Fireside House of Centralia

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that the food storage area was kept clean and swept and failed to ensure that policies and procedures were followed to prevent cross contamination. This failure has the potential to affect all 60 residents who reside in the facility. The Findings Include:On 02/17/2026 at 9:23 AM during the initial tour of the kitchen, the following items were observed:Dry storage room floor was littered with hair restraints, food crumbs, and spilled cereal. The lid on the cereal storage container for the corn flakes was broken not allowing it to have an air tight seal and potential for pests to enter and become stale. A handled scoop was found in the bulk flour bin. The ice machine interior flap had a pink substance found on it indicating that it needed sanitized. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure resident diet orders were provided as ordered for 4 of 4 (R8, R22, R23, and R26) residents reviewed for diet order accuracy in a sample of 44. The Findings Include:R8's admission Profile documents an admission date of 7/30/24. This same document includes the following diagnoses: dementia, type 2 diabetes, and dysphagia. The Order Listing Report documents that R8's diet order is easy to chew texture and regular/thin liquids. R22's admission Profile documents an admission date of 10/7/25. This same document includes the following diagnoses: Type 2 diabetes, depression and hypertension. The Order Listing Report documents R22's diet order is regular diet, regular/thin liquids and double protein with all meals, no double entrée. R23's admission Profile documents an admission date of 5/23/24. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain the desirable water temperature in the facility shower for 1 (R26) of 5 residents reviewed for environment in a sample of 44.

Inspectors wroteBased on interview and record review the facility failed to ensure that significant change assessments were completed timely for 1 of 1 (R63) residents reviewed for significant changes in a sample of 44. The Findings Include:R63's admission Profile sheet documents an admission date of 7/2/2022. This same document includes the following diagnoses: Hemiplegia and Hemiparesis, Type 3 Diabetes and Dysphagia. R63's current physician order sheet shows that Hospice was started on 10/29/2025. R63 did not have a significant change Minimum Data Set Assessment completed at this time. A Minimum Data Set submission report documents that R63's target date for her significant change assessment was 11/4/2025 and was submitted on 2/16/2026. There is a message documenting that the assessment completed late: is more than 14 days after assessment reference date. [...]

Inspectors wroteBased on interview and record review the facility failed to timely submit quarterly assessments for 1 of 1 (R45) residents reviewed for timely submission of assessments in a sample of 44. The Findings Include: R45's admission Record documents an admission date of 7/11/2024. This same document includes the following diagnoses: heart failure, anxiety disorder and chronic kidney disease. R45's quarterly Minimum Data Set (MDS) Assessment with a target due date of 1/13/2026 did not document that it was transmitted. A Final Validation Report documents that R45's MDS with a target date of 1/13/2026 was submitted on 2/19/2026 with a warning that the assessment was completed late due to being more than 14 days after the assessment reference date. [...]

Inspectors wroteBased on interview and record review the facility failed to timely submit discharge assessments for 1 of 1 (R36) residents reviewed for discharge assessments in a sample of 44. The Findings Include:R36's admission Record documents an admission of 9/2/25. The same document includes the following diagnoses: Type 2 Diabetes, Hypertension, Cognitive Communication Deficit, and anemia. R36's discharge Minimum Data Set (MDS) Assessment documented it was completed but not submitted on 9/30/2025. A Final Validation Report documents that R36's discharge MDS with a target date of 9/30/2025 was transmitted on 2/19/2026 with the warning error: Record submitted late, the submission date is more than 14 days after the assessment reference date. On 2/19/2026 at 2:00 PM, V2 (Director of Nursing) confirmed that R36's discharge assessment had not been transmitted.

Inspectors wroteBased on observation, record review and interview the facility failed to provide assistive devices at meals as ordered for 3 of 3 residents (R3, R25 and R55) in a sample of 44 reviewed for assistive devices at meals. The Findings Include:R3's admission Profile documents an admission date of 11/24/25. This same document includes the following diagnoses: Type 2 Diabetes Mellitus, unspecified lack of coordination, and major depressive disorder. R3's diet listed on the Facility Order Listing Report is as follows: Regular texture, regular/thin liquids, 8 ounces of extra fluids and built-up silverware to assist while eating. R25's admission Profile documents an admission date of 8/6/25. This same document includes the following diagnoses: Major Depressive Disorder, Anxiety Disorder, and Alzheimer's Disease. R25's diet listed on the Facility Order Listing Report is as follows: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow Enhanced Barrier Precaution (EBP) infection control precautions for 1 of 6 residents (R11) residents reviewed for infection control in the sample of 44.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain a functioning call light system for 2 (R15 and R54) of 5 residents reviewed for environment in a sample of 44.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure sufficient staff to meet the needs of the residents timely. This has the potential to affect all 54 residents currently residing at the facility. Findings Include: The Midnight Census Report dated 7/2/25 documents there are 54 residents residing at the facility. R8's admission Record with a print date of 7/9/25 documents R8 was admitted to the facility on [DATE] with diagnoses that include dementia, muscle weakness, and vision loss. R8's Minimum Data Set (MDS) dated [DATE] documents R8 has a BIMS score of 09, indicating a moderate cognitive deficit. This same MDS documents R8 is dependent on staff for transfers. R8's current Care Plan documents a Focus area of Risk for falls. This Focus area includes the intervention mechanical lift for transfers. There are no dates documented on this Care Plan. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure supplements were available for 4 of 6 (R1, R2, R10, and R14) residents reviewed for nutrition in the sample of 14. Findings Include: 1. R1's admission Record with a print date of 7/9/25 documents R1 was admitted to the facility on [DATE] with diagnoses that include diabetes, dementia, and vitamin deficiency. R1's MDS (Minimum Data Set) dated 3/26/25 documents a BIMS score of 05, indicating R1 has a severe cognitive deficit. R1's current Care Plan documents a Focus area of, Actual alteration in nutrition or hydration status r/t (related to) Vitamin D deficiency, hypomagnesium, n/v (nausea/vomiting), GERD (gastroesophageal reflux disease). 3/2025 weight loss. This same Focus area include the intervention of, Supplements as ordered: 7/4/2025- Boost 90 ml (milliliters) TID (three times daily). [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure two staff were available when using a mechanical lift for 1 of 3 (R8) residents reviewed for accidents in the sample of 14. Findings Include: R8's admission Record with a print date of 7/9/25 documents R8 was admitted to the facility on [DATE] with diagnoses that include dementia, muscle weakness, and vision loss. R8's Minimum Data Set (MDS) dated [DATE] documents R8 has a BIMS score of 09, indicating a moderate cognitive deficit. This same MDS documents R8 is dependent on staff for transfers. R8's current Care Plan documents a Focus area of Risk for falls. This Focus area includes the intervention mechanical lift for transfers. There are no dates documented on this Care Plan. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a cognitively impaired resident was adequately supervised to prevent her exiting the facility without staff knowledge for 1 (R1) of 3 residents reviewed for accidents and supervision in the sample of 3. This failure resulted in R1, who has a diagnosis of dementia and was already on 15-minute visual checks for previous exit seeking behavior, exiting the facility at an unknown time without staff knowledge or supervision, walking approximately 1.3 miles away from the facility and was found by two unknown teenage female citizens who took R1 to the local emergency room. This failure resulted in an Immediate Jeopardy, which was identified to have begun on 5/15/2025 at approximately 7:45pm when R1 exited the facility and was found by two teenage girls approximately 1.3 miles from the facility. [...]

Inspectors wroteBased on, interview, observation and record review, the facility failed to provide a sufficient number of staff to ensure residents timely and safe assistance with care and transfers. The failure has the potential to affect all 60 residents living in the facility.

Inspectors wroteBased on interview, observation and record review the facility failed to provide the correct textured diet as ordered for 4 of 17 residents (R8, R20, R41, and R47) reviewed for meal texture in the sample of 35.

Inspectors wroteBased on interview, observation, and record review the facility failed to provide extra supplementation as ordered for 4 of 17 residents (R8, R45, R47, and R56) reviewed for dietary supplementation in the sample of 35.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain infection control practices in accordance with current standards of practice during patient care for 8 of 8 residents (R8, R16, R24, R28, R32, R41, R64, R65) reviewed for infection control in the sample of 35.

Inspectors wroteBased on observation, interview and record review the facility failed to provide feeding assistance for dependent residents in a way that promoted dignity for 2 out of 2 residents (R11, R23) reviewed for dignity in a sample of 35.

Inspectors wroteBased on interview and record review, the facility failed to ensure an individual admitted with a mental illness diagnosis was referred to the appropriate state-designated authority for a Level II PASARR (Preadmission Screening and Resident Review) evaluation and determination of need for any specialized service for 2 of 3 residents (R32 and R35) reviewed for PASARR requirements in a sample of 35.

Inspectors wroteBased on interview and record review the facility failed to keep a resident's environment free of accident hazards and failed to implement new interventions to reduce falls for 7 of 10 residents (R2, R3, R9, R41, R49, R51, R54) reviewed for falls in a sample of 40. This failure resulted in R2 falling out of bed on 11/29/2023 due to a loose bed enabler and suffering a fractured left acetabular medial wall, a fractured iliopubic junction fracture and a fractured pubic rami.

Inspectors wroteBased on interview and record review the facility failed to protect a resident's right to be free from neglect when they failed identify a change in condition as emergent and to ensure a system was in place to obtain timely emergency transport for 1 of 3 (R1) residents reviewed for neglect in the sample of 9. This failure resulted in R1 not being transported to the hospital emergency room for an hour while experiencing worsening symptoms of sluggish dilated pupils, temperature of 95.7, difficulty with speech, slow response time, and facility staff were unable to obtain an oxygen saturation. R1 expired in the hospital emergency room and cause of death is documented as a massive gastrointestinal bleed. This failure has the potential to affect all 37 residents residing at the facility. [...]

Inspectors wroteBased on interview and record review the facility failed to identify a decline in condition as an emergent situation and ensure a system was in place to obtain timely emergency transport for 3 of 6 (R1, R8, and R9) residents reviewed for hospital transfers in the sample of 9. This failure resulted in R1 not being transported to the hospital emergency room for an hour while experiencing worsening symptoms of sluggish dilated pupils, temperature of 95.7, difficulty with speech, slow response time, and facility staff were unable to obtain an oxygen saturation. R1 expired in the hospital emergency room and cause of death is documented as a massive gastrointestinal bleed. This failure has the potential to affect all 37 residents residing at the facility. [...]