Centralia Manor: CPR Failure Triggers Immediate Jeopardy - IL
The citation, assigned under Tag F0678, was documented during a complaint inspection completed September 9, 2025.
Centralia Manor sits on East McCord Route 161 on the eastern edge of Centralia, a small city in southern Illinois. The facility is certified by Medicare and Medicaid. What inspectors found there this fall was not a paperwork lapse or a staffing ratio question. It was a nurse who, during a cardiac emergency, did not follow the steps the facility had written down and trained staff to follow when a resident's heart stops.
The nurse, identified in inspection records only as V11, held a registered nurse license. She did not return to work after the date of the incident.
Centralia Manor's own emergency policy, numbered 3.06, lays out what any staff member must do the moment a cardiac arrest is identified. Note the time. Call for help immediately. Check the resident's code status, meaning whether they have a do-not-resuscitate order or a POLST form directing whether CPR should be performed. If CPR is appropriate, begin it according to American Heart Association or American Red Cross guidelines. Use the facility's automated external defibrillator if needed.
The policy also requires that at least one person on duty at any time hold current CPR certification. Any employee on the premises can be called in to assist.
What V11 did, or failed to do, during the emergency is not spelled out in granular detail in the inspection narrative. But the consequence of her actions was severe enough that federal inspectors assigned Immediate Jeopardy, and the facility's own corrective action plan acknowledged the deficiency extended beyond one nurse. The administrator and the director of nursing both required re-training on the cardiac arrest protocol. Every nursing staff member was brought in for in-service education, twice, once on the emergency policy itself and once specifically on how to locate a resident's code status and POLST documentation.
That second in-service is telling. One of the basic requirements in a cardiac emergency is knowing, before starting CPR, whether the resident has asked not to be resuscitated. Performing CPR on a resident who has a valid DNR order is a serious violation of that person's wishes. Failing to perform CPR on a resident who needs it and has no such order can be fatal. Either error, in either direction, represents a fundamental breakdown in emergency care. The fact that the director of nursing found it necessary to train every nursing staff member on where to find code status documents suggests the problem was not isolated to one nurse on one shift.
The Immediate Jeopardy designation was removed after the facility completed its corrective actions. The administrator, identified as V1, and the director of nursing, identified as V2, were trained by a regional nurse, V13, on the emergency policy. The director of nursing then led the facility-wide in-services. A monitoring plan was added to the facility's quality assurance program, requiring the director of nursing or a designee to audit ten employees per week for a month to verify that staff know where to find code status documentation and understand the emergency protocol. That monitoring is to continue as a permanent part of the facility's quality assurance process.
The registered nurse at the center of the incident did not return to work after the date of the emergency. The inspection record does not say whether she resigned, was terminated, or left for another reason.
What the record does not contain is also worth noting. There is no description of the resident's outcome. The inspection narrative does not say whether the person whose heart stopped survived, whether CPR was ultimately performed by someone else, or whether the resident had a DNR order that should have governed the response. Federal inspection reports frequently omit resident outcomes to protect privacy, but the absence means it is not possible, from this document alone, to know what happened to the person at the center of the emergency.
What is known is that inspectors found the failure serious enough to trigger the highest-level citation available to them. Immediate Jeopardy citations are not issued for documentation errors or missed charting. They are issued when inspectors determine that a facility's practices have caused, or are likely to cause, serious harm or death to a resident.
The corrective actions Centralia Manor took were accepted by regulators as sufficient to remove the Immediate Jeopardy finding. The facility completed its in-services, updated its quality assurance plan, and submitted a plan of correction. Inspectors accepted that plan and closed out the immediate jeopardy on the date the corrective actions were verified.
But the sequence of events that led to the citation, a nurse who did not follow a cardiac arrest protocol during an actual cardiac arrest, staff who needed to be retrained on something as basic as where to find a resident's code status, an administrator and a director of nursing who both required re-education on a foundational emergency policy, points to a gap that existed before September 9 and was only exposed when it mattered most.
Nursing facilities are required to maintain CPR certification among their staff precisely because cardiac emergencies are not hypothetical. They happen. The protocol exists because, in the minutes after a heart stops, there is no time to look up what to do or ask someone else what the resident's wishes were. The nurse has to know. The aide who runs in to help has to know. The person who finds the AED cart has to know where the POLST is filed.
At Centralia Manor this past September, during an actual emergency, that system failed.
The nurse who was there that day did not come back.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Centralia Manor from 2025-09-09 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 30, 2026 · Our methodology
CENTRALIA MANOR in CENTRALIA, IL was cited for immediate jeopardy violations during a health inspection on September 9, 2025.
The citation, assigned under Tag F0678, was documented during a complaint inspection completed September 9, 2025.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.