A list of the most recent deficiencies for Siloam Healthcare, LLC. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-12-15 | 2024-01-14 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-12-15 | 2024-01-14 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-12-15 | 2024-01-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-12-15 | 2024-01-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-12-15 | 2024-01-14 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-12-15 | 2024-01-14 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2023-12-14 | 2024-01-14 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-12-14 | 2024-01-14 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-02-06 | 2023-02-28 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-09-09 | 2022-10-09 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2022-09-09 | 2022-10-09 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-09-09 | 2022-10-09 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-09-09 | 2022-10-09 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-09-09 | 2022-10-09 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-09 | 2022-10-09 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-09-09 | 2022-10-09 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-09-09 | 2022-10-09 | N |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2022-09-09 | 2022-10-09 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2022-09-09 | 2022-10-09 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-09-09 | 2022-10-09 | N |
| Implement a program that monitors antibiotic use. | Health | 2022-09-09 | 2022-10-09 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-09-09 | 2022-10-09 | Y |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2022-09-09 | 2022-10-09 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-09-09 | 2022-10-09 | Y |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2022-09-09 | 2022-10-09 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-09-09 | 2022-10-09 | Y |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2022-09-09 | 2022-10-09 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-09-09 | 2022-10-09 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-09-08 | 2022-10-09 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-09-08 | 2022-10-09 | N |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2022-09-09 | 2022-09-09 | N |
| Report COVID19 data to residents and families. | Health | 2022-09-09 | 2022-09-09 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-06-20 | 2022-07-20 | Y |
| Provide appropriate foot care. | Health | 2022-06-20 | 2022-07-20 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-06-18 | 2021-07-16 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2021-06-18 | 2021-07-16 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-06-18 | 2021-07-16 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-06-18 | 2021-07-16 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2021-06-18 | 2021-07-16 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-06-18 | 2021-07-16 | N |
| Ensure that residents are free from significant medication errors. | Health | 2021-06-18 | 2021-07-16 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2021-06-18 | 2021-07-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-06-18 | 2021-07-16 | N |
| Dispose of garbage and refuse properly. | Health | 2021-06-18 | 2021-07-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-06-18 | 2021-07-16 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-06-18 | 2021-07-16 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2021-06-18 | 2021-07-16 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-06-17 | 2021-07-16 | N |
| Install proper backup exit lighting. | Fire Safety | 2021-06-17 | 2021-07-16 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-06-17 | 2021-07-16 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2021-06-17 | 2021-07-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-06-17 | 2021-07-16 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-06-17 | 2021-07-16 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-06-17 | 2021-07-16 | N |
| Assure the security of all personal funds of residents deposited with the facility. | Health | 2021-06-18 | 2021-06-18 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2021-06-18 | 2021-06-18 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-06-18 | 2021-06-18 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2021-06-18 | 2021-06-18 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-03-30 | 2021-04-29 | Y |
