SILOAM SPRINGS, AR - Federal health inspectors cited Siloam Healthcare for multiple safety violations during a January inspection, including failing to investigate the root causes of repeated resident falls and inadequate monitoring of critical heart medication, putting vulnerable residents at risk for serious injuries and medical complications.
Pattern of Falls Ignored Despite Serious Injuries
The most significant violation involved a resident with severe cognitive impairment who experienced seven documented falls over nearly one year, with the facility failing to conduct proper investigations to prevent future incidents. The resident, diagnosed with stroke, dementia, and other conditions, sustained multiple head injuries including hematomas and abrasions from these preventable falls.
Despite having a documented fall prevention plan, inspectors found the facility repeatedly implemented the same ineffective interventions after each incident. After the resident fell on February 12, 2024, crawling out of bed and sustaining a head hematoma and knee abrasion, staff were educated to use adaptive walking equipment if the resident became restless. When the resident fell again on March 24 with similar circumstances, staff received the same education about using the walking equipment.
The pattern continued through multiple incidents, with the resident found crawling on bedroom floors, falling from adaptive equipment, and sustaining injuries. On January 7, 2025, the resident fell from a wheelchair in the TV room, hitting another resident's wheelchair while not wearing required non-slip footwear.
"The facility had not completed a root cause analysis of Resident #35's falls for the last year and had only looked at the most recent falls," the Director of Nursing acknowledged during the inspection, according to the report.
Medical research demonstrates that comprehensive fall investigations are essential for preventing repeat incidents in high-risk populations. Effective fall prevention requires analyzing patterns, environmental factors, medication effects, and individual risk factors to develop targeted interventions. When facilities fail to investigate systematically, residents remain at elevated risk for serious injuries including fractures, traumatic brain injuries, and life-threatening complications.
The inspection revealed additional systemic failures in fall prevention. Fall assessments contained inaccurate information, with one assessment stating the resident "was not at risk for falls" despite having experienced three falls within the previous three months. Care plans were outdated and inaccurate, with interventions not properly communicated to nursing assistants responsible for direct care.
Critical Heart Medication Monitoring Failures
Inspectors identified dangerous gaps in medication oversight for a resident with congestive heart failure who required careful monitoring of diuretic therapy. The resident had visible swelling in both feet extending beyond their shoes, yet nursing staff failed to assess for edema or administer prescribed medication for the entire month of January 2025.
The resident's physician had prescribed a diuretic "as needed for swelling related to chronic diastolic congestive heart failure." However, nursing staff demonstrated poor understanding of their monitoring responsibilities. When questioned, a Licensed Practical Nurse stated she was unaware the resident had edema and had not administered the medication despite clear physical signs of fluid retention.
The facility's Director of Nursing confirmed there was no systematic indicator in their electronic medical record to remind nurses to assess for edema in patients with heart failure. This represents a significant oversight in patient safety protocols, as untreated fluid retention in heart failure patients can lead to respiratory distress, hospitalization, and life-threatening complications.
Congestive heart failure requires careful fluid balance monitoring, as excess fluid retention can worsen the condition rapidly. Diuretics help remove excess fluid, but their effectiveness depends on proper assessment and timely administration. When nursing staff fail to recognize swelling or administer prescribed medications, patients face increased risks of pulmonary edema, breathing difficulties, and cardiac complications.
The resident's physician expressed concern about the monitoring gaps during the inspection, stating he expected nursing staff to assess for edema at least daily and acknowledged "I should have written the order better." However, professional nursing standards require competent assessment skills regardless of physician order specificity.
Kitchen Safety Hazards Create Fire and Contamination Risks
The facility's kitchen operations violated food safety standards due to inadequate cleaning practices that created fire hazards and potential contamination risks. Inspectors found grease traps containing an extensive accumulation of charred food particles and spillage that had not been properly maintained.
When the Food Service Director demonstrated the grease trap condition, inspectors observed an 18-inch by 9-inch area covered with black spillage and charred particles. The director acknowledged this posed fire risks and could attract pests, stating grease traps should be cleaned more frequently than the weekly schedule currently in place.
Documentation revealed the last recorded grease trap cleaning occurred in July 2024, approximately six months before the inspection. The facility lacked comprehensive cleaning schedules that specifically addressed grease trap maintenance, creating gaps in essential food service safety protocols.
Proper grease trap maintenance is critical for preventing kitchen fires, which can spread rapidly and endanger residents who may have limited mobility or evacuation assistance needs. Additionally, accumulated grease and food particles create environments for bacterial growth and pest infestation, potentially contaminating food preparation areas.
Incomplete Emergency Preparedness Assessment
The facility failed to maintain a comprehensive assessment of resources needed for resident care during normal operations and emergencies. The facility-wide assessment, last updated in November 2024, omitted critical elements required for effective care planning and emergency response.
Missing components included processes for admitting residents with unfamiliar diagnoses, assessment of cultural and religious needs, staff training requirements, and emergency preparedness protocols. The facility also lacked documentation of third-party service agreements and health information technology resources essential for coordinating care.
The Administrator acknowledged during the inspection that they were unaware all assessment components were required and committed to completing the evaluation by the end of the day.
Additional Issues Identified
Inspectors documented several other areas of concern during their review. These included inadequate care plan documentation that failed to reflect current resident conditions and equipment changes, inconsistent communication of safety interventions to direct care staff, and gaps in medication administration policies.
The facility's electronic health record system lacked adequate prompts to ensure proper assessment and monitoring of high-risk conditions. Staff interviews revealed inconsistencies in understanding safety protocols and intervention requirements for residents with complex medical needs.
The violations collectively demonstrate systemic issues in quality assurance, staff training, and care coordination that require comprehensive corrective actions to ensure resident safety and regulatory compliance.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Siloam Healthcare, LLC from 2025-01-17 including all violations, facility responses, and corrective action plans.
💬 Join the Discussion
Comments are moderated. Please keep discussions respectful and relevant to nursing home care quality.