Below average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Centralia Manor during CMS and state inspections, most recent first.
A CNA recorded a video of a resident with severe cognitive impairment and dementia-related behaviors while the resident was lying on the floor of a closet in her room, then later posted the video to Snapchat. The post included the facility name and showed the resident covered with a blanket after staff checked on her because she had not been out of her room for a while. The resident's care plan documented delusions, distress after family visits, and behaviors such as hiding in closets, bathrooms, and under beds.
A resident with severe cognitive impairment, dementia, psychotic disorder, anxiety, and depression was recorded by a CNA while lying on the closet floor and the video was later posted to the CNA’s social media account with the facility name visible. The CNA said the resident was a relative and that she did not realize she should not have posted it. Surveyor observation confirmed the post, and administration was not aware of the incident when it was discovered.
The facility failed to protect severely cognitively impaired residents from resident-to-resident abuse. A resident with dementia and a prior right humerus fracture was found on the floor near her bathroom after yelling, reporting that a man had pulled her from bed; staff and documentation indicated another cognitively impaired resident with known aggressive, intrusive behaviors had been in the room, and the injured resident exhibited right arm pain, mid-back redness, and painful/limited upper extremity ROM. Staff interviews described this aggressive resident as frequently trying to wake others, attempting to pull multiple residents out of bed, threatening residents, and becoming more argumentative with redirection, with behaviors worsening in the evening. In a separate dining room incident, another cognitively impaired resident, frustrated by the aggressive resident’s loud, repetitive questioning, poured cold coffee onto her face and head, though no injury was noted. These events occurred despite a facility policy prohibiting all forms of abuse and requiring protection of residents from verbal, mental, and physical abuse.
A resident with dementia and a prior humerus fracture was found on the floor near her bathroom after staff heard another resident in her room telling her to get out of bed; the resident repeatedly stated that a man pulled her out of bed. Another cognitively impaired resident with documented behavioral issues, including physically trying to force others out of bed and threatening residents, was observed standing next to the fallen resident, and staff and a family member reported that this resident had pulled the victim from bed. Despite these allegations and the facility’s abuse reporting policy requiring timely notification to the state agency, no report of alleged resident-to-resident abuse related to this incident was submitted to the Illinois Department of Public Health.
A cognitively impaired resident with dementia and documented behavioral symptoms repeatedly entered other residents’ rooms and beds, argued with staff, and was reported by CNAs to have attempted to pull multiple residents out of bed, including once by their ankles. Another cognitively impaired resident with a right humerus fracture and muscle weakness was later found on the floor near her bathroom after staff heard shouting; she stated that a man had pulled her out of bed, and staff found the behaviorally impaired resident standing next to her with a new red spot noted on her back. Staff interviews indicated that leadership had been informed of prior similar incidents, yet the Administrator stated the event was not treated as a resident-to-resident incident because it was not directly witnessed and the injured resident could not clearly describe it, and the report does not show that the abuse investigation steps required by facility policy were carried out.
Multiple residents with mobility and continence needs experienced delayed assistance due to a nonfunctional call light system, relying instead on alternative devices like horns, whistles, and bells. Staff had difficulty identifying and responding to these signals, leading to incontinence episodes and feelings of embarrassment among residents. Staff interviews confirmed the challenges in hearing and locating the source of the calls, and there was no documentation of increased monitoring or a policy on dignity.
A facility failed to maintain a working call system for 32 residents across three halls, instead providing alternative devices like horns, bells, and whistles that were often ineffective. Multiple residents, many of whom were cognitively intact, reported long response times and difficulty getting staff attention. Staff and leadership confirmed the call system outage and acknowledged challenges in hearing and locating residents needing assistance, with some residents lacking accessible alternative devices.
A resident with a full code status was found unresponsive and pulseless, but staff delayed initiating CPR for 10-20 minutes despite clear physician orders and documentation. The RN on duty failed to respond urgently, did not immediately check code status, and did not direct staff to begin resuscitation, resulting in a significant delay before CPR was started and emergency services were called.
The facility was unable to provide documentation that annual training was completed for all staff, as required by its policy. During the survey, the Administrator confirmed that records of annual training could not be located, affecting all 66 residents currently residing in the facility.
The facility did not provide or document effective communication training for direct care staff, as required by its own in-service training policy. This deficiency was confirmed by the Administrator and could impact all 66 residents currently in the facility.
The facility did not provide or document required training on resident rights for its staff, as confirmed by the administrator and a review of in-service records. This deficiency potentially affected all 66 residents currently residing in the facility.
The facility was unable to provide documentation that all staff received compliance and ethics training, as required by policy. Review of in-service records and confirmation from the Administrator showed that records of such training were not available for all staff, affecting all 66 residents.
The facility did not provide documentation that CNAs completed required annual in-service training, including dementia care and abuse prevention, as mandated by facility policy. This lapse potentially affects all 66 residents currently in the facility.
The facility did not provide or document required behavioral health services training for all staff, as confirmed by a review of training records and communication with the Administrator. This deficiency affected all 66 residents currently in the facility.
Two residents at high risk for falls experienced multiple incidents due to inadequate fall prevention measures. Despite having care plans in place, interventions were inconsistently applied, and staff were unaware of specific strategies. The facility lacked a fall policy and proper staff training, contributing to repeated falls and potential harm.
A resident with multiple health issues experienced severe weight loss due to the facility's failure to provide prescribed nutritional supplements and adequate meal assistance. Despite requiring substantial help with eating, the resident was often left unattended or minimally assisted, consuming less than 25% of meals. Staff interviews revealed confusion and inconsistency in monitoring meal intake, with inadequate implementation of facility policies on weight monitoring and food service.
The facility failed to provide sufficient staffing, resulting in unmet care needs for residents. A resident with severe cognitive impairment received minimal assistance during meals, consuming less than 25% of her food. Cognitively intact residents reported long delays in call light responses, leading to incontinent episodes. Staff confirmed the shortage, especially on the second shift, impacting their ability to assist residents adequately.
The facility failed to provide timely assistance and maintain resident dignity, as evidenced by delayed call light responses and inadequate feeding and grooming support. A resident with severe cognitive impairment received minimal help with meals, consuming less than 25% of her food. Another resident experienced incontinent episodes due to delayed assistance, while a third resident was left with noticeable facial hair. Staff shortages, particularly on the second shift, were reported, affecting the quality of care.
Several residents in a LTC facility experienced inadequate assistance with ADLs, particularly in toileting and feeding, due to staffing shortages. A resident with severe cognitive impairment received insufficient feeding support, consuming less than 25% of meals. Another resident, legally blind, reported delayed toileting assistance, leading to incontinent episodes. A third resident, dependent on staff for eating, was lethargic and received minimal encouragement during meals. These deficiencies highlight the facility's failure to provide timely care.
A resident with multiple medical conditions, including dysphagia and dementia, did not receive necessary cueing and assistance with eating from staff, despite being observed not eating during meals. The resident's wife provided assistance, but staff failed to offer help or alternatives, contrary to facility expectations.
A facility failed to properly label and date insulin pens for a resident with Type 2 diabetes. Observations revealed that insulin pens were not labeled with the date they were opened, and one pen lacked the resident's name. Interviews with nursing staff confirmed the oversight, despite recent training on proper labeling procedures.
A resident with complex medical conditions and dietary preferences was not provided with a diet meeting the recommended protein intake. Observations showed meals lacking in protein, and the dietary manager and dietician acknowledged the absence of a specific menu or supplements to meet the resident's needs, resulting in a deficiency.
The facility failed to offer pneumococcal vaccinations to three residents, despite their medical histories and the facility's policy requiring such offers. One resident had only received the Prevnar-13 vaccine in 2016, another had no vaccination records, and a third had received both Prevnar-13 and PPV23 but lacked documentation for the PVC 20 vaccine. The DON and ADON confirmed the oversight, acknowledging that these residents should have been offered the PVC 20 vaccine.
Resident Video Posted on Social Media
Penalty
Summary
The facility failed to ensure privacy was maintained for 1 of 3 residents reviewed for privacy in a sample of 6. The resident had an admission date of 7/26/2023 and diagnoses including unspecified dementia with severe cognitive impairment, anxiety, depression, psychotic disorder, insomnia, and rapid eye movement sleep behavior disorder. The MDS documented a BIMS score of 04, and the care plan described delusions, distress after family visits, packing belongings throughout the day and evening waiting for family to pick her up, and prior behaviors of hiding in closets, bathrooms, and under beds while stating that someone was going to kidnap her or that she had been raped, heard gunshots, or thought others were trying to kidnap her. A CNA stated she had recorded a video of the resident about a month earlier while the resident was lying on the floor of her closet sleeping. The CNA said the resident was a relative and that she did not realize until later that she should not have posted the video to her Snapchat. She stated she recorded the resident when she and another CNA checked on her because she had not been out of her room for a while, and the video showed the closet door being opened and the resident lying on the closet floor covered with a blanket. The surveyor viewed the video posted on the CNA's social media account, which included the facility name and showed the recorded scene from the resident's room. Administration stated the expectation was for all staff to follow the policy and procedure for residents' privacy, and the facility's Resident Rights Policy stated residents have a right to personal privacy and confidentiality of personal and medical records.
Resident Recorded and Posted on Social Media by CNA
Penalty
Summary
The facility failed to ensure a resident was free from abuse by a CNA. The resident had a face sheet documenting admission to the facility on 7/26/2023 with diagnoses including unspecified dementia with psychotic disturbance, mood disturbance, and anxiety, depression, generalized anxiety disorder, insomnia, and rapid eye movement sleep behavior disorder. The resident’s MDS documented a BIMS score of 04, indicating severe cognitive impairment, and the care plan described delusions, distress after family visits, packing belongings while waiting for family, and prior behaviors of hiding in closets, bathrooms, and under beds while stating that someone was going to kidnap or rape her and that she heard gunshots. During the investigation, a CNA stated she had recorded a video of the resident lying on the closet floor sleeping and later posted it to her social media account. The CNA stated the resident was a relative and that she did not realize until later that she should not have posted the video. Surveyor observation confirmed the video showed the CNA opening the closet door and the resident lying on the floor covered with a blanket, with the facility name visible in the post. The administration stated it had not been aware of the incident at the time it was discovered, and the facility’s initial reportable event documented that the resident had been recorded sleeping on her closet floor by the CNA.
Failure to Protect Cognitively Impaired Residents From Repeated Resident-to-Resident Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect cognitively impaired residents from abuse, specifically resident-to-resident physical and verbal aggression, resulting in two residents not being kept free from abuse. Resident R2, admitted with multiple diagnoses including dementia, a displaced fracture of the right humerus, muscle weakness, pain, and severe cognitive impairment (BIMS score of 03), was found on the floor near her bathroom door after yelling, following another resident’s command to “get out of bed.” Documentation shows that R2 reported that “a man pulled me out of bed,” and staff noted pain in her right arm, mid-back redness, and painful/limited ROM in the upper extremity, with refusal to move the right arm. Staff and event reports identified that another resident, R1, had been in R2’s room and was believed to have pulled R2 from bed. R1 was also severely cognitively impaired (BIMS score of 04) with diagnoses including Alzheimer’s disease, dementia, seizures, major depressive disorder, anxiety disorder, and visual loss. R1’s care plan identified behavioral symptoms such as verbal, physical, and rejection-of-care behaviors, as well as exit-seeking, with approaches focused on snacks, drinks, independent activities, calling a friend, and inviting her to activities. Interviews with the Director of Memory Care and CNAs described R1 as having sporadic, often worsening evening behaviors, including trying to wake other residents, almost forcing them out of bed, telling residents to “go play in traffic” and to get out of “her house,” and becoming more argumentative with redirection. Multiple CNAs reported that R1 had tried to pull more than one resident out of bed, including being observed pulling another resident (R5) out of bed by the ankles, and that R1 could be very aggressive toward staff and residents, with threats and attempts to pick fights. A separate incident involved R3, another resident with severe cognitive impairment (BIMS score of 03) and multiple diagnoses including dementia, end stage renal disease, metabolic encephalopathy, muscle weakness, and depression. In the dining room, while two residents were seated at adjacent tables, R1 was repeatedly speaking loudly and asking the same question, and R3 became visibly frustrated and poured cold coffee onto R1, striking R1’s face and right side of the head. Documentation indicates the coffee was cold and there was no redness or complaint of pain from R1. The facility’s abuse prohibition and reporting policy states that residents are to be protected from all kinds of abuse, including verbal, mental, and physical abuse, neglect, and other prohibited actions. Despite this policy and known behavioral histories, the facility did not prevent resident-to-resident physical contact and verbal aggression that resulted in R2 being pulled from bed and R1 having coffee thrown on her. The survey findings, based on interviews, progress notes, event reports, and the facility’s own investigation, show that the facility was aware of R1’s ongoing aggressive and intrusive behaviors toward other residents, including attempts to pull residents from bed and verbal threats. Staff accounts confirm that R1’s behaviors were “all over the place,” could escalate quickly, and that redirection often did not work and sometimes worsened the situation. Nonetheless, R1 continued to have access to other residents in ways that allowed her to enter their rooms, get into their beds, and attempt to force them out, culminating in the incident where R2 was pulled from bed and sustained pain and observable physical findings. Additionally, R1’s loud, repetitive verbal behavior in the dining room led to R3’s frustrated act of pouring coffee on her. These events demonstrate that the facility did not effectively protect R1, R2, and R3 from abuse as required by its abuse prohibition policy.
Failure to Report Alleged Resident-to-Resident Abuse After Fall From Bed
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of resident-to-resident abuse to the Illinois Department of Public Health as required by facility policy. One resident (R2), with severe cognitive impairment and multiple diagnoses including dementia, fracture of the right humerus, diabetes, muscle weakness, and major depressive disorder, was admitted on 12/11/25. Another resident (R1), also with severe cognitive impairment and diagnoses including Alzheimer’s disease, dementia, seizures, and major depressive disorder, had documented behavioral symptoms such as verbal, physical, and exit-seeking behaviors, with care plan approaches focused on redirection, snacks, and activities. The facility’s abuse prohibition and reporting policy required notification to the state agency within specific timeframes when alleged abuse or serious bodily injury occurs. On 01/20/26 at approximately 10:06 PM, an LPN documented that while passing medications on the 200 hall, a resident in the room next to R2’s was heard saying “get out of bed,” followed by R2 yelling. A CNA entered R2’s room and found R2 on the floor near the bathroom door. R2 stated that “a man pulled me out of bed,” and neuro checks were initiated; R2 was moved to a recliner and given PRN pain medication. An event report for this incident documented that R2 had been in bed prior to the fall, that she believed she fell because “a man pulled me out of bed,” and that staff had heard another resident in the adjacent room telling someone to get out of bed before R2 was found on the floor. A subsequent progress note on 01/22/26 documented an IDT root cause analysis of the 01/20 fall, stating that R2 had been in bed, staff heard R1 in R2’s room telling her to get up, then heard R2 yelling and found her on the floor, with R2 again stating that a man pulled her out of bed. Staff interviews further described R1’s history of aggressive and intrusive behaviors toward other residents, including trying to wake them, forcing them out of bed, getting into bed with them, threatening them, and an instance where R1 was reported to have partially pulled another resident (R5) out of bed. A CNA reported that during the incident in question, she heard R1 screaming and then R2 screaming, and found R2 on the floor with R1 standing next to her, and noted a new red spot on R2’s back. A family member stated the facility had informed him that R2 was pulled out of bed by another resident. Despite these observations and statements, as of 02/10/26 there had been no report of resident-to-resident abuse related to this incident submitted to the Illinois Department of Public Health, constituting the failure to report the alleged abuse.
Failure to Prevent and Investigate Alleged Resident-to-Resident Abuse Involving Repeated Bed-Entry and Pulling Incidents
Penalty
Summary
The deficiency involves the facility’s failure to prevent and investigate alleged abuse related to a cognitively impaired resident with known behavioral issues entering other residents’ rooms and beds and attempting to pull residents out of bed. One resident with Alzheimer’s disease, dementia, severe cognitive impairment (BIMS 04), and documented behavioral symptoms had multiple progress notes describing her going into other residents’ rooms, lying in their beds, arguing with staff, and being difficult to redirect. Staff documented that this resident had previously been found in another resident’s bed without a shirt and that she had been moved to a different room due to going through a shared bathroom and disturbing another resident. Care plan approaches focused on redirection, snacks, activities, and independent activity supplies, but did not address the escalating pattern of entering other residents’ rooms and beds and attempting to pull residents from bed. On the date of the key incident, another resident with dementia, severe cognitive impairment (BIMS 03), a right humerus fracture, muscle weakness, and pain was found on the floor near the bathroom door after staff heard a nearby resident say “get out of bed” and heard the resident yelling. The resident on the floor stated “a man pulled me out of bed,” and staff later documented that another resident had been in the room at the time and was redirected. A subsequent IDT root cause analysis note documented that staff heard the behaviorally impaired resident in the injured resident’s room telling her to get up, followed by the injured resident yelling and being found on the floor. Staff interviews confirmed that a CNA heard the behaviorally impaired resident scream, then the injured resident scream, and then found the injured resident on the floor with the behaviorally impaired resident standing next to her; the injured resident again stated that “that guy pulled me out of bed,” and staff noted a new red spot on her back. Additional staff interviews revealed that CNAs had previously observed or been told that the same behaviorally impaired resident had tried to pull more than one resident out of bed, including an incident where she was seen holding another resident by the ankles and pulling her out of bed. Staff reported that the Director of Memory Care and the Administrator were aware of these prior incidents. Despite these reports and the facility’s written Abuse Prohibition and Reporting policy requiring interviews with all involved parties and use of an abuse investigation checklist when there is reasonable cause to suspect willful abuse, the Administrator stated that the incident between the two residents was not considered a resident-to-resident incident because it was not witnessed and the injured resident could not give a description of the event. The report does not describe that a full abuse investigation, as outlined in the facility’s policy, was conducted in response to the allegations and observed pattern of behavior.
Delayed Response to Alternative Call Lights Resulting in Loss of Dignity
Penalty
Summary
The facility failed to answer alternative call lights for residents needing assistance in a timely manner, resulting in a lack of dignity for several residents. The call light system on three halls had been nonfunctional since the end of August, and residents were provided with alternative devices such as bike horns, whistles, and bells to signal for help. Multiple residents reported that these devices were often ineffective, as staff had difficulty hearing or locating the source of the sound, especially when residents were at the end of the hall or had their doors closed. Staff interviews confirmed these challenges, noting that it was hard to determine which resident needed help and that response times were delayed as a result. Several residents with significant medical needs, including those with mobility impairments, overactive bladder, and cognitive limitations, experienced incontinence episodes while waiting for assistance. These residents described feelings of humiliation, embarrassment, and shame as they were left to sit in their own urine or feces until staff could respond. Some residents reported that they had to rely on their roommates to signal for help, and in some cases, staff discouraged this practice. Residents also expressed frustration with the alternative call system, stating that it was unreliable and did not meet their needs for timely assistance. Staff interviews corroborated the residents' accounts, acknowledging that the alternative devices were difficult to hear and that it often took longer to respond to residents' needs. Staff described having to walk down halls and call out to identify which resident was signaling for help, further delaying response times. The facility did not have documentation of any increased monitoring, such as 15-minute checks, and there was no policy on dignity. The facility's existing call light policy required functioning call lights, which were not available on the affected halls during the period in question.
Failure to Provide Functional Call System for Residents
Penalty
Summary
The facility failed to provide a functional call system for 32 residents living on the 300, 400, and 500 halls. Multiple residents reported that the call light system had been nonfunctional since their admission, and instead, they were given alternative devices such as bike horns, bells, and whistles to alert staff when assistance was needed. Residents described significant difficulties with these alternatives, including uncertainty about whether staff could hear them, long response times, and the need to repeatedly use the devices to get attention. Some residents did not have any alternative device within reach, and others expressed frustration with the ineffectiveness of the provided solutions. Several residents were cognitively intact, as indicated by their BIMS scores, and were able to clearly articulate the challenges they faced due to the lack of a working call system. Staff interviews confirmed that the call light system on these halls had been out of service since the end of August. Staff acknowledged the challenges in identifying which resident was signaling for help, especially when multiple residents used similar devices simultaneously or when residents' doors were closed. Staff also reported that it was difficult to determine the location of the sound, leading to delays as they walked the halls to identify who needed assistance. Observations further revealed that some residents did not have their alternative devices within reach, and staff had to search for these devices in residents' rooms. Facility leadership confirmed that the call light system had failed and that alternative devices were distributed to residents. However, they also acknowledged that staff had difficulty hearing the devices, particularly for residents at the end of the halls or with closed doors. There was mention of implementing 15-minute checks on affected residents, but there was no documentation to support that these checks were consistently performed. The facility's own policy required a functioning call light system to respond to residents' requests and needs, which was not met during the period in question.
Delayed CPR Initiation for Full Code Resident
Penalty
Summary
Facility staff failed to initiate cardiopulmonary resuscitation (CPR) in a timely manner for a resident who was found unresponsive, pulseless, and not breathing. The resident had a documented status as a full code, with clear physician orders and a POLST form indicating that all life-sustaining treatments, including CPR, were to be attempted in the event of cardiac arrest. Despite this, staff did not begin CPR for approximately 10-20 minutes after the resident was discovered in bed without vital signs. Multiple staff interviews and record reviews revealed that certified nursing assistants (CNAs) discovered the resident unresponsive and immediately notified the registered nurse (RN) on duty. The RN, however, responded slowly, initially dismissed the urgency, and did not promptly check the resident’s code status or initiate CPR. Other staff members, including another RN and LPN, were eventually involved, but only after a significant delay and after being reminded by oncoming staff that the resident was a full code. During this period, staff began preparing the resident for post-mortem care, believing the resident had expired, until the code status was clarified and CPR was finally started. Documentation and staff statements confirm that the delay in initiating CPR was due to the RN’s inaction and lack of leadership, as well as a lack of immediate recognition and response to the resident’s code status. The facility’s policy required immediate emergency care and CPR in accordance with the resident’s wishes, but this was not followed. The failure to provide timely CPR resulted in the resident being without resuscitative efforts for an extended period before emergency medical services arrived and transported the resident to the hospital, where death was pronounced shortly after arrival.
Removal Plan
- Facility administrator and DON were in-serviced by the regional nurse on the emergencies policy 3.06 regarding cardiac arrest and CPR.
- DON initiated and completed in-servicing with all nursing staff on the emergencies policy 3.06 regarding cardiac arrest and CPR.
- DON initiated and completed in-servicing with all nursing staff on location of code status/POLST for residents.
- Plan was added to the facility QA program regarding CPR and code status.
- The facility DON or designee will audit employees to ensure that location of code status/POLST is known and understanding of the emergencies policy.
- This will remain as part of the facility QA process for continued monitoring.
Lack of Documentation for Annual Staff Training
Penalty
Summary
The facility failed to provide reproducible evidence that annual training was completed for all staff members. During the survey, a review of the facility's training and in-service records revealed that there was no documentation of specific annual training for all staff. The Administrator confirmed via email that they were unable to locate documentation showing that annual training had been completed. The facility's own policy requires ongoing in-service programs with appropriate documentation of time, program content, and personnel attending, but this documentation was not available for review. At the time of the survey, there were 66 residents residing in the facility.
Lack of Staff Training on Effective Communication
Penalty
Summary
The facility failed to ensure that staff were trained on effective communication, as evidenced by the absence of documentation showing that such training had been completed for all staff members. A review of the facility's training and in-service records did not show any evidence of effective communication training. The Administrator confirmed via email that they were unable to locate documentation of this training for staff. The facility's policy on in-service training requires ongoing education and documentation of training content, attendance, and timing, but this was not met. This deficiency has the potential to affect all 66 residents currently residing in the facility, as documented in the facility's resident directory.
Failure to Train Staff on Resident Rights
Penalty
Summary
The facility failed to ensure that all staff members were trained on resident rights, as required by facility policy. A review of the training and in-service records showed no documentation that staff had received education on resident rights. The administrator confirmed that they were unable to locate any records indicating such training had occurred. At the time of the survey, there were 66 residents residing in the facility, all of whom could potentially be affected by this lack of staff training. The facility's own policy mandates ongoing in-service programs, including documentation of training content and attendance, but this was not followed in regard to resident rights education.
Lack of Documented Compliance and Ethics Training for Staff
Penalty
Summary
The facility failed to provide reproducible evidence that staff were trained on compliance and ethics, as required by facility policy. A review of the training and in-service records did not show documentation of specific compliance and ethics training for all staff members. The Administrator confirmed via email that documentation of such training could not be located. The facility's policy on in-service training states that the Administrator is responsible for coordinating and documenting all in-service training, including time, program content, and personnel attending. At the time of the survey, there were 66 residents residing in the facility, according to the Resident Directory.
Failure to Document Required Annual CNA In-Service Training
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistants (CNAs) completed the required annual in-service training, including education in dementia care and abuse prevention. A review of the facility's training and in-service records did not show documentation that the mandated training for CNAs had been completed. The facility's own policy requires an ongoing in-service program coordinated by the Administrator, with appropriate documentation of time, program content, and personnel attendance. During the survey, the Administrator confirmed via email that they were unable to locate documentation verifying completion of the required CNA training. This deficiency has the potential to affect all 66 residents currently residing in the facility, as documented in the facility's Resident Directory.
Lack of Staff Training on Behavioral Health Services
Penalty
Summary
The facility failed to ensure that all staff received training on behavioral health services as required by facility policy and regulatory standards. A review of the facility's training and in-service records revealed no documentation that staff had been trained in behavioral health services. The facility's resident directory indicated that 66 residents were currently residing in the facility at the time of the review. During the survey, the Administrator confirmed via email that they were unable to locate records showing staff had completed behavioral health services training. The facility's in-service training policy requires ongoing education and documentation of training content, time, and attendance, but this was not met for behavioral health services.
Inadequate Fall Prevention Measures for High-Risk Residents
Penalty
Summary
The facility failed to implement effective and progressive interventions to prevent falls for two residents, R1 and R2, who were at high risk for falls due to their medical conditions and cognitive impairments. R1, with severe cognitive impairment and multiple physical limitations, experienced several falls, many of which were unwitnessed. Despite being at high risk for falls, R1's care plan interventions, such as keeping her at the nurse's station for monitoring and providing activities to keep her occupied, were inconsistently applied. Staff interviews revealed a lack of awareness and understanding of R1's specific fall prevention interventions, contributing to the repeated incidents. R2, who had moderate cognitive impairment and required assistance with mobility, also experienced multiple falls. R2's care plan included interventions such as using a low bed, fall mats, and encouraging the use of a call light for assistance. However, these interventions were not consistently implemented, as evidenced by the absence of fall mats in R2's room and the urinal being out of reach. Staff interviews indicated a lack of knowledge about R2's fall prevention measures, and R2 himself was unaware of how to use the call light, further increasing the risk of falls. The facility's lack of a fall policy and inadequate staff training on fall interventions contributed to the deficiencies in fall prevention for both residents. The absence of alarms and inconsistent application of care plan interventions left R1 and R2 vulnerable to falls, highlighting a systemic issue in the facility's approach to fall prevention. The facility's failure to ensure staff were informed and trained on specific fall prevention strategies for high-risk residents resulted in repeated falls and potential harm to the residents.
Failure to Provide Nutritional Support and Meal Assistance
Penalty
Summary
The facility failed to provide prescribed nutritional supplements and assistance with meals for a resident, leading to severe weight loss. The resident, who had multiple diagnoses including chronic obstructive pulmonary disease, major depressive disorder, and dementia, was on a pureed diet with specific nutritional supplements. However, the care plan did not address nutrition or weight loss, and there was a lack of documentation regarding meal intake percentages since December of the previous year. Observations revealed that the resident was not consistently assisted with meals, despite requiring substantial assistance due to severely impaired cognition. On multiple occasions, the resident was left unattended or received minimal assistance, resulting in the consumption of less than 25% of meals. Staff interviews indicated confusion and inconsistency in monitoring meal intake, with some staff unaware of the resident's need for assistance or the process for documenting intake. The facility's policies on weight monitoring and food service were not effectively implemented, as evidenced by the lack of consistent meal intake documentation and monitoring for residents at risk of weight loss. Staff shortages were cited as a reason for inadequate assistance during meals, and there was a general lack of clarity among staff regarding the procedures for monitoring and documenting meal intake for residents like the one in question.
Inadequate Staffing Leads to Unmet Resident Needs
Penalty
Summary
The facility failed to ensure sufficient staffing to meet the needs of all 75 residents, as evidenced by multiple instances of inadequate care and assistance. Resident R20, who has severe cognitive impairment and requires substantial assistance with eating, was observed on multiple occasions receiving minimal assistance during meals. Despite having a care plan that includes specific dietary interventions, R20 was left with less than 25% of her meal consumed on two separate days, indicating a lack of adequate staff support during mealtime. Resident R22, who is cognitively intact but dependent on staff for toileting and transfers, reported significant delays in response to call lights, leading to prolonged waiting times for assistance. This sentiment was echoed by Resident R38, who also experienced delays in call light responses, resulting in incontinent episodes due to the inability to reach the bathroom in time. Both residents expressed frustration and embarrassment over these incidents, highlighting the impact of insufficient staffing on their dignity and quality of care. Additional testimonies from residents R73 and R179, as well as staff members V8, V9, V16, V12, and V3, further corroborate the issue of inadequate staffing, particularly on the second shift. Staff members reported being overwhelmed with the number of residents requiring assistance, often having to divide their attention among multiple residents simultaneously. The facility's staffing policy, last revised in 2018, was not effectively implemented, resulting in unmet care needs and resident complaints about delayed assistance and incontinent episodes.
Deficiencies in Resident Care and Assistance
Penalty
Summary
The facility failed to uphold residents' rights to dignity and self-determination by not answering call lights in a timely manner and not providing adequate grooming and feeding assistance. Resident R20, who has severe cognitive impairment and requires substantial assistance with eating, was observed to have her meal in front of her without receiving proper assistance. Staff members intermittently provided minimal help, resulting in R20 consuming less than 25% of her meal. Additionally, her meal tray was missing fortified pudding, which was part of her dietary plan. Resident R38, who is legally blind and requires assistance with toileting, reported that the facility is consistently short-staffed, leading to delayed responses to call lights. This delay has caused R38 to experience incontinent episodes, which she finds embarrassing. Similarly, Resident R179, who is alert and oriented, also reported long wait times for assistance, resulting in bowel and urine incontinent episodes. Staff members confirmed the shortage of staff, particularly on the second shift, which affects their ability to provide timely assistance. Resident R61, who is severely cognitively impaired, was observed with noticeable facial hair, which she was embarrassed about. Despite the expectation that staff should assist with grooming, no attempts were made to help R61 with her facial hair. Resident R13, who is also severely cognitively impaired and dependent on staff for eating, was observed to be lethargic during meals and received minimal encouragement or assistance from staff, resulting in poor food intake. The facility lacks a specific policy on feeding assistance, contributing to inconsistent care practices.
Inadequate ADL Assistance Due to Staffing Shortages
Penalty
Summary
The facility failed to provide timely assistance with activities of daily living (ADL) for several residents, specifically in the areas of toileting and feeding. Resident R20, who has severe cognitive impairment and requires substantial assistance with eating, was observed on multiple occasions to receive inadequate feeding assistance. Despite having a care plan that specifies a puree diet and nutritional supplements, R20 was left unattended for extended periods during meals, resulting in the consumption of less than 25% of her meals. Staff members were observed giving R20 only a few bites of food intermittently, without consistent or adequate support. Resident R38, who is legally blind and requires moderate assistance with toileting, reported that the facility's staff shortages often lead to delayed responses to call lights. This delay has resulted in R38 experiencing incontinent episodes, causing embarrassment and distress. Similarly, Resident R179, who is at risk for falls and has multiple health issues, also reported long wait times for assistance, leading to both bowel and urine incontinent episodes. These incidents highlight the facility's inability to provide timely and adequate care due to staffing issues. Resident R13, who is severely cognitively impaired and dependent on staff for eating, was observed to be lethargic during meals and received minimal encouragement or assistance from staff. Despite the care plan indicating independence in eating, R13 required significant help, which was not adequately provided. Staff members were observed standing while assisting R13, without using verbal cues or other interventions to encourage eating. The facility's policy on personal care was not effectively implemented, as evidenced by the repeated failures to provide necessary assistance to these residents.
Failure to Assist Resident with Eating
Penalty
Summary
The facility failed to provide necessary cueing and assistance with eating for a resident diagnosed with multiple conditions, including cerebral infarction, dysphagia, and unspecified dementia. The resident, who has impairments in both upper extremities, was observed on multiple occasions not eating or drinking during meals, despite being more alert on one occasion. The resident's wife was present and provided verbal cues and assistance, but the staff did not offer any assistance or alternatives during these observations. The Speech Language Pathologist noted that the resident had been doing better after adjustments to tube feeding schedules but had recently declined, possibly due to depression. Despite the resident's history of requiring some prompting to eat, staff members, including CNAs and the Assistant Director of Nursing, acknowledged the expectation to encourage and assist residents with eating, regardless of their usual level of assistance. However, during the observed meals, the staff did not fulfill this expectation, leading to the deficiency.
Improper Labeling and Dating of Insulin Pens
Penalty
Summary
The facility failed to properly label and date insulin pens for a resident diagnosed with Type 2 diabetes mellitus. During an observation, it was noted that two Lantus insulin pens and one Novolog insulin pen were not labeled with the date they were opened, and the Novolog pen did not have the resident's name on it. The resident's care plan required insulin administration as ordered, and the physician's orders specified the use of Novolog and Lantus insulin pens. However, the insulin pens were found in the medication cart without the necessary labeling, which is crucial for tracking the duration of use and ensuring the correct administration to the resident. Interviews with the nursing staff revealed a lack of adherence to the facility's protocol for labeling insulin pens with the date they are opened and the resident's name. The registered nurse responsible for the medication cart acknowledged the oversight and mentioned that the insulin pens should be labeled immediately after being taken out of the refrigerator. The Assistant Director of Nursing confirmed that the insulin pens should have been discarded if the opening date was unknown, and all pens should be labeled with the resident's name. Despite a recent in-service training on proper labeling, the deficiency persisted, indicating a lapse in following established procedures.
Failure to Meet Resident's Protein Needs
Penalty
Summary
The facility failed to provide a diet that met the recommended protein requirements for one resident, identified as R15, who was part of a sample of 34 residents reviewed for nutrition. R15 has a complex medical history, including atrial fibrillation, chronic kidney disease, and major depressive disorder, and is cognitively severely impaired. The resident's care plan indicated a regular diet with specific preferences and dislikes, such as a dislike for meat and eggs, which were not adequately addressed in the dietary plan. Observations over several days revealed that R15 consistently received meals lacking in protein, such as mashed potatoes, green beans, and ice cream, without any meat or egg substitutes. The dietary manager, V4, acknowledged the absence of a specific menu to accommodate R15's dietary preferences and protein needs. The registered dietician, V28, confirmed that R15's protein intake was below the recommended 48-58 grams per day and that no supplement was currently ordered to address this deficiency. The dietitian's assessments noted R15's weight loss over six months, although it was not deemed significant. Despite this, the dietitian recognized the need for additional protein sources, such as cottage cheese or grilled cheese, to meet R15's dietary needs. The facility's failure to provide a diet that met the resident's protein requirements was evident, as there was no documented plan or menu to ensure R15 received adequate nutrition, leading to the identified deficiency.
Failure to Offer Pneumococcal Vaccinations
Penalty
Summary
The facility failed to offer pneumococcal vaccinations to three residents, as identified during a survey. Resident 15, who has a history of atrial fibrillation, cardiac pacemaker, and chronic kidney disease, only had documentation of receiving the Prevnar-13 vaccine in 2016, with no record of being offered or administered any subsequent pneumococcal vaccinations. Similarly, Resident 58, diagnosed with dementia and chronic kidney disease, had no documentation of any pneumococcal vaccination being offered or administered, and the Director of Nursing confirmed the absence of vaccination records or consents. Resident 13, with a history of dementia, heart failure, and bacterial pneumonia, had records of receiving both Prevnar-13 and PPV23 vaccines, but there were no consents or declinations for the PVC 20 vaccine. The facility's policy requires offering the pneumococcal vaccine to residents aged 65 or older and those at high risk, as recommended by the CDC. However, the Director and Assistant Director of Nursing acknowledged that Residents 15, 13, and 58 should have been offered the PVC 20 vaccine, indicating a lapse in following the facility's vaccination policy.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 83 citations issued within 25 miles in the last 12 months — including the 5 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Centralia
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Fireside House Of Centralia | 0 mi | ★★★★★ | 0 | 0 |
| Odin Health And Rehab Center | 7.7 mi | ★★★★★ | 2 | 1 |
| Doctors Nursing & Rehab Center | 12 mi | ★★★★★ | 29 | 1 |
| Twin Willows Nursing Center | 12.9 mi | ★★★★★ | 12 | 0 |
| Carlyle Healthcare & Sr Living | 13.5 mi | ★★★★★ | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.