Centralia Manor

In the surveyor’s words

From the most serious findings on record at Centralia Manor, in the surveyor’s own words.

• Immediate jeopardy, isolatedF678Sep 9, 2025

  Based on interview and record review the facility failed to initiate cardiopulmonary resuscitation (CPR) timely for 1 of 3 (R1) residents reviewed for death in the sample of 11. This failure resulted in facility staff not initiating CPR for 10-15 minutes after finding R1, who had chosen to be a full code with full treatment, in bed with no pulse and no respirations. CPR was not initiated until V11 (RN/Registered Nurse) was told by oncoming staff that R1 was a full code. After CPR was initiated, R1 was transferred via ambulance to the local hospital and pronounced dead.This failure resulted in an Immediate Jeopardy, which was identified to have begun on [DATE] when facility staff failed to immediately initiate CPR after finding R1 with no pulse and no respirations. […]

• Actual harm, isolatedF600Feb 10, 2026

  Based on interview and record review the facility failed to keep residents free from abuse for 2 (R1 and R3) of 3 residents reviewed for abuse in a sample of 5. This failure would cause a reasonable person to experience feelings of fear, anxiety and anger while residing in their home.Findings include:1. R2's Face Sheet documents an admission date of 12/11/25 with diagnoses including: displaced fracture of upper end of right humerus, dementia, type 2 diabetes mellitus, muscle weakness, cognitive communication deficit, candidiasis of skin and nail, pain, vitamin D deficiency, major depressive disorder, and essential hypertension. […]

• Actual harm, isolatedF550Sep 24, 2025

  Based on interview and record review the facility failed to answer alternative call lights for residents needing assistance in a timely manner to promote dignity for 5 residents of 13 residents (R1, R2, R4, R6, and R7) reviewed for call light response in a sample of 13. This failure resulted in R1, R2 and R4 having bowel and bladder accidents which lead to feelings of humiliation, embarrassment and shame. Findings include: 1. R1's Face Sheet dated 09/23/25 documents an admission date of 08/21/25 with diagnoses in part of fusion of the spine lumbar region, muscle weakness, other rupture of muscle, spinal stenosis lumbar region, other specified local infection of the skin and subcutaneous tissue, anxiety, rheumatoid arthritis, overactive bladder, and unspecified injury at unspecified level… […]

• Actual harm, isolatedF689Jul 1, 2025

  Based on interview, observation, and record review, the facility failed to consistently identify hazards/risks related to falls and ensure individualized, resident centered interventions were developed and implemented for prevention of falls for 4 of 7 residents (R13, R17, R28, R263) reviewed for accidents in a sample of 40. This failure resulted in R17 receiving a laceration to the back of the head, requiring emergency room treatment which included 3 staples to the back of R17's head. Findings include: 1. […]

• Actual harm, isolatedF692Jul 1, 2025

  Based on interview, observation, and record review, the facility failed to ensure residents maintained acceptable parameters of nutritional status for two (R7 and R213) of 7 residents reviewed for nutrition in a sample of 40. This failure resulted in further contributing to continued harm for R7, who is documented to be severely underweight with a Body Mass Index of 16.66%. Findings include: R7's Resident Face Sheet documents an admission date of 01/30/2018 with diagnoses that included dementia, atherosclerotic heart disease, osteoarthritis, dysphagia, major depressive disorder, cachexia, pain in right arm, ventral hernia without obstruction or gangrene, abnormal weight loss, anxiety disorder, heartburn, vitamin deficiency, gastro-esophageal reflux disease without esophagitis, and vitamin… […]