Deficiencies (last 3 years)
Deficiencies (over 3 years)
12 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
131% worse than Arkansas average
Arkansas average: 5.2 deficiencies/yearDeficiencies per year
24
18
12
6
0
Census
Latest occupancy rate
83 residents
Based on a January 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy over time
Inspection Report
Routine
Census: 83
Deficiencies: 6
Date: Jan 17, 2025
Visit Reason
The inspection was conducted as a routine regulatory oversight visit to assess compliance with healthcare facility regulations and standards.
Findings
The facility was found deficient in multiple areas including inaccurate Minimum Data Set (MDS) assessments, failure to promptly initiate physician order changes, inadequate fall prevention interventions and supervision, failure to assess and administer as-needed diuretic therapy, improper food service safety practices related to grease trap cleanliness, and an incomplete facility-wide assessment lacking critical information for resource allocation and emergency preparedness.
Deficiencies (6)
Failure to ensure the Minimum Data Set (MDS) assessment was accurately completed for Resident #88 regarding dialysis services.
Failure to ensure physician order changes for anti-psychotic medications were immediately initiated for Resident #13.
Failure to investigate causative factors of falls and develop effective interventions for Resident #35, resulting in multiple falls and injuries.
Failure to assess edema and administer prescribed as-needed diuretic therapy for Resident #7.
Failure to maintain grease traps clean of charred food particles and spillage, posing fire risk and pest attraction.
Facility-wide assessment did not include critical information necessary for competent resident care and emergency preparedness.
Report Facts
Residents reviewed for MDS accuracy: 22
Residents reviewed for anti-psychotic medications: 5
Resident census: 83
Falls documented for Resident #35: 7
BIMS score for Resident #88: 12
BIMS score for Resident #13: 14
BIMS score for Resident #35: 3
BIMS score for Resident #7: 3
Medication dosage for Resident #13: 42
Medication dosage change for Resident #13: 21
Diuretic dosage for Resident #7: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding failure to initiate physician order changes and fall interventions |
| MDS Coordinator | MDS Coordinator | Interviewed regarding inaccurate MDS assessment for Resident #88 |
| Licensed Practical Nurse #7 | Licensed Practical Nurse | Interviewed regarding Resident #35's care and fall risk |
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Interviewed regarding Resident #35's falls and behavior |
| Registered Nurse #4 | Registered Nurse | Interviewed regarding Resident #35's care and footwear |
| Certified Nursing Assistant #5 | Certified Nursing Assistant | Interviewed regarding Resident #35's fall risk and interventions |
| Certified Nursing Assistant #6 | Certified Nursing Assistant | Interviewed regarding Resident #35's fall risk and footwear |
| LPN #1 | Licensed Practical Nurse | Interviewed regarding Resident #7's edema assessment and medication administration |
| LPN #2 | Licensed Practical Nurse | Interviewed regarding frequency of edema assessment for Resident #7 |
| Primary Care Physician | Primary Care Physician | Interviewed regarding Resident #7's diuretic medication change and condition |
| Food Service Director | Food Service Director | Interviewed regarding grease trap cleaning and kitchen safety |
| Administrator | Administrator | Interviewed regarding incomplete facility-wide assessment |
Inspection Report
Deficiencies: 7
Date: Dec 15, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to medication administration, oxygen therapy orders, medication storage, infection control, food safety, and environmental safety in the nursing home.
Findings
The facility was found deficient in multiple areas including failure to ensure residents were properly assessed and ordered for self-administration of medications, lack of physician orders for oxygen therapy, improper medication storage, inadequate infection control practices including hand hygiene, failure to label and date resident food items in refrigerators, and unsafe environmental conditions such as broken chairs and sharp door edges.
Deficiencies (7)
Failure to ensure Resident #29 was assessed and had an order for self-administration of updraft treatments.
Failure to obtain an order for oxygen therapy for Resident #94 to minimize potential respiratory complications.
Failure to ensure nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Failure to ensure medications were stored securely and labeled according to professional standards for Residents #94 and #39.
Failure to ensure resident's personal food and beverage items stored in refrigerator were labeled and dated, and failure to perform hand hygiene during meal tray delivery.
Failure to ensure infection control measures including hand hygiene before entering contact isolation room for Resident #91.
Failure to maintain a safe, functional, sanitary, and homelike environment related to broken geriatric chairs, shower chairs, and door frames with sharp edges.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 16
Residents affected: 90
Residents affected: 1
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed about Resident #29 self-administration order |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Interviewed about medication orders, oxygen orders, medication storage, and infection control |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Interviewed about refrigerator food labeling and hand hygiene during meal tray delivery |
| Certified Nursing Assistant #2 | Certified Nursing Assistant | Observed and interviewed about hand hygiene during meal tray delivery |
| Certified Nursing Assistant #9 | Certified Nursing Assistant | Observed and interviewed about hand hygiene before entering contact isolation room |
| Infection Control Preventionist Nurse | Infection Control Preventionist | Interviewed about hand hygiene and infection control practices |
| Maintenance #1 | Maintenance Supervisor | Interviewed about reporting and repair of environmental safety issues |
| Administrator | Administrator | Interviewed about oxygen orders and refrigerator usage |
| Dietary #1 | Dietary Staff | Interviewed about food labeling and hand hygiene during meal tray delivery |
| Certified Nursing Assistant #3 | Certified Nursing Assistant | Observed about shower chair cleaning and condition |
| Certified Nursing Assistant #4 | Certified Nursing Assistant | Observed assisting Resident #72 |
Inspection Report
Annual Inspection
Deficiencies: 1
Date: May 9, 2023
Visit Reason
The inspection was conducted to assess the facility's compliance with care standards, specifically focusing on the provision of activities of daily living (ADL) care for residents dependent on staff assistance.
Findings
The facility failed to ensure that residents dependent on staff for personal hygiene were provided care to promote hygiene and dignity, as evidenced by Resident #3 being left with food and liquid on her face and clothes in the dining room for an extended period. Staff and administration acknowledged responsibility but could not explain the lapse.
Deficiencies (1)
Failure to provide adequate personal hygiene care to Resident #3, who was left with food and liquid on her face and clothes in the dining room.
Report Facts
Residents affected: 1
Sample residents reviewed: 3
Assessment Reference Date: Feb 27, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed regarding responsibility for cleaning residents after meals |
| CNA #1 | Certified Nursing Assistant | Interviewed about care of Resident #3 and responsibility for hygiene |
| Director of Nursing | Director of Nursing | Interviewed about responsibility for resident hygiene and care |
| Minimum Data Set Coordinator | MDS Coordinator | Interviewed about responsibility for resident hygiene and facility policy |
Inspection Report
Routine
Deficiencies: 1
Date: Feb 6, 2023
Visit Reason
The inspection was conducted to assess the facility's compliance with care standards, specifically focusing on personal hygiene and grooming related to nail care for residents dependent on staff.
Findings
The facility failed to ensure that residents' fingernails were cleaned and trimmed to promote good personal hygiene and grooming for 2 of 3 sampled residents dependent on staff for nail care. Observations and interviews revealed that residents had long, uneven, jagged nails with brown substances under the nail tips, indicating inadequate nail care.
Deficiencies (1)
Failure to ensure residents' fingernails were cleaned and trimmed to promote good personal hygiene and grooming for 2 of 3 sampled residents dependent on staff for nail care.
Report Facts
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Interviewed regarding nail care responsibilities and described residents' nail conditions |
| CNA #1 | Certified Nursing Assistant | Interviewed regarding nail care duties and schedule |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding nail care responsibilities and facility policy |
Inspection Report
Routine
Census: 99
Deficiencies: 21
Date: Sep 9, 2022
Visit Reason
Routine inspection of Siloam Healthcare, LLC nursing home to assess compliance with regulatory requirements including resident care, safety, infection control, and facility maintenance.
Findings
The facility had multiple deficiencies including failure to ensure call lights were accessible to residents, inadequate support for resident self-determination regarding smoking, failure to notify Medicaid recipients about trust balances, unsafe environmental conditions, incomplete admission assessments and care plans, inadequate personal care and hygiene assistance, improper storage of razors, failure to date and store oxygen equipment properly, lack of pain medication prior to wound care, improper meal preparation and serving temperatures, poor infection control practices including COVID-19 screening and masking, incomplete antibiotic stewardship, failure to timely notify residents and families of COVID-19 cases, and incomplete COVID-19 vaccination coverage for residents and staff.
Deficiencies (21)
Failed to ensure resident call lights were in reach for residents to notify staff of their needs.
Failed to ensure resident self-determination regarding smoking was respected and facilitated.
Failed to notify Medicaid recipient residents or responsible parties when trust balances approached or exceeded Medicaid limits.
Failed to maintain safe, clean, and homelike environment including repair of walls and courtyard decking.
Failed to complete admission nursing assessments and baseline care plans timely and completely.
Failed to develop and implement comprehensive care plans meeting residents' needs with measurable objectives and timetables.
Failed to provide nail care and scheduled showers or baths to residents requiring assistance.
Failed to ensure razors were stored safely to prevent accidents or hazards.
Failed to date and store oxygen tubing and nebulizers properly to prevent infections.
Failed to administer pain medication as ordered prior to wound care.
Failed to prepare and serve meals according to planned menus and nutritional needs, including portion sizes and fortified foods.
Failed to serve food at safe and appetizing temperatures to maintain palatability and encourage intake.
Failed to ensure pureed food items were blended to a smooth, lump-free consistency.
Failed to provide physician ordered therapeutic diets and nutritional supplements.
Failed to serve meals and snacks at regularly scheduled times to provide dependable eating schedule.
Failed to ensure food storage areas were clean, foods were covered, sealed, and dated, and staff practiced proper hand hygiene and food handling.
Failed to ensure COVID-19 screening of all persons entering facility and proper mask use by employees.
Failed to implement a comprehensive antibiotic stewardship program for all infections and prescribed antibiotics.
Failed to timely inform residents, representatives, and families of new suspected or confirmed COVID-19 cases in the facility.
Failed to ensure COVID-19 vaccinations or exemptions were received for all employees and maintain accurate vaccination tracking.
Failed to ensure COVID-19 vaccinations were provided timely to eligible residents and properly document vaccination status.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 44
Residents affected: 99
Residents affected: 24
Residents affected: 99
Residents affected: 24
Residents affected: 15
Residents affected: 2
Residents affected: 1
Residents affected: 7
Residents affected: 26
Residents affected: 21
Residents affected: 97
Residents affected: 99
Residents affected: 99
Residents affected: 99
Residents affected: 99
Residents affected: 47
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #10 | CNA | Refused COVID-19 screening and not listed on staff vaccination matrix |
| Director of Nursing | DON | Interviewed regarding call light placement, care plan completion, COVID-19 screening and vaccination |
| Administrator | Observed with mask below nose, involved in COVID-19 screening and vaccination discussions | |
| Infection Control & Preventionist | ICP | Interviewed regarding antibiotic stewardship, COVID-19 vaccination, and screening |
| Assistant Director of Nursing | ADON | Interviewed regarding pain medication refill and COVID-19 vaccination |
| Dietary Supervisor | Interviewed regarding meal preparation, food storage, and food safety | |
| Licensed Practical Nurse #1 | LPN | Interviewed regarding pain medication availability |
| Wound Care Nurse | Interviewed regarding pain medication for wound care |
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