Health inspection·July 10, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure two staff were available when using a mechanical lift for 1 of 3 (R8) residents reviewed for accidents in the sample of 14. Findings Include: R8's admission Record with a print date of 7/9/25 documents R8 was admitted to the facility on [DATE] with diagnoses that include dementia, muscle weakness, and vision loss. R8's Minimum Data Set (MDS) dated [DATE] documents R8 has a BIMS score of 09, indicating a moderate cognitive deficit. This same MDS documents R8 is dependent on staff for transfers. R8's current Care Plan documents a Focus area of Risk for falls. This Focus area includes the intervention mechanical lift for transfers. There are no dates documented on this Care Plan. R8's Order Summary Report dated 7/9/25 includes the following physician order, Mechanical Lift for transfers every shift, with a start date of 10/05/2019. On 7/8/25 at 7:05 PM, V4 (Certified Nursing Assistant/CNA) was in R8's room transferring R8 from chair to bed using a mechanical lift. V4 was attempting the transfer without assistance of another staff. V4 had R8 in the lift and in the air when this surveyor started the observation. V4 wheeled the lift to the bed and started to lower R8 onto the bed. V4 had to stop and raise R8 up again because she was high enough her head was too close to the head of the bed. V4 adjusted the lift and began lowering R8 to the bed again. V4 stopped the lift and had to adjust R8 to the center of the bed because she was too close to the edge. V4 then lowered R8 to the bed. V20 (Licensed Practical Nurse/LPN) was in the hallway preparing medications to administer to other residents, throughout this observation. On 7/8/25 at 7:16 PM, V4 (CNA) stated she came to work at 6 am and was supposed to leave at 6 PM. V4 stated they had other CNA's not show up for work tonight and she would be leaving as soon as she got the residents settled for the night. V4 stated there were two other CNA's working on her hall and one CNA working on the other hall. V4 stated three CNA's is enough to meet the needs of the residents after they are all in bed. V4 stated she transferred R8 using a mechanical lift without the assistance of another CNA. V4 stated she did that because the other CNA's were providing care to other residents and they didn't have enough staff to meet the needs of the residents right now. On 7/8/25 at 7:08 PM, V20 (LPN) stated she had three CNA's working with her. V20 stated that is (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 6 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 07/10/2025 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)