Health inspection·January 17, 2025

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based observation, interview, and record review, the facility failed to notify a family representative of a significant illness and test results for one of one resident (R31) reviewed for notification in the sample of 34. Findings include: R31's undated Face Sheet documents an admission date of 8/8/22 with a primary medical diagnosis of Syncope and Collapse. R31's Minimum Data Set (MDS) dated [DATE] documents R31 has moderate cognitive impairment. V4, R31's daughter, filed a grievance dated 10/11/14 documenting a concern for R31's well-being and the failure of staff to notify her of the results of x-rays. R31's chest x-ray dated 10/11/24 documents Impression: bronchovascular prominence with differential as above. No lobar consolidation is seen. There is some increased density at the left base suggestive of infiltrate. On 1/14/25 at 12:13 PM, V4 stated she did not receive notification her mother (R31) had pneumonia. V4 stated she emailed the Social Service Director (SSD) to get her mother tested because of the concern of her mothers' wheezing and coughing. R31 was tested and she did have pneumonia. V4 stated she was not notified that her mother had pneumonia. R31's Nurse Progress notes dated 10/14/24 documents resident daughter here to visit stated to this nurse that she was not aware resident had an x-ray and was not aware of the results. Daughter stated her distaste for not knowing what was going on with her mother. This nurse did inform daughter of the new orders given for resident's X-ray results for pneumonia all new orders confirmed by this nurse. Informed management of daughters concerns and that she would like a call also put on (HIPAA/Health Insurance Portability and Accountability Act-compliant secure messaging and communication tool). Grievance Log dated October 2024 documents V4 did file a Grievance with the facility regarding the lack of notification of chest X-ray results. The Grievance final report dated 10/18/24 was founded and the employee (V28, Licensed Practical Nurse, LPN) receive a write up and re-education on notification of family's regarding any changes. On 01/17/25 at 2:30 PM V1, Administrator, stated her expectations are that the assigned duty nurse Page 1 of 5 146122 146122 01/17/2025 St Paul's Senior Community 1021 West E Street Belleville, IL 62220

F 0580 would notify the family. V1 stated that nurse has been re-educated on the importance of family notification. Level of Harm - Minimal harm or potential for actual harm On 01/17/25 at 2:46 PM V27, Social Service Director (SSD) stated she did receive a text from V4 regarding R31's wheezing and coughing. The information was passed on to the nurse on duty for follow-up. Later discovered that V4 daughter of R31 did not receive follow-up information from the X-rays and that treatment had been initiated. Residents Affected - Few On 01/17/25 at 2:50 PM V28, stated that she did attempt to notify the family around 7:00 PM but no answer. V28 stated she did not leave a message. She did however request that the night shift nurse alert morning shift to contact the family of the resident's change in condition. V28 stated she did receive a write-up and re-education for failing to notify the family. The facility policy on Significant Condition Change and Notification dated 12/2024 documents the purpose is to ensure that the resident's family and /or representative and/or medical practitioner are notified of resident changes such as those listed below. A significant change in the resident's physical, mental or psychosocial status. 146122 Page 2 of 5 146122 01/17/2025 St Paul's Senior Community 1021 West E Street Belleville, IL 62220

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review the facility failed to ensure food was stored and prepared in a manner which prevents potential contamination. This has the potential to affect all 103 residents living in the facility. On 01/14/25 at 10:02 AM on the 100 South Hall there are two refrigerators in the kitchen unit, in the first refrigerator there was a non- resident refrigerator and inside was a block of yellow cheese slices approximate 30 slices that was not covered as the plastic wrap had come off and was exposing it to the air the top slice was leathery in texture, and all dried out. There was also a large styrofoam container containing some type of rice with vegetables inside of it that was not labeled or dated. On 1/14/2025 at 10:08 AM on the 100 South Hall in the resident refrigerator there was four cooked eggs in a metal container with no date or label. There was a large three-quart clear pitcher that was full and was brown in color with no date and or label. There was also a plastic container full of a brown meat like product that was not labeled and or dated. On 1/14/2025 at 10:11 AM, in the Resident Refrigerator on the 100 South Hall was a laminated sign that was hanging on the door of the refrigerator that documented the following: Any items placed in the refrigerator and freezer should be clearly labeled with name and date. Any items that are not properly labeled with a name and date will be discarded immediately. Thanks Household Dietary Manager. On 1/14/2025 at 10:18 AM, on the 100 North Hall kitchen unit in the Resident's Refrigerator there are five bags of food tied of with a grocery bag with no date or labels. There is also a package of Swiss cheese that was halfway opened and was not covered entirely in plastic wrap that was not covered, dated, or labeled. There were two two-quart pitchers of thickened clear substance that was not dated and or labeled. There was a large three-quart brown pitcher of a substance with no date and or label on it. On 1/14/2025 at 10:22 AM, on the 100 North Hall kitchen unit the other refrigerator were five bags of food wrapped in a grocery store none of the bags were dated and or labeled. There was also a block of yellow cheese not dated and or labeled. There was a large box of pizza not dated or labeled. And a metal container of what appeared to be chocolate pudding was sitting on the shelf that was not dated and or labeled. On 1/14/2025 at 10:24 AM, on the 200 South Hall in the main refrigerator there was a styrofoam container of rice with no date and or label on it. There was a large industrial pitcher of a brown liquid with no date and or label. There was a block of butter wrapped in aluminum foil with no date and or label. On 1/14/2025 at 10:26 AM, on the 200 Hall Resident Refrigerator there were two fast food bags with food inside with no date and or label. There was a sausage patty with no date and or label. There were two slices of pizza with no name, date and or label. On 1/14/2025 at 10:29 AM, on the 300 North Hall there were five small round pancakes wrapped in plastic wrap with no date or label. There was also a block of yellow cheese with no date or label. 146122 Page 3 of 5 146122 01/17/2025 St Paul's Senior Community 1021 West E Street Belleville, IL 62220

F 0812 Level of Harm - Minimal harm or potential for actual harm On 1/14/2025 at 10:30 AM, in the Resident Refrigerators there was a plastic container with a substance that appeared red with beans that was not dated and or labeled. There was a large 30-ounce container of yogurt with a use by date of 12/24/2024. (23 days old), and three styrofoam containers of food covered with grocery bags with no name, date and or labels. On the top shelf was a dinner plate with a thermal lid on top with no date and or label. There was also a sausage patty wrapped in plastic with no date and or label. Residents Affected - Many On 1/14/2025 at 1:14 PM, V9, Dietary Manager stated, Any items placed in the refrigerator and freezer even on the kitchenette should always be clearly labeled with name and date. The Labeling and Dating Foods (Date Marking) Policy undated documents, All Foods stored will be properly labeled according to the following guidelines. Once opened, all ready to eat, potentially hazardous food will be re-dated with a use by date according to current safe food storage guidelines or be the manufactures expiration date. Prepared food or opened food items should be discarded. The CMS 671 Form dated 1/14/2025 documents there were 103 residents living in the facility. 146122 Page 4 of 5 146122 01/17/2025 St Paul's Senior Community 1021 West E Street Belleville, IL 62220

F 0851 Level of Harm - Minimal harm or potential for actual harm Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. Based on Interview and Record Review the facility failed to submit the required Payroll-Based Journal (PBJ) data for the 4th quarter of 2024. This has the potential to affect all 103 residents in the facility. Residents Affected - Many Findings include: PBJ report for the 4th quarter of 2024 dated 10/1/2024-12/31/2024, documents Low weekend staffing, RN (Registered Nurse) coverage for 8 consecutive hours/day, licensed nurse for 24 hours/day, one star staffing rating, failed to submit PBJ data. On 1/14/2025 V1, Administrator, provided a notice the facility received from the State Agency documenting the facility had failed to provide the required staffing information. On 1/17/2025 at 12:50PM V1, Administrator, stated the corporate office had a new employee. The PBJ data was submitted to the corporate office from our facility in a timely manner, but not submitted to CMS On 1/17/2025 at 1:10PM V1, Administrator, stated facility has no policy regarding PBJ submission data. 146122 Page 5 of 5