on 12/6/25 showed 77 residents reside in the facility.On 12/6/25 at 8:39 AM, V3 [NAME] stated bacon used to be provided for the residents prior to the current owners acquiring the building. (New corporation took ownership on 10/1/25.) V3 said, We used to make bacon all the time.I had four residents ask for it this morning.On 12/6/25 at 8:45 AM and 8:47 AM respectively, a walk-through of the facility's walk-in freezer and walk-in refrigerator showed no bacon.On 12/6/25 at 8:53 AM, V2 Dietary Aide stated We do have residents asking for bacon all the time, but we were told the company won't allow it. [V4] is the dietary manager, and he called the company, and they said no bacon. V2 stated R2, R3, R4, and R5 routinely ask for bacon.On 12/6/25 at 1:16 PM, V7 Certified Nursing Assistant (CNA) stated, he has received a lot of complaints about not getting bacon.On 12/6/25 at 1:21 PM, V8 Registered Nurse stated, I have had many complaints from many residents about not getting bacon.On 12/6/25 at 1:35 PM, V9 CNA stated, They don't get any bacon in the morning, and they are not getting meat in the morning. There are a lot of residents complaining about that.On 12/6/25 at 1:00 PM, R3 stated, .Breakfast is a mess, we don't get any bacon, as far as I know there is no bacon. I like bacon, it's the only breakfast meat I want. They say it's too expensive for us and I said that's bull crap, but I didn't say crap. I think I should be allowed to have bacon. All I want is bacon toast and coffee and now I can't get it. I think I pay enough to get that. I know bacon doesn't have any nutritional value, but it tastes good. I think I should be able to make my own choices about what I eat even if it's not the best for me. I'm [AGE] years old; I should get what I want.What they serve us has a big impact on how I feel, I enjoy going and seeing my friends and talking with them and eating a good meal.On 12/6/25 at 9:40 AM, R2 stated the facility no longer makes bacon and they ran out of bread the other day. R2 stated she would like to have her thin cut bacon.On 12/6/25 at 10:09 AM, R4 stated No bacon anymore. I ask for it, and they say they don't have it anymore. I can't remember the last time we had bacon; it's been months. We had sausage for a while, but they stopped that several days ago. We don't get any meat with our breakfast. I think we should be able to get the bacon all the time or at least a couple times a week, now we get nothing.On 12/6/25 at 10:22 AM, R5 stated . there is no bacon.When I first came here, I had bacon every day and now that they (new owners) have taken over I have not had bacon once since they took over. [V1] has been having a series of resident meetings and the food stuff, the food is the main thing we talk about. The rice and beans are cheap, and I just can't eat rice anymore.Eating is one of the few things that we old people have left to enjoy, so we pay the same as we did before, so why can't they serve us the same stuff. Yesterday they served lasagna at lunch, and I got it again at supper time. I got leftover lasagna.We do have an Page 1 of 2 145935 145935 12/06/2025 The Citadel at Saint Joseph Village 659 East Jefferson Street Freeport, IL 61032

F 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some alternative menu. I have no idea how they would do the alternative menu if they don't have bacon, I would really like some bacon once in a while. (R5 pointed to a facility provided alternative menu. Listed on the menu was Egg, bacon, and cheese sandwich for breakfast and for lunch/supper a BLT (bacon, lettuce, tomato sandwich) was listed.)On 12/6/25 at 11:03 AM, V1 Administrator provided the facility's Always Available Menu (aka alternative menu). The menu showed, Egg, Cheese Sandwich and the BLT sandwich was not listed. The alternative menu was otherwise identical in format to the one on R5's wall.On 12/6/25 at 11:03 AM, V1 Administrator stated The alternative menu, it was changed 2 to 3 weeks ago. We can't get bacon. My understanding, [food service provider] does our menus, they said it has no nutritional value and they will not add it to our menus. It used to be available. The residents would like to have bacon.On 12/6/25 at 11:24 AM, V4 Dietary Manager stated So, I was able to get it (bacon) through [food service provider] one time. I asked the food rep (representative) to order it for me, because residents had asked for it. So, I put it out (provided the bacon to the residents), then after that [food service provider] said I couldn't get any longer because it had no nutritional value. So, then I had to remake the menu without the bacon. The only time I have gotten bacon is when it's a part of a recipe and not served independently. It (bacon has no nutritional value) was from my [food service representative] via their dietitian that I was told we could not get bacon. Bacon is a protein; it doesn't have as much nutritional value as other meats. I'm just going off of what I was told. I have conversations with residents where we try and find a solution to their concerns, and its conversations we continue to have. I would absolutely agree that food is big part of their enjoyment in their life. I think if a food item is not the most nutritious, but it brings them enjoyment they should most definitely be allowed to have that food item.On 12/6/25 at 11:50 AM, V5 Registered Dietitian (V5 does not work for the food service provider, and she was not the dietitian who removed bacon from the menu) stated she has worked for the facility for 5 years. V5 stated, Recently the facility was purchased, and we are no longer able to offer them bacon. [V4] attempted to get it but we are not able to serve it. The issue with bacon is one serving size, which is less than an ounce, doesn't have enough protein to count towards the macronutrients for the menu.It does have some value, but 2 pieces of bacon has only 8 grams of protein. There is nothing dangerous with allowing them to have bacon, but it can be pleasurable for the residents. I do see that mealtime is a big part of their enjoyment especially in the long-term care setting. I could see how having bacon or not having bacon could affect the residents either positively or negatively. We are taught that having things in moderation is okay.The facility's Menu from November 30, 2025, through December 27, 2025, showed no bacon on the breakfast menu. The facility's November grievance log showed R10 reported on 11/18/25 Not receiving breakfast meat.The 11/6/25 Resident Council Meeting minutes showed, Concerns expressed around resident rights discussed: Still not getting bacon.On 12/6/25 at 2:10 PM, V1 stated the facility does not have policy that pertains to the menu and resident preferences. 145935 Page 2 of 2