Health inspection·September 5, 2025

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 (R1, R2, R5) reviewed for food and nutrition services in the sample of 5.Findings Include:1- R1's Face Sheet documents he was admitted to the facility on [DATE] with diagnoses including gastric ulcer, end stage renal disease, and muscle wasting and atrophy.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.R1's Minimum Data Set (MDS) dated [DATE] documented R1 was cognitively intact.On 9/4/25 at 9:20 AM, R1 stated the food is not good and is always cold.2-R2's Face Sheet documents R2 was admitted to the facility on [DATE] with diagnoses including stage 3 sacral pressure ulcer, burns involving 50-59% of body surface, dependence on renal dialysis, and muscle wasting and atrophy.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.R2's MDS dated [DATE] documented R2 was cognitively intact.On 9/4/25 at 9:45 AM, R2 stated the food is awful about half the time. It usually arrives late and is cold.3-R5's Face Sheet documents R5 was admitted to the facility on [DATE] with diagnoses including unspecified pressure ulcer of sacral region, muscle wasting and atrophy, and need for assistance with personal care.R5's 11/14/24 Diet Order documents pureed diet with double portions and mechanical soft preferences, per Speech Language Pathologist (SLP).R5's MDS dated [DATE] documented R5 was moderately cognitively impaired.The Facility's 6/11/25 Grievance by R5 documents R5 concerned that food quality is not good.On 9/4/25 at 3:10 PM, 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 Page 1 of 2 146122 146122 09/05/2025 St Paul's Senior Community 1021 West E Street Belleville, IL 62220

F 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 (R2, R5) reviewed for food and nutrition services in the sample of 5.1-R2's Face Sheet documents R2 was admitted to the facility on [DATE] with diagnoses including stage 3 sacral pressure ulcer, burns involving 50-59% of body surface, dependence on renal dialysis, and muscle wasting and atrophy.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.R2's MDS dated [DATE] documented R2 was cognitively intact. On 9/4/25 at 9:45 AM, R2 stated the Facility has an alternative menu, but is always told they do not have the items he requests.2-R5's Face Sheet documents R5 was admitted to the facility on [DATE] with diagnoses including unspecified pressure ulcer of sacral region, muscle wasting and atrophy, and need for assistance with personal care.R5's 11/14/24 Physician Order documents pureed diet with double portions and mechanical soft preferences, per Speech Language Pathologist (SLP).R5's MDS dated [DATE] documented R5 was moderately cognitively impaired.R5's 6/11/25 Grievance documents the Facility is always out of food items.On 9/4/25 at 3:10 PM, 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. 146122 Page 2 of 2