Health inspection·March 6, 2025

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many come in and help, she's even left her groceries in the middle of the store to come in and assist with breakfast. V4 stated there are only 4 CNA's on the floor right now. On 03/04/25 at 2:26pm, V5 (LPN) stated most of the management will not help, there are very few who will. V5 stated and if they help, it's the nurse duties, they wouldn't dare be caught doing CNA work. V5 stated V1 (Administrator) is the only one who will answer her phone on the weekends, and will come in. V5 stated sometimes there is one CNA for both sides. V5 stated there are times when things are not done timely because everyone is trying to pitch in and make sure the residents are getting taken care of, med passes and Meals are a few of the things that run late. On 03/05/25 at 10:16am, V10 (CNA) stated staffing for CNAs is terrible, especially on the weekend that she works. V10 stated there have been weekends recently that it is just two CNAs for the whole building, herself and one other person. V10 stated there is a fair amount of people who require the assistance of two people. V10 stated it's a lot to expect of two people to do. V10 stated it takes them working constantly all day to get everyone up, changed and cleaned up and then to keep them clean and repositioned all day. V10 stated showers do not get done as they are supposed to, but we work very hard to keep everyone clean. V10 stated breakfast is supposed to start around 7:45am, sometimes it's 8:30am or later before they can get dependent residents to breakfast, and even then, they don't have anyone to assist with feeding. On 03/05/25 at 10:21am, V8 (Registered Nurse/RN) stated staffing is terrible, especially for the CNAs, weekends, evenings and nights are the worst. V8 stated too many times there are only 2 CNAs for the entire building, occasionally there is only one. V8 stated management will not answer their phones or turn it off on weekends, even if they are on call. V8 stated management will help with medication pass and nursing duties, but wouldn't do CNA work, beyond helping in the dining room. V8 stated she tries to help the best that she can, but sometimes that means her work is not completed timely, and everyone gets behind. On 03/05/25 at 12:25pm, V10 (CNA) stated she had worked the weekend of February 22 and remembered it was just herself and one other CNA. V10 stated showers were not able to be given as scheduled, but everyone who should have been showered received a bed bath. V10 stated that transfers and care requiring 2 staff members could not always be done with 2 staff members, so they must prioritize the things that they can do safely with one. V10 stated most nurses will step in when they can, but they have their own job duties and just barely enough of them to complete them. V10 stated management does not come in to assist, they won't even answer their phones. On 03/05/25 at 12:32pm, V11 (CNA) stated she specifically remembered Monday February 17, she was on the east side by herself and there were two CNAs on the west side. V11 stated the working schedule is not always an accurate representation of how staffing went for the day. V11 stated not all nurses are helpful on those days, but there are some that are. V11 stated she also understands they have their own tasks they have to complete as well and it's not like there is a bunch of them either. V11 stated management is not helpful at all. V11 stated on really short days, showers do not get done as scheduled, but we do try to give them a thorough bed bath when getting them up. V11 stated they have to make sure everyone stays clean enough and fed. V11 stated when there are only 2-3 CNAs total in the building, they have to figure out what 2 assists they can manage alone so that they can get residents taken care of until someone is available to assist with the others. V11 stated they do have discipline in place for calling in, but it only applies to certain people and a lot of times everyone gets in trouble, not just the people who are the problem. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145791 If continuation sheet Page 2 of 4 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 03/06/2025 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many On 03/05/25 at 2:23pm, V12 (CNA) confirmed today there were only two CNAs on west hallway for 2-10 shift. V12 stated it happens this way sometimes, more staff would be ideal, but they manage the best that they can. On 03/05/25 at 2:25pm, R8 who was alert to person, place and time, stated she used to be the president of resident council and still participates. R8 stated they do not ask anything about staffing at resident council other than if they have a problem with any of the CNAs. R8 stated there would be enough staff to go around if they would just show up. R8 stated there are ones that frequently do not show up and no one replaces them. R8 stated her care is pretty good but she doesn't ask for much. R8 stated she feels sorry for the ones who need assistance, not that staff don't try, but they can only be expected to do so much. On 03/05/25 at 2:28pm, R9 who was alert to person, place and time, stated they do not discuss staffing issues at resident council much. R9 stated they do not have enough people on the floor to get things done for sure. R9 stated her care is fine, but sometimes it takes the girls a while to get to her. On 03/05/25 at 2:32pm, V13 (CNA) confirmed today there was only 3 CNA staff present on east hallway for 2-10 shift. V13 stated rarely does she feel they have enough staff to safely and effectively complete their jobs timely. V13 stated they can't keep people; they hire people, and they see what they have to deal with and quit. V13 stated they will ask people that are off if they want to work when they are short, but people can't always work, they are tired and have their own lives. V13 stated there are some nurses that will help, and then there are some that will come get you in the middle of a transfer to get someone ice water. V13 stated management will help the nurses at times and maybe assist with the dining room. V13 stated they just do not have enough staff with everyone who is a 2 assist or a mechanical lift, to always do it with two people. V13 stated over half of the people in the building require assistance and there are a lot of residents on both sides that use mechanical lifts. V13 stated they have to figure out how they can safely manage to do as much as they can with one person, otherwise they would not be able to get everything done. V13 stated sometimes they are not able to get everyone up for supper, they may have 15 people eating on the hall, especially when they only have one person for each side. On 03/05/25 at 3:38pm, V1 stated she did not have a specific plan in place for times when they may have had only 1-3 CNAs that were scheduled show up, but she can assure that everyone that isn't scheduled on the floor pitches in, but they don't count for the numbers. V1 stated she will always answer her phone on the weekends, because no one else does, and she will come in if she can. On 03/04/25 at 10:56am, it was observed that there were 2 CNA staff on west hallway. On 03/04/25 at 10:59am, it was observed that there were 2 CNA staff on east hallway. On 03/05/25 at 2:22pm, it was observed that there were 2 CNA staff on the west hallway. On 03/05/25 at 2:24pm, it was observed that there were 3 CNA staff on east hallway. A document titled Facility assessment tool with an assessment date of 08/06/25 was provided by V1 as the facility's current assessment tool. This document states on page 6 in Example 3, there are 32 residents that require an assist of 1-2 staff and 26 residents that are dependent for Assistance with Activities of Daily Living. On page 9 of this document under staffing plan example 1; it documents (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145791 If continuation sheet Page 3 of 4 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 03/06/2025 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many that licensed nurse providing direct care work 12-hour shift and the total number needed is 4 for 6a-6p and 2 for 6p-6a. Also documented in this section is Nurse aides work 8 hour shifts and the total number needed for first shift is 7, second shift is 7, and third shift is 4. Undated facility document titled, February 2025 1st shift, documents on Monday 02/17 there were 4 CNAs scheduled to work the first shift. On Saturday 02/22 there were 3 CNAs scheduled to work the first shift and two worked 6a-2p and one worked 5a-9a. Undated facility document titled, February 2025 3rd shift, documents on Wednesday 02/05 there were 4 CNAs scheduled to work and 3 called in, leaving one to work. Undated facility document titled, March 2025 1st shift, documents on 03/04 there were 4 CNAs scheduled for the whole shift and 1 scheduled for 5-9. Undated facility document titled, March 2025 2nd shift, documents on 03/05 there are 7/6 CNAs scheduled. On 03/05/25 at 10:33am, V1 stated they do not have a policy specific to staffing, they follow federal guidelines. Resident Room Roster dated 3/3/25 documents there are currently 60 residents living in the facility. According to the Food and Drug Administration (FDA) guide, found on their website at www.fda.gov/files/medical%20devices/published/Patient-Lifts-Safety-Guide.pdf, it documents under preparing environment, Most lifts require two or more caregivers to safely operate lift and handle patient. Facility Policy titled Safe Lifting and moving of Residents with a revision date of July 2017, documents under policy statement, In order to promote safety and well-being of staff and residents, and to promote quality of care, this facility uses appropriate techniques and devices to lift and move residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145791 If continuation sheet Page 4 of 4