Siloam Healthcare, Llc

F-F689

Based on observations, record review, interviews, document review, and facility policy review, the facility failed to investigate to determine the causative factors of falls to facilitate development of effective interventions to prevent further falls and minimize the risk of fall-related injuries for 1 (Resident #35) of 3 sampled residents reviewed for accidents, which resulted in numerous abrasions and two separate hematomas to the forehead resulting from a fall for Resident #35.

The findings include:

A review of a facility policy titled, Care Plans, Comprehensive Person-Centered with a revision date of March 2022, indicated Care plans interventions are developed after data gathering, proper sequencing of events, consideration of relationships or the underlying source and problem. Also, assessments are on going and updated when condition changes.

A review of the Admission Record, indicated the facility admitted Resident #35 with diagnoses that included cerebral infarction (stroke), dementia, diabetes mellitus, spondylolysis (a defect or damage via a stress fracture in one of the vertebrae of the spinal column), anxiety, and psychotic Disorder.

The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/24/2024, revealed Resident #35 had a Brief Interview of Mental Status (BIMS) of 3 indicating severe cognitive impairment. Further review indicated the resident had two or more falls with no injuries since admission .

A review of Resident #35 ' s care plan, revealed the resident was a fall risk related to impaired cognition, communication problems, impaired mobility and had actual falls on 02/12/2024, 02/24/2024, 06/27/2024, 10/08/2024, and 01/07/2025. Interventions included the following:

- Observe the resident for appropriate footwear, initiated on 04/17/2022

- To have proper footwear intact while up in a wheelchair, initiated on 01/08/2025

- Staff were to assist the resident into merry walker (adaptive equipment that is utilized to help with a physical or cognitive impairment) instead of recliner, initiated on 10/09/2024

- To keep the bed in the lowest position with fall mat, initiated on 12/10/2023

- If the resident was restless in bed, to assist the resident into a merry walker, initiated on 04/09/2024

Further review of the care plan indicated the resident had poor safety awareness and required supervision, prompts, and cues for safety.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 12 045356 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 045356 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Siloam Healthcare, LLC 811 West Elgin Street Siloam Springs, AR 72761

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 A review of Resident 35 ' s tasks revealed the following:

Level of Harm - Minimal harm or - Staff were educated to provide non-slip footwear daily to the resident on 10/08/2024 potential for actual harm - Staff were to encourage the resident to get up for meals Residents Affected - Few - The resident was to always wear Velcro strap tennis shoes when out of bed

- To keep the resident ' s bed at lowest position

- To ensure a floor mat was beside the bed

- The resident was to wear a soft helmet at all times while out of bed.

A review of the last 12 months of incident and accident reports indicated Resident #35 had the following falls:

- 02/12/2024, the resident was found crawling on the bedroom floor after climbing out of bed and sustained

a hematoma to the head and an abrasion to the knee. The fall intervention was continue with the bed in the lowest position, fall mat at bedside, and staff were educated to put the resident in a merry walker if the resident becomes restless.

- 03/24/2024, the resident was found crawling on the bedroom floor after climbing out of bed and sustained abrasions to the elbow and a raised area to the forehead. Staff again were educated to put the resident in a merry walker if the resident becomes restless.

- 06/27/2024, the resident was found on the bedroom floor. Staff were educated to encourage the resident to get up for meals.

- 07/03/2024, the resident was found crawling on the bedroom floor. Staff again were educated to put the resident in a merry walker if the resident becomes restless.

- 09/30/2024, the resident was found in the floor in a hallway. The resident had been sitting in the merry walker and staff noticed the safety buckle was undone. Staff educated to ensure safety belt and front bar were secured when the resident was in the chair.

- 10/08/2024, the resident was found on the floor in the resident ' s room and had fallen out of the merry walker. The resident was not wearing non-skid socks. Staff were educated to provide non-slip footwear daily.

- 01/07/2025, the resident was found on the floor in the TV room. The resident had fallen out of their wheelchair and the resident ' s helmeted head hit another resident ' s wheelchair. The resident was not wearing non-skid footwear.

A review of fall assessments for the last 12 months were reviewed and indicated the following:

- On 03/26/2024, the assessment indicated the resident did not have any falls in the past 3 months.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 12 045356 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 045356 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Siloam Healthcare, LLC 811 West Elgin Street Siloam Springs, AR 72761

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 - On 08/09/2024, the assessment indicated the resident had 1-2 falls in the past 3 months.

Level of Harm - Minimal harm or - On 10/01/2024, the assessment indicated the resident was not at risk for falls, even though the resident potential for actual harm had 3 falls within the last 3 months.

Residents Affected - Few - On 01/07/2025, the assessment indicated the resident did not have any falls within the last 6 months.

During an observation on 01/13/2025 at 2:05 PM, Resident #35 was wearing a soft helmet and was sitting in

a wheelchair.

During an interview on 01/17/25 at 8:28 AM, Licensed Practical Nurse (LPN) #7 stated that Resident #35 was dressed by staff and unable to take footwear off by themselves.

During an interview on 01/17/2025 at 8:47 AM, LPN #3 stated Resident #35 had slid of the bad a few times. LPN #3 stated that if the resident urinates in bed at night, the resident gets fidgety and crawls out of bed because the resident does not know how to use the call light for assistance. LPN #3 stated the resident was no longer in a merry walker and was in a regular wheelchair.

During an interview on 01/17/25 at 9:11 AM, Registered Nurse (RN) #4 stated that Resident #35 was fully dependent on staff dressing them and had never seen them remove footwear.

During an interview on 01/17/25 at 9:48 AM, Certified Nursing Assistant (CNA) #5 stated Resident #35 was a fall risk because the resident was unable to use their legs. CNA #5 stated staff dressed Resident #35 and the resident was not able to take off socks or shoes independently. CNA #5 stated that one of Resident #35 ' s fall interventions was non-slips socks on at all times. CNA #5 also stated that the resident used a walker and not a wheelchair for ambulation.

During an interview on 01/17/25 at 9:56 AM, CNA #6 stated Resident #35 was a fall risk, the resident does not use to call light for assistance, and it had been approximately 5 months since the resident was changed from a merry walker to a wheelchair. CNA #6 stated Resident #35 was unable to take off socks and shoes by themselves.

During an interview on 01/17/25 at 10:06 AM, Minimum Data Set (MDS) nurse stated Resident #35 already had proper footwear as a fall intervention prior to a fall on 01/07/2025and stated it was not acceptable to repeat a fall intervention that is already in place. MDS nurse stated the Director of Nurses (DON) formulates

the fall interventions, and she places them on the care plan. The MDS nurse stated that the resident no longer used a merry walker and was changed to a wheelchair, however, the MDS nurse verified that the care plan had not been updated to reflect the change. The MDS nurse stated not all fall interventions are indicated on Kardex, where the CNAs complete their charting, so CNAs would not know all of the fall interventions. At the end of the interview, the MDS nurse stated Resident #35 ' s care plan was not accurate or up to date.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 12 045356 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 045356 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Siloam Healthcare, LLC 811 West Elgin Street Siloam Springs, AR 72761

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 During an interview on 01/17/25 at 10:34 AM, the DON stated that she was aware of proper footwear being

on at all times was already a fall intervention, however, on 01/07/2025, Resident #35 did not have them on, Level of Harm - Minimal harm or so staff were not following interventions that should have been in place. The DON also stated that fall potential for actual harm assessments should be completed correctly or it could affect the fall score, indicating if the resident was a fall risk or not. The DON stated the facility had not completed a root cause analysis of Resident #35 ' s falls for Residents Affected - Few the last year and had only looked at the most recent falls.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 12 045356 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 045356 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Siloam Healthcare, LLC 811 West Elgin Street Siloam Springs, AR 72761

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0726 Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Level of Harm - Minimal harm or potential for actual harm 35684

Residents Affected - Few Based on observation, interview and record review the facility failed to assess resident for edema and administer prescribed, as needed medication, according to physician's orders for 1 (Resident #7) of 1 sampled resident who had, as needed, diuretic therapy.

The findings are:

Resident #7 ' s Physician's January 2025 orders were reviewed and read in part that resident had diagnoses of cerebrovascular disease, hypertensive heart disease with heart failure, chronic diastolic heart failure and chronic kidney disease. [Name brand diuretic] Oral Tablet 40 MG [milligram] Give 1 tablet by mouth every 24 hours as needed for prn [as needed] swelling related to chronic diastolic congestive heart failure prn swelling.

A significant change minimum data set [MDS] with an ARD [assessment reference date] of 11/13/2024, indicated a BIMS [brief interview for mental status] score of 03 [00-07 suggests severe impairment]

On01/13/25 at 11:47 AM Resident #7 was observed sitting in a wheelchair, in the day area. Resident #7 was observed to have on shoes with straps, swelling to both feet that extended beyond both shoes approximately 1 to 1.5 inches.

On 01/15/25 at 1:08 PM, Resident #7 was observed sitting in their wheel chair, in the dining room. Resident #7 was observed to have on shoes with swelling to both feet that extended beyond both shoes approximately 1 to 1.5 inches. Resident #7 ' s PCP [primary care physician] was notified of observations during phone conversation conducted on 01/15/2025 at 1:16 PM.

On 01/15/25 at 11:04 AM, LPN #1 was asked to review Resident #7's record and relate the reason resident ' s diuretic was changed from routine, to as needed. LPN #1 was unable to locate any progress note that was related to the resident's edema, or [Brand name diuretic] change to as needed. LPN #1 denied knowledge of Resident #7 having edema, LPN #1 denied administering as needed diuretic for edema observed to bilateral lower extremities. LPN #1 unable to voice reasoning for medication change, or if the resident had edema. LPN #1 stated there was not an automatic assessment indicator on the facility electronic medical record to indicate a required assessment for edema.

On 01/15/25 at 11:30 AM, DON [director of nursing] interview--reviewing record for reasoning behind diuretic change to PRN, the DON voiced recollection of the doctor making rounds on that Sunday, December 29, 2024, the physician changed the [Brand name diuretic] order from routine to PRN, due to weight fluctuations. DON verified there was not an indicator for nursing to assess for edema in the electronic medical record.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 12 045356 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 045356 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Siloam Healthcare, LLC 811 West Elgin Street Siloam Springs, AR 72761

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0726 On 01/15/25 at 1:16 PM, during a phone interview with Resident #7 ' s primary care physician [PCP] who stated he had been the residents PCP for 3 to 4 years. The PCP was asked about the change in the diuretic Level of Harm - Minimal harm or from routine to as needed. He remarked that the nursing staff had informed him of resident #7 ' s change in potential for actual harm condition and lethargy, and the PCP was concerned that Resident #7 was becoming dehydrated due to the diuretic. PCP indicated Resident #7 had not been doing well and wanted to see if the change in the diuretic Residents Affected - Few would make a difference. The PCP indicated that the diuretic was prescribed for Resident #7 due to a diagnosis of CHF [congestive heart failure]. The PCP expected nursing staff to assess resident for edema at least daily and stated, I should have written the order better.

On 01/15/25 at 2:49 PM, LPN #1 was asked to assess Resident #7 ' s feet, after LPN #1 assessed Resident #7 ' s feet, LPN #1 reported that 1+ edema and wheezing lung sounds were assessed. LPN #1 was asked to confirm resident #7 ' s medication for edema. LPN #1 pulled up residents' information on the electronic medical record and indicated resident #7 ' s current order for [Brand name diuretic]40 mg 1 po [by mouth] q [every] 24 hours PRN [as needed]. LPN #1 was asked how often resident #7 should be assessed for edema and the response was daily. LPN #1 was asked to review the medication administration record from the electronic health record, LPN #1 confirmed resident #7 ' s PRN diuretic order.

On 01/15/25 at 2:49 PM, LPN #2 was asked how often the assigned nurse should check for edema if they have an as needed diuretic; LPN #2 responded, they should check at least every shift.

Resident #7 ' s January Medication Administration Record (MAR) was reviewed, and the as needed diuretic had not been documented as be administered for the entirety of January.

On 1/16/2025 at 10:49 AM, an Administering Medications policy was received from the DON. The policy was reviewed and read in part that medications were to be administered in a safe and timely manner, and as prescribed; 4. Medications are administered in accordance with prescriber orders, including any required time frame; 5. Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include: enhancing optimal therapeutic effect of the medication.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 12 045356 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 045356 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Siloam Healthcare, LLC 811 West Elgin Street Siloam Springs, AR 72761

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm 49981

Residents Affected - Many Based on observation, interview, and facility document review, the facility failed to ensure that food was prepared in accordance with professional standards for food service safety by not keeping the grease trap clean of charred food particles and spillage.

The findings are:

On 01/13/2025 at 11:33am during an observation of the facility's kitchen, the Food Service Director (FSD) pulled out the grease traps on the stove. When the FSD pulled open the slide out tray, there was a piece of aluminum foil covering the top of the tray that contained an 18 inch by 9 inch area of black spillage and charred particles.

On 01/13/2025 at 11:35am, the FSD stated grease traps were checked and cleaned once a week by one of

the kitchen staff and the kitchen has a cleaning schedule.

On 01/13/2025 at 11:50pm, the FSD stated the grease traps should be checked and changed more frequently than once per week. The FSD stated that leaving the charred particles and spillage in the grease trap posed a fire risk in the kitchen and could attract pests.

On 01/15/2025, in-service training on the kitchen's cleaning schedule was provided by the FSD dated 10/10/2024 and 12/12/2024.

A review of dietary Cleaning Schedules, for the last 3 months indicated staff were to clean the range hood and hood filters. Cleaning of the stove and/or grease trap was not indicated.

A review of dietary Cleaning Schedules, for the last 3 months indicated all staff were responsible for cleaning

the stovetop and/or grill. Cleaning of the grease trap was not indicated.

A review of Cleaning Assignments which indicated the morning and evening cooks were responsible for cleaning the grease traps, which were last cleaned by staff in July 2024. No other documents provided by the facility indicated staff were to clean the grease traps after July 2024, indicating July was the last documented time the grease traps were cleaned.

On 01/15/2025, a facility kitchen cleaning policy was requested and was not provided to the surveyor prior to exiting the facility

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 12 045356 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 045356 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Siloam Healthcare, LLC 811 West Elgin Street Siloam Springs, AR 72761

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0838 Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. Level of Harm - Minimal harm or potential for actual harm 43262

Residents Affected - Some Based on record review and interview, the facility failed to ensure a Facility-wide Assessment included pertinent information to determine what resources were allocated to care and to meet the needs of the residents competently during both day-to-day operations, and emergencies in 1 of 1 facility. This deficient practice had the potential to affect all residents of the facility. The total census was 83 residents.

The findings are:

A review of a facility document titled Facility Assessment Tool, indicated an update on 11/27/2024.

The facility-wide assessment did not include the following:

- The process of making admission or continuing care decisions for persons that have diagnoses, (dx) or conditions the facility are less familiar with, and have not previously supported.

- Assessment of residents' ethnic, cultural, or religious factors that may need to be considered to meet resident needs, such as activities, food preferences, and any other aspect of care identified.

- Other pertinent facts or descriptions of the resident population that must be considered when determining staffing and resource needs such as, daily schedules, bathing, activities, naps, food, going to bed, etc.

- Review of staff assignments for coordination and continuity of care.

- A description of staff training/education and competencies necessary to provide the level of care for the facility's resident population.

- A description of how the facility evaluates what policies and procedures may be required in the provision of care, and how to ensure the facility meets current professional standards of practice.

- The plan to recruit and retain enough medical personnel who are adequately trained and knowledgeable in

the care of residents, and/or management of expectations for medical personnel.

- How the management and staff familiarize themselves with what they should expect from medical practitioners and other healthcare professionals, related to standards of care and competencies that are necessary to provide the level and types of support and care needed for the facility ' s resident population.

- List of contracts and memoranda of understanding or other agreements with third parties to provide services or equipment to the facility during both normal operations and emergencies.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 12 045356 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 045356 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Siloam Healthcare, LLC 811 West Elgin Street Siloam Springs, AR 72761

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0838 - List heath information technology resources for managing resident records and sharing information with other organizations. Level of Harm - Minimal harm or potential for actual harm - A description of how the facility would evaluate their infection prevention and control program, that included systems for preventing, identifying, reporting, investigating, and controlling infections. Residents Affected - Some - A facility-based and community-based risk assessment, utilizing an all-hazards approach, focusing on capacities and capabilities critical to emergency preparedness.

During an interview on 01/17/2025 at 9:17 AM, Administrator said I was not aware that all the bullet points of

the facility assessment had to be completed. I will work on it and have it completed by the end of the day.

The Administrator confirmed the facility assessment was not completed, and the facility would work on the facility assessment to complete it and make it more accurate.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 12 045356