Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Fireside House Of Centralia during CMS and state inspections, most recent first.
A staffing shortage occurred when several CNAs did not report for their shifts, leading to inadequate staff coverage. As a result, a resident with dementia and mobility issues was transferred using a mechanical lift by a single CNA, contrary to care plan requirements. Staff interviews confirmed that the shortage caused delays in care, including answering call lights and providing incontinence care, and that typical staffing levels were not met.
Four residents with significant medical conditions did not receive their ordered nutritional supplements for several days due to a supply shortage caused by a delivery and billing issue. Staff confirmed the supplements were unavailable for about a week, and MARs documented multiple missed doses during this period.
A CNA transferred a resident with dementia, muscle weakness, and vision loss using a mechanical lift without assistance from another staff member, despite the resident's care plan and facility policy requiring two staff for such transfers. The CNA acted alone due to staffing shortages, while the LPN was occupied with medication administration. The resident was dependent for transfers and required a mechanical lift, but no injury or fall was reported during the incident.
A cognitively impaired resident with dementia, previously identified as an elopement risk and placed on 15-minute visual checks, exited the facility without staff knowledge and was found over a mile away by two individuals who took her to a hospital. Staff failed to communicate the resident's elopement risk during shift changes, did not perform required visual checks, and did not properly respond to a door alarm, resulting in the resident's unsupervised exit.
The facility failed to maintain adequate staffing levels, leading to delays in resident care and assistance. Interviews and observations revealed that the facility often operated with insufficient CNAs, particularly on weekends and nights, affecting the timely delivery of care such as transfers and showers. Despite the administrator's efforts to assist, the lack of a specific plan for addressing staffing shortages and the absence of agency staff for over six weeks contributed to the deficiency.
The facility failed to provide the correct textured diets for four residents who required easy to chew (mechanical soft) diets. Despite specific dietary orders, these residents received meals inconsistent with their needs, including items like toasted garlic bread and ambrosia. The dietary manager confirmed the error, acknowledging the meals did not adhere to the prescribed texture-modified diets.
The facility failed to provide prescribed dietary supplements for four residents, including ice cream and double protein, as part of their nutritional care plans. Observations revealed that these supplements were not consistently provided, despite being ordered by physicians to address specific health conditions such as chronic kidney disease, dementia, and diabetes. The Dietary Manager acknowledged the oversight, confirming that residents should have received the prescribed nutritional support.
A long-term care facility failed to maintain infection control practices, as observed in multiple instances involving several residents. Staff members did not perform hand hygiene or change gloves appropriately during medication administration and personal care tasks. Additionally, enhanced barrier precautions were not followed for residents requiring such measures. The facility's policies on infection control were not adhered to, leading to deficiencies in care.
Two residents with cognitive impairments were not provided dignified feeding assistance. CNAs stood over them while feeding, failed to engage with residents, and one used a clothing protector to clean a resident's mouth. The DON expected CNAs to be seated and engage with residents during meals.
The facility failed to refer two residents with mental illness diagnoses for a Level II PASARR evaluation. One resident with Bipolar II disorder and Major Depressive Disorder was not properly assessed due to a lack of notification to the screening agency. Another resident with schizophrenia lacked documentation of a Level II PASARR, as only a Level I was available. The facility's policy on coordinating with the PASARR program was not adequately followed.
Insufficient Staffing Resulting in Inadequate Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents in a timely manner, as evidenced by direct observation, interviews, and record review. On the evening in question, several Certified Nursing Assistants (CNAs) did not report for their scheduled shifts, resulting in inadequate staffing levels. One CNA was observed transferring a resident with dementia, muscle weakness, and vision loss using a mechanical lift without the required assistance of another staff member, as specified in the resident's care plan and physician orders. The CNA stated she performed the transfer alone because other CNAs were occupied with other residents and there was not enough staff available at the time. Multiple staff interviews confirmed that the facility was short-staffed that evening, with only two CNAs and a nurse on one unit with 35 residents, and two CNAs and a nurse on another unit with 17 residents, instead of the typical three to four CNAs per unit. Staff reported that this shortage led to delays in answering call lights, providing incontinence care, and monitoring resident behaviors. The Assistant Director of Nursing acknowledged that staffing is only sufficient when there are no call-ins, and the Administrator was not aware of the staffing shortage at the time. The facility's staffing policy requires sufficient numbers of staff to meet resident needs in accordance with care plans and facility assessment.
Failure to Provide Prescribed Nutritional Supplements Due to Supply Shortage
Penalty
Summary
The facility failed to ensure that prescribed nutritional supplements were available and administered as ordered for four out of six residents reviewed for nutrition. These residents had medical conditions such as diabetes, dementia, vitamin deficiencies, muscle weakness, and GERD, and had physician orders for specific supplements to address weight loss and nutritional needs. Medication Administration Records (MARs) showed multiple missed doses of supplements over several days for each resident, despite active physician orders and care plan interventions specifying the need for these supplements. Interviews with staff confirmed that the facility was out of dietary supplements for about a week due to a delivery issue related to a billing problem with the supplier. During this period, staff attempted to purchase some supplements locally but were unable to obtain all required products. Staff acknowledged that the MARs accurately reflected the missed administrations, and the administrator was aware of the shortage, which was described as lasting only a short time.
Mechanical Lift Transfer Performed by Single CNA Without Assistance
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) transferred a resident using a mechanical lift without the assistance of another staff member, contrary to facility policy and the resident's care plan. The resident in question had diagnoses including dementia, muscle weakness, and vision loss, and was assessed as having a moderate cognitive deficit and being dependent on staff for transfers. The care plan and physician orders specified the use of a mechanical lift for all transfers, but did not indicate that single-staff transfers were permitted. During the observed incident, the CNA operated the lift alone, making multiple adjustments to the resident's position while the resident was suspended in the air, as no other staff were available to assist due to staffing shortages. Interviews with staff confirmed that the CNA performed the transfer alone because other CNAs were occupied with resident care and there were not enough staff available at the time. The LPN on duty was preparing medications and did not assist with the transfer. The facility's policy on safe lifting and movement of residents emphasizes the use of appropriate techniques and devices to ensure safety, but this policy was not followed during the observed transfer. The resident did not report any injury or fall during the transfer.
Failure to Supervise Cognitively Impaired Resident Results in Elopement
Penalty
Summary
A cognitively impaired resident with diagnoses of Parkinsonism and unspecified dementia was admitted to the facility and initially assessed as not being at risk for elopement. However, after multiple attempts to leave the facility, the resident was placed on 15-minute visual checks. Despite this intervention, the resident was able to exit the facility without staff knowledge and walked approximately 1.3 miles away, where she was found by two unknown individuals and taken to a local hospital. The incident occurred while the resident was supposed to be under increased supervision due to her recent exit-seeking behavior. The failure to prevent the resident's elopement was due to several lapses in communication and procedure. Staff members responsible for the resident's care were not informed during shift reports that the resident was on 15-minute visual checks, resulting in the checks not being performed or documented. Additionally, the facility's 24-hour report sheets did not consistently include information about the resident's elopement risk or the need for visual checks. Multiple staff members, including nurses and CNAs, reported being unaware of the resident's status and did not perform the required monitoring. Compounding the issue, the facility's door alarm system was not effectively managed. Staff reported that the door alarm frequently sounded during visiting hours and was often reset without verifying the cause or checking on residents at risk for elopement. On the evening of the incident, a staff member reset the alarm after hearing it but did not investigate further or notify others, which may have allowed the resident to leave undetected. These combined failures in communication, documentation, and adherence to policy led to the resident's unsupervised exit and the resulting Immediate Jeopardy finding.
Staffing Deficiency Leads to Delayed Resident Care
Penalty
Summary
The facility failed to provide a sufficient number of staff to ensure residents received timely and safe assistance with care and transfers. This deficiency was observed to potentially affect all 60 residents living in the facility. Interviews with staff and residents revealed that the facility was consistently short-staffed, particularly on weekends, evenings, and nights. Residents reported delays in receiving care, such as assistance with transfers and showers, due to the lack of available staff. Staff members, including CNAs and LPNs, confirmed that they were often unable to complete their duties in a timely manner due to the insufficient number of staff. Observations and interviews indicated that the facility often operated with only 1-3 CNAs on duty, which was inadequate to meet the needs of residents, especially those requiring assistance from two staff members or mechanical lifts. The facility's assessment tool documented that a significant number of residents required assistance with activities of daily living, yet the staffing levels did not align with these needs. Staff members reported that management was not consistently available to assist, particularly on weekends, and that the facility had not used agency staff for over six weeks. The facility's staffing plan outlined the need for more CNAs per shift than were actually present, as documented in the facility's records. Despite the administrator's efforts to assist when possible, the lack of a specific plan for addressing staffing shortages exacerbated the issue. The facility's policy on safe lifting and moving of residents emphasized the need for appropriate techniques and devices, yet the staffing levels did not support the safe implementation of these practices. This deficiency in staffing had the potential to compromise the safety and quality of care provided to residents.
Failure to Provide Correct Textured Diets
Penalty
Summary
The facility failed to provide the correct textured diet as ordered for four residents who required an easy to chew (mechanical soft) diet. The dietary orders for these residents specified a regular diet with easy to chew texture, regular/thin liquid consistency, and additional dietary requirements such as high fiber and double protein. However, during meal service, these residents received meals that did not comply with their prescribed dietary orders. Specifically, they were served spaghetti with meat sauce, beets, toasted garlic bread, and ambrosia, which were not consistent with the easy to chew diet requirements. The residents affected by this deficiency had various medical conditions that necessitated the prescribed dietary modifications. These conditions included chronic kidney disease, type 2 diabetes mellitus, dementia, Parkinson's disease, dysphagia, and muscle weakness. The facility's dietary manager acknowledged that the mechanical soft diets should not have included ambrosia salad or toasted garlic bread, indicating a failure to adhere to the facility's policy on texture-modified diets. This oversight in meal preparation and service led to the deficiency identified by the surveyors.
Failure to Provide Prescribed Dietary Supplements
Penalty
Summary
The facility failed to provide dietary supplements as ordered for four residents, leading to a deficiency in nutritional care. Resident R47, who has chronic kidney disease and other health issues, was prescribed a regular diet with ice cream once daily as a supplement. However, observations on multiple days revealed that R47 did not receive the prescribed ice cream with her meals, and she confirmed receiving it only a few times a week. Her care plan indicated the need for this supplement due to potential nutritional or hydration status alterations. Similarly, Resident R56, diagnosed with muscle weakness, dementia, and dysphagia, was ordered to receive nutritional ice cream with lunch. Observations showed that R56 did not receive the ice cream on several occasions, despite the care plan highlighting the necessity of this supplement for nutritional support. The resident's inability to communicate effectively further complicated the situation, as no BIMS assessment was performed. Resident R45, with severe cognitive impairment and diabetes, was also supposed to receive ice cream daily, but observations indicated this was not consistently provided. Additionally, Resident R8, with multiple health issues including diabetes and muscle wasting, was ordered to receive double protein with meals. However, observations showed that R8 did not receive the double protein as prescribed. The Dietary Manager acknowledged the oversight and confirmed that all residents with orders for additional nutritional items should have received them, as per the facility's policy on therapeutic nutritional support.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain proper infection control practices during patient care, as observed in multiple instances involving several residents. A registered nurse, identified as V4, was observed not performing hand hygiene before and after administering medications to residents R64, R32, and R24. Additionally, V4 did not sanitize a bedside table used for a dressing change before serving breakfast on it. The facility's policies on hand hygiene and administering medications were not followed, as confirmed by the Director of Nursing and a Licensed Practical Nurse. In another instance, a CNA, V12, did not change gloves or perform hand hygiene during peritoneal and catheter care for resident R28, who has a history of urinary tract infections. The facility's policy on catheter care, which requires glove changes and hand hygiene between different care tasks, was not adhered to. Similarly, during a treatment for resident R8, a Licensed Practical Nurse, V13, failed to perform hand hygiene between glove changes while treating excoriation and cleaning after a bowel movement. The report also highlights failures in adhering to enhanced barrier precautions for residents R16, R41, and R65, who required such precautions due to their medical conditions. Staff members, including V9 and V3, did not don gowns while performing treatments on these residents, despite the facility's policy requiring gowns and gloves for high-contact care activities. The Infection Preventionist and Director of Nursing acknowledged the staff's confusion and lack of adherence to the enhanced barrier precautions policy.
Failure to Promote Dignity During Feeding Assistance
Penalty
Summary
The facility failed to provide feeding assistance in a manner that promoted dignity for two residents, both of whom required assistance with eating due to cognitive impairments. One resident, diagnosed with Alzheimer's disease and dysphagia, was observed being assisted by a CNA who stood over them while feeding and used the resident's clothing protector to clean their mouth. This behavior was noted on multiple occasions, indicating a lack of respect for the resident's dignity during meal times. Another resident, diagnosed with vascular dementia and dependent on staff for eating, was also observed being assisted by a CNA who stood over them. Additionally, several CNAs were observed talking amongst themselves and not engaging with the residents during meal times, with one CNA wearing earbuds. The Director of Nursing expressed that CNAs are expected to be seated and engage with residents during meals, which was not adhered to in these instances.
Failure to Conduct Level II PASARR for Residents with Mental Illness
Penalty
Summary
The facility failed to ensure that individuals admitted with mental illness diagnoses were referred to the appropriate state-designated authority for a Level II PASARR evaluation. This deficiency was identified for two residents, R32 and R35, out of a sample of 35 residents reviewed for PASARR requirements. R32 was admitted with diagnoses of Bipolar II disorder and Major Depressive Disorder, yet the initial OBRA screening incorrectly indicated no reasonable basis to suspect a mental illness. The Business Office Manager, V8, acknowledged that the facility failed to notify the screening agency of R32's qualifying diagnosis, leading to an incorrect assessment. Similarly, R35 was admitted with an active diagnosis of schizophrenia, but the medical record lacked documentation of a Level II PASARR. The preadmission screening for R35 did not include the schizophrenia diagnosis, and V8 confirmed that only a Level I PASARR was available for R35. The facility's policy requires coordination with the PASARR program for individuals with mental disorders, but this was not adequately followed, resulting in the oversight.
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What surveyors actually found near you
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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.
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Nursing homes near Centralia
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Centralia Manor | 0 mi | ★★★★★ | 19 | 1 |
| 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 |
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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.