Fireside House of Centralia

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689May 28, 2025

  Based on observation, interview, and record review the facility failed to ensure a cognitively impaired resident was adequately supervised to prevent her exiting the facility without staff knowledge for 1 (R1) of 3 residents reviewed for accidents and supervision in the sample of 3. This failure resulted in R1, who has a diagnosis of dementia and was already on 15-minute visual checks for previous exit seeking behavior, exiting the facility at an unknown time without staff knowledge or supervision, walking approximately 1.3 miles away from the facility and was found by two unknown teenage female citizens who took R1 to the local emergency room. […]

• Immediate jeopardy, isolatedF600Oct 23, 2023

  Based on interview and record review the facility failed to protect a resident's right to be free from neglect when they failed identify a change in condition as emergent and to ensure a system was in place to obtain timely emergency transport for 1 of 3 (R1) residents reviewed for neglect in the sample of 9. This failure resulted in R1 not being transported to the hospital emergency room for an hour while experiencing worsening symptoms of sluggish dilated pupils, temperature of 95.7, difficulty with speech, slow response time, and facility staff were unable to obtain an oxygen saturation. R1 expired in the hospital emergency room and cause of death is documented as a massive gastrointestinal bleed. […]

• Immediate jeopardy, isolatedF684Oct 23, 2023

  Based on interview and record review the facility failed to identify a decline in condition as an emergent situation and ensure a system was in place to obtain timely emergency transport for 3 of 6 (R1, R8, and R9) residents reviewed for hospital transfers in the sample of 9. This failure resulted in R1 not being transported to the hospital emergency room for an hour while experiencing worsening symptoms of sluggish dilated pupils, temperature of 95.7, difficulty with speech, slow response time, and facility staff were unable to obtain an oxygen saturation. R1 expired in the hospital emergency room and cause of death is documented as a massive gastrointestinal bleed. […]

• Actual harm, isolatedF760Aug 17, 2026

  Based on interview and record review the facility failed to ensure residents were free from significant medication errors for 1 (R1) of 3 residents reviewed for medication administration in the sample of 8. This failure resulted in R1 receiving an intermittent access (INT) needle placed in her left hand, after unsuccessful attempt to right forearm, two doses of Meropenem 500 MG (milligrams) IV (intravenous), and sent to the local emergency room for treatment of nausea.This past non-compliance occurred between 7/27/2026 and 7/28/2026. […]

• Actual harm, isolatedF689Feb 29, 2024

  Based on interview and record review the facility failed to keep a resident's environment free of accident hazards and failed to implement new interventions to reduce falls for 7 of 10 residents (R2, R3, R9, R41, R49, R51, R54) reviewed for falls in a sample of 40. This failure resulted in R2 falling out of bed on 11/29/2023 due to a loose bed enabler and suffering a fractured left acetabular medial wall, a fractured iliopubic junction fracture and a fractured pubic rami. Findings include: 1. According to R2's face sheet, R2 was admitted on [DATE] with diagnosis of Parkinson's, Muscle Weakness, Muscle wasting and Atrophy, Alzheimer's, Osteoporosis and Convulsions among others. […]