Deficiencies (last 3 years)
Deficiencies (over 3 years)
6.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
21% worse than Arkansas average
Arkansas average: 5.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Routine
Deficiencies: 5
Date: Jun 5, 2025
Visit Reason
The inspection was a routine survey conducted to assess compliance with regulatory requirements related to resident safety, medication storage, food safety, and facility operations at Fianna Hills Nursing and Rehabilitation Center.
Findings
The facility was found deficient in multiple areas including improper storage of oxygen canisters, medication left at bedside and improper medication refrigeration temperatures, lack of sanitizer chemicals and inadequate cleaning in the kitchen, failure to properly clean and sanitize food preparation surfaces and equipment, and expired or unlabeled food items in the kitchen pantry. These deficiencies posed minimal harm or potential for actual harm to residents.
Deficiencies (5)
Failed to properly store oxygen canisters while not in use for Resident #53, with oxygen tank found on floor unsecured.
Medication was left at the bedside and insulins and antianxiety medications were stored at improper temperatures.
Chemical sanitizers were unavailable for dishwashing and kitchen sanitation; sanitizer logs were incomplete or missing.
Dietary staff failed to wash hands between tasks and did not properly sanitize food preparation surfaces or equipment.
Expired and unlabeled food items and spices were found in the kitchen pantry.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 89
Dishwasher temperature: 140
Medication refrigerator temperature: 24
Sanitizer PPM: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #7 | CNA | Interviewed regarding oxygen tank storage for Resident #53 |
| Licensed Practical Nurse #8 | LPN | Interviewed regarding oxygen tank storage and medication storage |
| Director of Nursing | DON | Interviewed regarding oxygen tank storage and medication storage deficiencies; provided staff education |
| Administrator | Administrator | Interviewed regarding oxygen tank storage and medication storage policies |
| Medical Director | MD | Interviewed regarding medication administration and storage concerns |
| Dietary Aide #1 | DA | Observed and interviewed regarding sanitizer availability and dishwasher operation |
| Dietary Aide #2 | DA | Provided statement about sanitizer availability |
| Dietary Aide #3 | DA | Interviewed regarding sanitizer availability and food temperature testing |
| Dietary Aide #4 | DA | Observed during food preparation and cleaning practices |
| Certified Dietary Manager | CDM | Interviewed regarding sanitizer ordering, logs, and kitchen sanitation |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: May 31, 2024
Visit Reason
The inspection was conducted as an annual survey of Fianna Hills Nursing and Rehabilitation Center to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Routine
Census: 87
Deficiencies: 14
Date: Apr 28, 2023
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with healthcare facility regulations, including resident rights, care planning, infection control, and other standards.
Findings
The facility was found deficient in multiple areas including failure to ensure residents' dignity during dining, call lights within reach, accurate Minimum Data Set (MDS) assessments, updated PASARR screening, complete care plans, pressure ulcer care, catheter care, oxygen therapy management, meal preparation and serving according to menus, food safety and hygiene practices, infection prevention and control, COVID-19 vaccination education and documentation, and staff COVID-19 vaccination compliance.
Deficiencies (14)
Failed to ensure residents' dining space was respected to promote dignity and respect, resulting in residents refusing to eat meals touched by others.
Failed to ensure call lights were kept within reach for residents dependent on staff assistance.
Failed to ensure accurate Minimum Data Set (MDS) assessments related to indwelling catheters and discharge status.
Failed to ensure updated PASARR screening for residents with mental disorders.
Failed to update individualized care plans to reflect new or changed services for multiple residents.
Failed to provide appropriate pressure ulcer care including floating heels as ordered.
Failed to ensure proper care and maintenance of indwelling foley catheters including tubing and drainage bag positioning and cleanliness.
Failed to ensure oxygen therapy was administered at prescribed rates with properly dated and maintained humidifier bottles and tubing.
Failed to ensure meals were prepared and served according to the planned menu, including correct portion sizes and inclusion of all menu items.
Failed to ensure pureed food items were blended to a smooth, lump-free consistency.
Failed to ensure foods stored in the freezer were covered and sealed; failed to ensure dietary staff washed hands before handling clean equipment.
Failed to ensure Binding Arbitration Agreements included a neutral venue selection clause agreed upon by both parties.
Failed to ensure visitors wore personal protective equipment while visiting a resident on contact isolation; failed to ensure staff performed hand hygiene and glove changes during incontinent care; failed to ensure hand hygiene before serving meals.
Failed to ensure education regarding COVID-19 vaccine benefits, risks, and resident choice was documented for residents; failed to ensure all staff were fully vaccinated or had approved exemptions and accurate vaccination tracking.
Report Facts
Residents affected: 87
Residents on mechanical soft diets: 23
Residents on pureed diets: 7
Residents on regular diets: 58
Milk cartons expired: 41
Days worked without vaccination or exemption: 29
Days worked without vaccination or exemption: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #5 | Licensed Practical Nurse | Involved in seating residents during dining room incident affecting dignity |
| Activity Director | Activity Director | Intervened in dining room incident to move resident and provide replacement meal |
| Director of Nurses | Director of Nursing | Interviewed regarding dignity issues, call light placement, care planning, infection control, and COVID-19 vaccination |
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Interviewed regarding catheter care and infection control |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Interviewed regarding oxygen therapy and catheter care |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Observed not performing hand hygiene before meal setup |
| Certified Nursing Assistant #4 | Certified Nursing Assistant | Interviewed regarding catheter care and infection control |
| Certified Nursing Assistant #10 | Certified Nursing Assistant | Interviewed regarding PPE use in contact isolation |
| Certified Nursing Assistant #8 | Certified Nursing Assistant | Observed not performing hand hygiene during incontinent care |
| Certified Nursing Assistant #7 | Certified Nursing Assistant | Observed not performing hand hygiene during incontinent care |
| Certified Nursing Assistant #3 | Certified Nursing Assistant | Interviewed regarding pureed food consistency |
| Dietary Employee #2 | Dietary Employee | Observed preparing meals with incorrect portions and pureed food consistency; observed poor hand hygiene |
| Dietary Employee #1 | Dietary Employee | Observed poor hand hygiene and contamination of clean equipment |
| Social Service Director | Social Service Director | Interviewed regarding arbitration agreement |
| Administrator | Administrator | Interviewed regarding arbitration agreement, infection control, and COVID-19 vaccination policies |
| Infection Control Preventionist | Infection Control Preventionist | Interviewed regarding infection control and COVID-19 vaccination |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Staff member with religious exemption for COVID-19 vaccination |
| Certified Nursing Assistant #2 | Certified Nursing Assistant | Partially vaccinated staff member |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Partially vaccinated staff member |
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