Inspection Reports for
Fianna Hills Nursing and Rehabilitation Center
8411 South 28th Street, Fort Smith, AR, 72908-8646
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
7.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
40% worse than Arkansas average
Arkansas average: 5.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Routine
Deficiencies: 9
Date: Jun 5, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to resident safety, medication storage and administration, food safety, and facility sanitation at Fianna Hills Nursing and Rehabilitation Center.
Findings
The facility was found deficient in several areas including improper storage of oxygen canisters, medication left at bedside, improper medication refrigeration temperatures, lack of sanitizing chemicals in the kitchen, inadequate cleaning and sanitizing of food preparation surfaces and equipment, expired and unlabeled food items, and failure to maintain proper logs for dishwasher and sanitizer temperatures.
Deficiencies (9)
Failed to properly store oxygen canisters while not in use for Resident #53, with oxygen tanks stored on the floor unsecured.
Medication was left at the bedside for Resident #48 and insulins and antianxiety medications were stored at temperatures below manufacturer recommendations.
Failed to ensure chemical solutions were available to effectively clean and sanitize dishware and kitchen equipment; sanitizer was unavailable for several days.
Failed to ensure dietary staff washed hands following glove removal and between tasks during meal preparation.
Failed to ensure food preparation surfaces were cleaned and sanitized using a sanitizing solution.
Failed to ensure equipment was clean and sanitized between uses, including a food scale with dried food residue.
Failed to ensure dietary staff cleaned and sanitized the test thermometer between testing food temperatures.
Multiple food items in the pantry were expired, unlabeled, or lacked use-by or expiration dates.
Failed to maintain proper logs for dishwasher and sanitizer temperatures and parts per million (PPM) readings for several months.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 89
Dishwasher temperature: 140
Sanitizer PPM: 0
Refrigerator temperature: 24
Recommended medication refrigerator temperature range: 36-46
Dishwasher temperature range: 120-150
Sanitizer PPM range: 150-400
Sanitizer temperature range: 65-70
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #7 | Certified Nursing Assistant | Interviewed regarding oxygen tank storage for Resident #53 |
| Licensed Practical Nurse #8 | Licensed Practical Nurse | Interviewed regarding oxygen tank storage and medication observations |
| Director of Nursing | Director of Nursing | Provided education on oxygen tank storage and medication storage issues |
| Administrator | Administrator | Interviewed regarding oxygen tank storage and medication storage policies |
| Medical Director | Medical Director | Interviewed regarding medication administration and food safety monitoring |
| Dietary Aide #1 | Dietary Aide | Observed and interviewed regarding sanitizer availability and dishwasher logs |
| Dietary Aide #2 | Dietary Aide | Provided statement about sanitizer availability |
| Dietary Aide #3 | Dietary Aide | Observed food serving and thermometer cleaning practices |
| Dietary Aide #4 | Dietary Aide | Observed food preparation and cleaning practices |
| Certified Dietary Manager | Certified Dietary Manager | Interviewed regarding sanitizer ordering and dishwasher logs |
| Dietary Consultant | Dietary Consultant | Interviewed regarding dishwasher temperatures and sanitizer availability |
Inspection Report
Deficiencies: 0
Date: May 31, 2024
Visit Reason
The document is a statement of deficiencies and plan of correction for Fianna Hills Nursing and Rehabilitation Center, summarizing the results of a regulatory survey completed on May 31, 2024.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Routine
Census: 87
Deficiencies: 13
Date: Apr 28, 2023
Visit Reason
Routine inspection of Fianna Hills Nursing and Rehabilitation Center to assess compliance with regulatory standards including resident dignity, care planning, infection control, nutrition, and COVID-19 vaccination status.
Findings
The facility was found deficient in multiple areas including failure to ensure resident dignity during dining, inaccurate Minimum Data Set (MDS) assessments, incomplete care plans, inadequate pressure ulcer care, improper catheter and oxygen therapy management, food preparation and handling issues, failure to enforce infection control precautions including PPE use and hand hygiene, incomplete COVID-19 vaccination education and documentation for residents, and incomplete staff COVID-19 vaccination compliance and documentation.
Deficiencies (13)
Failure to ensure resident dignity during dining with residents' personal space infringed and meals served improperly.
Inaccurate Minimum Data Set (MDS) assessments related to indwelling catheters and discharge status.
Failure to update individualized care plans to reflect current resident needs and physician orders.
Failure to provide appropriate pressure ulcer care including failure to float heels as ordered.
Failure to ensure proper care and infection prevention for residents with indwelling Foley catheters.
Failure to ensure oxygen therapy was administered as ordered including proper flow rates, dated tubing, and humidifier maintenance.
Failure to prepare and serve meals according to the planned menu and dietary specifications including insufficient portions and missing pureed bread.
Failure to ensure pureed food items were blended to a smooth, lump-free consistency.
Failure to ensure foods stored in the freezer were covered and sealed and failure of dietary staff to wash hands before handling clean equipment.
Failure to provide a neutral and fair arbitration process with venue selection agreed upon by both parties.
Failure to ensure visitors wore personal protective equipment while visiting a resident on contact isolation; failure of staff to perform hand hygiene and/or change gloves during incontinent care; failure to perform hand hygiene before serving meals.
Failure to document education and resident/responsible party decisions regarding COVID-19 vaccination for sampled residents.
Failure to ensure all staff received complete COVID-19 vaccinations or had approved exemptions or delays, and failure to accurately track and update staff vaccination status.
Report Facts
Residents affected by dignity issue: 87
Residents affected by call light issue: 62
Residents affected by pressure ulcer care deficiency: 5
Residents affected by catheter care deficiency: 6
Residents affected by oxygen therapy deficiency: 21
Residents affected by meal preparation deficiency: 7
Residents affected by food storage and hygiene deficiency: 86
Residents affected by infection control deficiency: 87
Residents who refused COVID-19 vaccine: 15
Staff partially vaccinated without complete documentation: 3
Staff unvaccinated without exemption: 1
Days worked by unvaccinated CNA #1: 29
Days worked by partially vaccinated CNA #2: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #5 | Licensed Practical Nurse | Named in resident dignity and dining interaction findings |
| Director of Nurses | Director of Nursing | Interviewed regarding dignity issues, care plans, infection control, oxygen therapy, and COVID-19 vaccination |
| Certified Nursing Assistant #9 | Certified Nursing Assistant | Interviewed regarding call light placement |
| MDS Coordinator | Interviewed regarding MDS accuracy and care plan updates | |
| Licensed Practical Nurse #6 | Licensed Practical Nurse | Interviewed regarding care plan and resident splints |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Interviewed regarding pressure ulcer care and oxygen therapy |
| Certified Nursing Assistant #4 | Certified Nursing Assistant | Interviewed regarding Foley catheter care |
| Certified Nursing Assistant #5 | Certified Nursing Assistant | Interviewed regarding Foley catheter care |
| Certified Nursing Assistant #6 | Certified Nursing Assistant | Interviewed regarding Foley catheter care |
| Dietary Employee #2 | Dietary Employee | Observed and interviewed regarding meal preparation and food consistency |
| Dietary Employee #1 | Dietary Employee | Observed handling food and equipment without proper hand hygiene |
| Certified Nursing Assistant #10 | Certified Nursing Assistant | Interviewed regarding PPE use in isolation |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Interviewed regarding PPE use in isolation and meal tray handling |
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Interviewed regarding hand hygiene during incontinent care |
| Infection Control Preventionist | Interviewed regarding infection control practices and COVID-19 vaccination | |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Named in staff COVID-19 vaccination non-compliance and exemption |
| Certified Nursing Assistant #2 | Certified Nursing Assistant | Named in staff COVID-19 vaccination partial compliance |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Named in staff COVID-19 vaccination partial compliance |
Report
June 5, 2025
Report
May 31, 2024
Report
April 28, 2023
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