Inspection visit
Health inspection
5 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 5 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0558
Reasonably accommodate the needs and preferences of each resident.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to ensure a call light was accessible and in
reach to notify staff when assistance was needed for one (R15) of one resident reviewed for
accommodation of needs in a sample of 37.
Residents Affected - Few
Findings include:
R15's Face sheet documents an admission date of 01/08/23 with diagnoses including: Hepatic failure,
Chronic obstructive pulmonary disease, Major Depressive Disorder, Seizures, Disorder of urea cycle
metabolism, Type 2 Diabetes Mellitus with Diabetic Nephropathy, Heart Failure, Peripheral Vascular
Disease, Anemia in other chronic Disease, Essential Hypertension, Hypothyroidism, Contracture of right
and left hand, and Abnormal posture. R15's Minimum Data Set (MDS) dated [DATE], documents a Brief
Interview for Mental Status (BIMS) score of 8, indicating R15 has moderate cognitive impairment.
On 04/24/23 at 10:10 AM, R15 was yelling for assistance and her call light was not on. R15's call light was
approximately 6 inches from her arm. She was in her wheelchair which was positioned alongside on her
bed, the call light was on the bed. On this same date and time, R15 was asked if she could reach her call
light and she stated, No.
On 04/26/23 at 1:05 PM, V17 and V18 (Certified Nurse Aide (CNA) stated, R15 could reach her call light
and utilize it if it is right next to her right hand. If she cannot reach it, she will yell. Sometimes she can use it
if it is near her left hand, and she can hold the button up against herself and push the button with the heal
of her left hand because of her contracture.
On 04/26/23 at 1:10 PM, R15 was laying in bed with her call light hanging over the edge of the
bed/mattress about 4 inches on her left side. On this same date and time, V18 (CNA) stated the call light
right now is not in R15's reach.
On 04/26/23 at 1:45 PM, R15 was in her room laying in her bed. The call light was hanging over the outside
of her bed rail on her left side by approximately 6 inches. R15 was asked if she could reach her call light
and she stated no, not really. R15 used one hand to grab her enabler and turn herself slightly, then pull the
call light up by the cord where she still could not reach the button to push it. R15 stated if she needs
assistance she will just yell or wait until someone comes by.
On 04/26/23 at 1:12 PM, V18 (CNA) stated when they put her to bed, the staff are supposed to put it (the
call light) over her and clip it to her so she can reach the call light when she needs it.
On 04/27/23 at 11:10 AM, R15 stated, there are times she struggles with the call light and cannot
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 8
Event ID:
145791
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145791
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/27/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Fireside House of Centralia
1030 Martin Luther King Blvd
Centralia, IL 62801
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0558
reach it.
Level of Harm - Minimal harm
or potential for actual harm
On 04/27/23 at 1:45 PM, V2 (Assistant Administrator) stated R15's left hand is contracted worse than her
right hand and she has more ability with her right hand than her left hand. The call light should be in the
vicinity of the hand that she can utilize it best with.
Residents Affected - Few
R15's Minimum Data Set (MDS) dated [DATE] documents: R15 has a bed mobility of extensive with a
two-person assistance, a transfer ability of total dependance with a two-person assistance, and toilet use of
did not occur.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145791
If continuation sheet
Page 2 of 8
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145791
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/27/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Fireside House of Centralia
1030 Martin Luther King Blvd
Centralia, IL 62801
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0584
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited
to receiving treatment and supports for daily living safely.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review the facility failed to ensure the facility was maintained for 3 of 3
(R27, R46, and R112) resident reviewed for resident rights in the sample of 38.
Findings Include:
1. R27's facility admission Record with a print date of 4/27/23 documents R27 was admitted to the facility
on [DATE] with diagnoses that include Parkinson's Disease, Chronic Obstructive Pulmonary Disease
(COPD), kidney disease, and hypertension.
R27's MDS (Minimum Data Set) dated 1/17/23 documents R27 has a BIMS (Brief Interview for Mental
Status) score of 12, which indicates R27 has a moderate cognitive impairment.
On 04/24/23 at 1:11 PM, the wall air conditioning unit in R27's room was observed. The trim around the unit
did not cover the area. The wall/trim did not meet the edge of the air conditioning unit. This surveyor was
able to see outside while looking at the edge of the air conditioning unit that should have been covered with
either the wall or the trim. On this same day and time R27 stated it had been that way since they had put
the unit in but she wasn't able to recall when that was. R27 stated she had her bed moved further from the
unit because the outside air came in to her room.
2. R46's facility admission Record with a print date of 4/27/23 documents R46 was admitted to the facility
on [DATE] with diagnoses that include metabolic encephalopathy, COPD, osteoarthritis and heart failure.
R46's MDS dated [DATE] documents a BIMS score of 10, which indicates R46 has a moderate cognitive
deficit.
On 04/24/23 at 1:56 PM, the wall air conditioning unit in R46's room was observed to be sitting crooked in
the wall. This surveyor could see outside around the unit. The dry wall was peeling in the corner behind
R46's bed and the wall board located on the wall behind R46's bed was coming loose from the wall causing
a bowed area where the wall underneath the wall board could be seen. On this same day and time R46
stated when the wind is blowing outside you can feel it around the edges of the air conditioning unit.
3. R112's facility admission Record with a print date of 4/27/23 documents R112 was admitted to the facility
on [DATE] with diagnoses that include heart failure, peripheral vascular disease, diabetes, and
hypertension.
R112's MDS dated [DATE] documents a BIMS score of 15, which indicates R112 is cognitively intact.
On 04/24/23 at 10:42 AM, the wall behind R112's bed was observed and had multiple areas that appeared
like gouges and/or scrapes where the top of the dry wall was missing.
On 4/27/23 at 12:53 PM, this surveyor observed the air conditioning unit in R27's room with V23
(Maintenance Director). V23 stated it looked like someone had hit the trim around the unit and busted it off.
V23 stated he had not been told about it or received a work order for it. R112's room was
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145791
If continuation sheet
Page 3 of 8
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145791
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/27/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Fireside House of Centralia
1030 Martin Luther King Blvd
Centralia, IL 62801
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0584
Level of Harm - Minimal harm
or potential for actual harm
observed with V23 present and V23 stated he thought the gouges in the wall came from R112's bed and
V23 had not been made aware of it. On this same day and time that R46's room was observed with V23,
V23 stated the air conditioning unit is supposed to be straight in the wall and confirmed the gap between
the unit and the wall. V23 stated he wasn't aware of it prior to this observation. V23 stated the wall panel
behind R46's bed have been pulled away from the wall and that he will have to repair it.
Residents Affected - Few
The facility Work Orders, Maintenance policy dated 4/2010 documents, Maintenance work orders shall be
completed in order to establish a priority of maintenance services. 1. In order to establish a priority of
maintenance service, work orders must be filled out and forwarded to the Maintenance Director. 2. It shall
be the responsibility of the department directors to fill out and forward such work orders to the Maintenance
Director.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145791
If continuation sheet
Page 4 of 8
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145791
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/27/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Fireside House of Centralia
1030 Martin Luther King Blvd
Centralia, IL 62801
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0686
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review the facility failed to identify and treat a pressure ulcer for 1 of 3
(R112) residents reviewed for pressure ulcers in the sample of 38.
Residents Affected - Few
Findings Include:
R112's facility admission Record with a print date of 4/27/23 documents R112 was admitted to the facility
on [DATE] with diagnoses that include pathological fracture, malignant neoplasm of left lung, peripheral
vascular disease, diabetes, and hypertension.
R112's MDS (Minimum Data Set) dated 4/12/23 documents a BIMS (Brief Interview for Mental Status)
score of 15, which indicates R112 is cognitively intact.
R112's Braden Scale for Predicting Pressure Ulcer Risk dated 4/26/23 documents a score of 15, which
indicates R112 is at risk for skin breakdown.
On 4/24/23 at 10:42 AM, R112 stated he had a pressure ulcer on his buttocks and the facility staff try to
treat it every day but sometimes they don't get it done.
R112's Skin Observation Tool dated dated 4/5/23 documents, Head to toe assessment completed with no
open or red areas noted.
R112's Order Summary Report dated active orders as of 4/27/23 does not document a treatment order for
a pressure ulcer on R112's buttocks.
On 4/27/23 at 9:10 AM, R112 was observed to have an open area on his inner left buttock, a white barrier
cream was noted covering the buttock area. On this same day and time, V20 (LPN/Licensed Practical
Nurse) stated she had not provided care to R112 the past few days and the skin breakdown was not
present the last time she assessed R112's skin. On this same day and time the area was reported to V6
(Wound Nurse/ADON-Assistant Director of Nurses) and V6 stated she was not aware of the area. V6
measured the area as 0.9 centimeters (cm) by 2.0 cm. V6 applied a foam dressing and assessed both of
R112's heels. V6 stated R112's right heel was soft and applied skin prep and a foam bandage to R112's
right heel.
On 04/27/23 at 10:25 AM, V24 (CNA/Certified Nursing Assistant) stated she had assisted R112 with a bed
bath on the evening of 4/26/23 and noted the pressure ulcer to R112's buttocks had worsened. V24 stated
she wasn't aware of any treatments being administered to the area and that she had not reported the area
to anyone since she didn't always work with R112 and wasn't sure when the area worsened.
On 04/27/23 at 10:35 AM, V10 (CNA) stated she was aware of an open area (pressure ulcer) on R112's
buttocks and first noticed it in the first few days R112 was at the facility. V10 stated she wasn't aware of the
nursing staff providing treatment to the pressure ulcer but the CNA's put zinc cream on it. When asked if
she reported the area to the nurses, V10 stated she thought they were aware of it.
On 04/27/23 at 2:46 PM, V3 (Director of Nurse) stated she was not aware of the pressure ulcer to
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145791
If continuation sheet
Page 5 of 8
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145791
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/27/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Fireside House of Centralia
1030 Martin Luther King Blvd
Centralia, IL 62801
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0686
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
R112's buttocks prior to the observation with the surveyor on 4/27/23. V3 stated she would expect the
CNA's to notify the nurses when they find a pressure area on a resident and would expect the nurse to get
an order and notify V6 (wound nurse) of the area. On this same day and time, V6 stated she assessed the
area on R112's buttocks and identified it as a Stage 2 pressure ulcer measuring 0.9 cm x 2.0 cm.
R112's progress notes dated 4/27/23 at 2:26 PM documents, Skin assessment completed. Stage 2
pressure area noted to left buttock and bilateral heels soft. Foam dressing was applied to left buttock and
skin prep was applied to bilateral heels. R112's progress notes do not document assessment or treatment
of the pressure ulcer prior to 4/27/23.
R112's active care plan documents a Focus Area date initiated 4/27/23 of, Alteration in skin integrity
Decreased mobility, wound #1 - left buttock- pressure #2, boggy heels. Interventions documented for this
Focus Area include: Braden scale assessments upon admission, quarterly, and with significant changes,
Dietary Consult as needed, Encourage good nutrition, Heels up cushion while in bed, identify potential
causative factors and eliminate/resolve when possible, monitor bony prominence's for redness and
blanching, notify physician as needed, pressure relieving devices as ordered.
The facility Pressure Ulcer Risk Assessment policy dated 9/2013 documents, The purpose of this
procedure is to provide guidelines for the assessment and identification of residents at risk of developing
pressure ulcers. 4. If pressure ulcers are not treated when discovered, they have the potential to become
larger, painful, and infected. 10. Routinely assess and document the condition of the resident's skin per
facility wound and skin care program for any signs and symptoms of irritation or breakdown. Immediately
report any sings of a developing pressure ulcer to the supervisor. 3. Monitoring: a. Staff will perform routine
skin inspections (with daily care). b. Nurses are to be notified to inspect the skin if skin changes are
identified. c. Nurses will conduct skin assessments weekly to identify changes.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145791
If continuation sheet
Page 6 of 8
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145791
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/27/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Fireside House of Centralia
1030 Martin Luther King Blvd
Centralia, IL 62801
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review the facility failed to ensure staff donned PPE (personal protective
equipment) per current standards of practice when entering a room with a Covid positive resident. This has
the potential to effect all 55 residents who reside at the facility.
Residents Affected - Many
Findings Include:
R9's facility admission Record with a print date of 4/27/23 documents R9 was admitted to the facility on
[DATE] with diagnoses that include atrial fibrillation, diabetes, hypertension, and muscle wasting.
R9's MDS (Minimum Data Set) dated 3/28/23 documents a BIMS (Brief Interview for Mental Status) score
of 08, which indicates R9 has a moderate cognitive impairment.
R9's progress notes dated 4/17/23 documents, readmitted to (facility room number) with Dx (diagnosis) of
pneumonia et (and) Covid positive with Droplet isolation started.
R9's progress notes dated 4/27/23 documents, Res (resident) remains on Droplet precautions for Covid
positive. Today is resident last day of isolation.
On 4/24/23 at 2:04 PM, V10 (CNA) was observed entering R9's room after donning a gown, gloves, eye
protection, and surgical mask. At 2:21 PM, V11 (CNA) was observed entering R9's room after donning a
gown, gloves, eye protection, and surgical mask. V10 and V11 assisted R9 to transfer from the bed to a
chair using a mechanical lift. Upon exiting R9's room V10 and V11 doffed all PPE per current standards of
practice.
On 4/25/23 at 4:10 PM, V1 (Administrator) stated staff should wear full PPE when entering rooms with
residents who have tested positive for Covid-19. V1 stated PPE should include a N95 grade mask.
04/26/23 at 9:47 AM, V13 (Infection Preventionist) stated staff should wear an N95, eye protection, gown,
and gloves when entering a room with a Covid positive resident.
The facility In-Service Training Report dated 4/4/23 documents Covid 19 guidelines that documents, If a
resident is suspected or confirmed to have Covid-19, HCP (health care professional) must wear an N95
respirator, eye protection, gown, and gloves.
The Centers for Disease Control and Prevention website
(https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html) guidelines titled
Recommended infection prevention and control (IPC) practices when caring for a patient with suspected or
confirmed SARS-CoV-2 infection (updated 9/27/22) documents under the section titled Personal Protective
Equipment that HCP who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection
should adhere to Standard Precautions and use a NIOSH (National Institute for Occupational Safety and
Health)-approved particulate respirator with N95 filters or higher , gown, gloves, and eye protection (i.e.,
goggles or a face shield that covers the front and sides of the face).
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145791
If continuation sheet
Page 7 of 8
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145791
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/27/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Fireside House of Centralia
1030 Martin Luther King Blvd
Centralia, IL 62801
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0886
Perform COVID19 testing on residents and staff.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review the facility failed to ensure symptomatic residents were tested for
Covid 19 for 1 of 1 (R112) resident who was reviewed for Covid testing in the sample of 38.
Residents Affected - Few
Findings Include:
R112's facility admission Record with a print date of 4/27/23 documents R112 was admitted to the facility
on [DATE] with diagnoses that include pathological fracture, heart failure, peripheral vascular disease,
diabetes, and hypertension.
R112's MDS (Minimum Data Set) dated 4/12/23 documents a BIMS (Brief Interview for Mental Status)
score of 15, which indicates R112 is cognitively intact.
On 4/24/23 at 10:42 AM, R112 was laying in bed in his room and was coughing. R112 stated he has had a
cough but it is worse now.
R112's progress notes document the following,
4/24/23 1:15 PM Resident c/o (complains of) freq (frequent) dry nonproductive cough. (name of physician)
office called and will return call if new orders.
4/24/23 3:15 PM To appointment with (name of physician) per staff and facility van.
4/24/23 4:05 PM Returned to facility with new orders for oxygen and Z-pack. O2 (oxygen) applied at
2L(liters)/min(minute)/NC(nasal cannula). POA (power of attorney) aware of new orders.
4/25/23 2:15 PM Resident was covid tested r/t (related to) dry cough. Results negative. Resident also
recently diagnosed with lung cancer.
On 4/25/23 at 1:59 PM, V6 (Assistant Director of Nurses/DON) stated a Covid test was not done on R112
when symptoms developed. V6 stated R112 had a non-productive cough and was sent to his physician
office and prescribed a Z-pack. V6 stated a Covid test should have been done and they will do one now.
On 4/25/23 at 2:23 PM, V6 (Assistant DON) stated R112's covid test was negative. V6 stated the nurse
didn't do a Covid test yesterday due to R112 having a diagnosis of lung cancer and R112 being evaluated
at his doctors office.
04/26/23 at 9:47 AM, V13 (Infection Preventionist) stated If someone has symptoms of Covid 19, they test
them. This surveyor reviewed R112 developing symptoms of cough and being sent for an evaluation by his
physician with no Covid-19 test administered. V13 stated she would expect staff to test a symptomatic
resident for Covid-19.
The facility In-Service Training Report dated 4/4/23 documents Covid-19 guidelines that include;
Symptomatic residents or HCP (Healthcare Professionals), even those with mild symptoms of Covid-19,
regardless of vaccination status, should receive a viral test for SARS-Cov-2 as soon as possible .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145791
If continuation sheet
Page 8 of 8
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Back to topCitations
5 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F686 - Skin Integrity
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
F558 - The right to reside and receive services in the facility with reasonable
Reasonably accommodate the needs and preferences of each resident.
F584 - Safe Environment
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
F880 - Infection Control
Provide and implement an infection prevention and control program.
- 0886GeneralS&S Dpotential for harm
Perform COVID19 testing on residents and staff.
FAQ · About this visit
Common questions about this visit
What happened during the April 27, 2023 survey of FIRESIDE HOUSE OF CENTRALIA?
This was a inspection survey of FIRESIDE HOUSE OF CENTRALIA on April 27, 2023. The surveyor cited 5 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at FIRESIDE HOUSE OF CENTRALIA on April 27, 2023?
Yes, 5 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide appropriate pressure ulcer care and prevent new ulcers from developing."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.