Cycle 1
Health 2025-01-17 · Fire 2025-01-17
6 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Siloam Springs, AR
Siloam Healthcare, LLC
2-star overall rating with 2-star inspections with 6 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
811 West Elgin Street, Siloam Springs, AR
(479) 524-3128
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
80
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Springs Arkansas
Operator or chain grouping
Approved since
1999-11-05
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
26 facilities
Chain averages 4 overall / 3 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.28
Registered nurse staffing · state 0.40 · national 0.68
LPN hours / resident day
1.04
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
2.81
Nurse aide staffing · state 2.72 · national 2.35
Total nurse hours
4.13
All reported nurse hours · state 4.07 · national 3.89
Licensed hours
1.32
RN + LPN hours · state 1.35 · national 1.54
Weekend hours
3.76
Weekend nurse staffing · state 3.48 · national 3.43
Weekend RN hours
0.16
Weekend registered nurse coverage · state 0.27 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.03 · national 0.07
Adjusted RN hours
0.33
CMS adjusted RN staffing hours
Adjusted total hours
4.86
CMS adjusted total nurse staffing hours
Case-mix index
1.16
Higher values indicate more complex resident acuity
RN turnover
43%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
49%
Annual nurse turnover · state 51% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,223
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
50.88
Composite VBP score used to determine payment impact.
Payment multiplier
1.0051
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.31
Baseline 24.46% · Performance 20.14% · Measure score 5.31 · Achievement 2.78 · Improvement 5.31
Healthcare-associated infections
5.11
Baseline 6.21% · Performance 6.31% · Measure score 5.11 · Achievement 5.11 · Improvement 0
Total nurse turnover
4.85
Baseline 90.10% · Performance 55.20% · Measure score 4.85 · Achievement 2.07 · Improvement 4.85
Adjusted total nurse staffing
5.09
Baseline 3.77 hours · Performance 4.53 hours · Measure score 5.09 · Achievement 5.09 · Improvement 3.24
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.66% |
10.72%
1.9 pts worse
|
No Different than the National Rate · Eligible stays 82 · Observed rate 15.85% · Lower 95% interval 8.79% |
| Discharge to community | 25.99% |
50.57%
24.6 pts worse
|
Worse than the National Rate · Eligible stays 55 · Observed rate 14.55% · Lower 95% interval 18.28% |
| Medicare spending per beneficiary | 0.85 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 91.43% |
95.27%
3.8 pts worse
|
Numerator 32 · Denominator 35 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 35 |
| Discharge self-care score | 50% |
53.69%
3.7 pts worse
|
Numerator 12 · Denominator 24 |
| Discharge mobility score | 37.5% |
50.94%
13.4 pts worse
|
Numerator 9 · Denominator 24 |
| Pressure ulcers or injuries, new or worsened | 2.86% |
2.29%
0.6 pts worse
|
Numerator 1 · Denominator 35 · Adjusted rate 2.52% |
| Healthcare-associated infections requiring hospitalization | 6.31% |
7.12%
0.8 pts better
|
No Different than the National Rate · Eligible stays 38 · Observed rate 2.63% · Lower 95% interval 3.59% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 96 |
| Staff flu vaccination coverage | 93.94% |
42%
51.9 pts better
|
Numerator 93 · Denominator 99 |
| Discharge function score | 58.33% |
56.45%
1.9 pts better
|
Numerator 14 · Denominator 24 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 5% |
25.2%
20.2 pts worse
|
Numerator 1 · Denominator 20 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.3 |
2.0
1.3 pts worse
|
1.9
1.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.3 · Observed 2.8 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.9 |
2.2
1.3 pts better
|
1.8
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.8 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.6% |
94.9%
3.7 pts better
|
93.4%
5.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 98.5% · Q4 95.7% · 4Q avg 98.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.3% |
96.1%
0.8 pts worse
|
95.5%
0.2 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.3% |
3.9%
3.6 pts better
|
3.3%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.4% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.9% |
1.4%
0.5 pts worse
|
11.4%
9.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.4% · Q3 3.1% · Q4 3.2% · 4Q avg 1.9% |
| Percentage of long-stay residents who lose too much weight | 4.8% |
4.9%
0.1 pts better
|
5.4%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 6.8% · Q3 6.7% · Q4 1.5% · 4Q avg 4.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.9% |
21.8%
1.9 pts better
|
19.6%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.7% · Q2 18.7% · Q3 20.3% · Q4 17.9% · 4Q avg 19.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 18.1% |
12.5%
5.6 pts worse
|
16.7%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.3% · Q2 17.3% · Q3 17.8% · Q4 18.9% · 4Q avg 18.1% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 12.3% |
11.4%
0.9 pts worse
|
16.3%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 24.5% · Q2 17.0% · Q4 3.9% · 4Q avg 12.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.6% |
10.4%
2.2 pts worse
|
14.9%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.6% · Q2 22.9% · Q3 10.0% · Q4 8.2% · 4Q avg 12.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
0.7%
0.4 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.3% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.7% |
1.1%
0.4 pts better
|
1.7%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.7% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 20.7% |
14.6%
6.1 pts worse
|
19.8%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.4% · Q2 21.4% · Q3 13.3% · Q4 23.4% · 4Q avg 20.7% |
| Percentage of long-stay residents with pressure ulcers | 3.3% |
4.6%
1.3 pts better
|
5.1%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 3.8% · Q3 4.1% · Q4 3.9% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 92.3% |
81.8%
10.5 pts better
|
81.7%
10.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 92.3% · Q2 91.6% · Q3 91.6% · Q4 93.8% · 4Q avg 92.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.6% |
13.8%
7.2 pts better
|
12.0%
5.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.6% · Observed 6.5% · Expected 10.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.9% |
1.4%
0.5 pts worse
|
1.6%
0.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.0% · Q4 4.8% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 75.3% |
77.9%
2.6 pts worse
|
79.7%
4.4 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 75.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.3% |
25.2%
6.9 pts better
|
23.9%
5.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 18.3% · Observed 16.1% · Expected 21.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-15 · Fire 2023-12-15
7 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
2 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Cycle 3
Health 2022-09-09 · Fire 2022-09-09
22 health deficiencies
Top issue: Nutrition and Dietary (6 deficiencies)
2 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-01-17
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2025-02-14
F · Potential for more than minimal harm
2025-01-17
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-02-14
F · Potential for more than minimal harm
2023-12-15
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2024-01-14
F · Potential for more than minimal harm
2023-12-15
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-01-14
F · Potential for more than minimal harm
2022-09-09
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-10-09
E · Potential for more than minimal harm
2022-09-09
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2022-10-09
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-01-17
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-02-14
E · Potential for more than minimal harm
2025-01-17
F838 · Administration Deficiencies
Health
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.
Corrected 2025-02-14
D · Potential for more than minimal harm
2025-01-17
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-02-14
D · Potential for more than minimal harm
2025-01-17
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-02-14
D · Potential for more than minimal harm
2025-01-17
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-02-14
D · Potential for more than minimal harm
2025-01-17
F726 · Nursing and Physician Services Deficiencies
Health
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.
Corrected 2025-02-14
J · Immediate jeopardy
2023-12-15
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-12-14
E · Potential for more than minimal harm
2023-12-15
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-01-14
E · Potential for more than minimal harm
2023-12-15
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-01-14
E · Potential for more than minimal harm
2023-12-15
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-01-14
E · Potential for more than minimal harm
2023-12-15
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-01-14
E · Potential for more than minimal harm
2023-12-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-01-14
E · Potential for more than minimal harm
2023-12-15
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-01-14
D · Potential for more than minimal harm
2023-05-09
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-05-30
F · Potential for more than minimal harm
2022-09-09
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-10-09
E · Potential for more than minimal harm
2022-09-09
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2022-10-09
E · Potential for more than minimal harm
2022-09-09
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2022-10-09
E · Potential for more than minimal harm
2022-09-09
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2022-10-09
E · Potential for more than minimal harm
2022-09-09
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-10-09
E · Potential for more than minimal harm
2022-09-09
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-10-09
E · Potential for more than minimal harm
2022-09-09
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-10-09
E · Potential for more than minimal harm
2022-09-09
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2022-10-09
E · Potential for more than minimal harm
2022-09-09
F803 · Nutrition and Dietary Deficiencies
Health
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.
Corrected 2022-10-09
E · Potential for more than minimal harm
2022-09-09
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2022-10-09
E · Potential for more than minimal harm
2022-09-09
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2022-10-09
E · Potential for more than minimal harm
2022-09-09
F809 · Nutrition and Dietary Deficiencies
Health
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.
Corrected 2022-10-09
E · Potential for more than minimal harm
2022-09-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-10-09
E · Potential for more than minimal harm
2022-09-09
F887 · Infection Control Deficiencies
Health
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.
Corrected 2022-10-09
D · Potential for more than minimal harm
2022-09-09
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2022-10-09
D · Potential for more than minimal harm
2022-09-09
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-10-09
D · Potential for more than minimal harm
2022-09-09
F808 · Nutrition and Dietary Deficiencies
Health
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.
Corrected 2022-10-09
D · Potential for more than minimal harm
2022-09-09
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2022-10-09
D · Potential for more than minimal harm
2022-09-09
F888 · Infection Control Deficiencies
Health
Ensure staff are vaccinated for COVID-19
Corrected 2022-10-09
C · Minimal harm
2022-09-09
F885 · Infection Control Deficiencies
Health
Report COVID19 data to residents and families.
Corrected 2022-09-09
B · Minimal harm
2022-09-09
F569 · Resident Rights Deficiencies
Health
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Corrected 2022-09-09
Penalties and ownership
What sits behind the stars
Ownership
Gutman, Isaac
5% Or Greater Direct Ownership Interest · Individual
Hoffman, Alexander
5% Or Greater Direct Ownership Interest · Individual
Shapiro, Chaim
5% Or Greater Direct Ownership Interest · Individual
Taub, Jacob
5% Or Greater Direct Ownership Interest · Individual
Safrin, Esther
5% Or Greater Direct Ownership Interest · Individual
Hoffman, Helen
5% Or Greater Direct Ownership Interest · Individual
Kurz, Chaim
5% Or Greater Direct Ownership Interest · Individual
Kurz, Solomon
5% Or Greater Direct Ownership Interest · Individual
Gutman, Isaac
Corporate Officer · Individual
Hamilton, Lance
Operational/Managerial Control · Individual
Shapiro, Chaim
Corporate Officer · Individual
Weaver, Kimberly
Operational/Managerial Control · Individual
Wellspring Healthcare LLC
Operational/Managerial Control · Organization
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#3
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