Cycle 1
Health 2025-06-05 · Fire 2025-06-05
3 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fort Smith, AR
Fianna Hills Nursing And Rehabilitation Center
5-star overall rating with 5-star inspections with 3 recent health deficiencies
8411 South 28th Street, Fort Smith, AR
(479) 648-9600
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
102
Certified beds
Average residents
96
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2000-01-25
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.27
Registered nurse staffing · state 0.40 · national 0.68
LPN hours / resident day
1.00
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
3.20
Nurse aide staffing · state 2.72 · national 2.35
Total nurse hours
4.46
All reported nurse hours · state 4.07 · national 3.89
Licensed hours
1.26
RN + LPN hours · state 1.35 · national 1.54
Weekend hours
3.55
Weekend nurse staffing · state 3.48 · national 3.43
Weekend RN hours
0.13
Weekend registered nurse coverage · state 0.27 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.03 · national 0.07
Adjusted RN hours
0.29
CMS adjusted RN staffing hours
Adjusted total hours
4.79
CMS adjusted total nurse staffing hours
Case-mix index
1.27
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
3,341
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
44.81
Composite VBP score used to determine payment impact.
Payment multiplier
0.9980
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.07
Baseline 20.56% · Performance 19.08% · Measure score 5.07 · Achievement 5.07 · Improvement 3.69
Healthcare-associated infections
3.08
Baseline 9.42% · Performance 7.84% · Measure score 3.08 · Achievement 0 · Improvement 3.08
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
5.29
Baseline 3.95 hours · Performance 4.58 hours · Measure score 5.29 · Achievement 5.29 · Improvement 2.95
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.96% |
10.72%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 140 · Observed rate 14.29% · Lower 95% interval 8.36% |
| Discharge to community | 54.82% |
50.57%
4.2 pts better
|
No Different than the National Rate · Eligible stays 102 · Observed rate 45.1% · Lower 95% interval 43.36% |
| Medicare spending per beneficiary | 1.11 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 99.16% |
95.27%
3.9 pts better
|
Numerator 118 · Denominator 119 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 119 |
| Discharge self-care score | 44.05% |
53.69%
9.6 pts worse
|
Numerator 37 · Denominator 84 |
| Discharge mobility score | 36.9% |
50.94%
14 pts worse
|
Numerator 31 · Denominator 84 |
| Pressure ulcers or injuries, new or worsened | 4.2% |
2.29%
1.9 pts worse
|
Numerator 5 · Denominator 119 · Adjusted rate 3.79% |
| Healthcare-associated infections requiring hospitalization | 7.84% |
7.12%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 102 · Observed rate 9.8% · Lower 95% interval 4.8% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 133 |
| Staff flu vaccination coverage | 99.21% |
42%
57.2 pts better
|
Numerator 252 · Denominator 254 |
| Discharge function score | 42.86% |
56.45%
13.6 pts worse
|
Numerator 36 · Denominator 84 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 77 · Denominator 77 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 9.43% |
25.2%
15.8 pts worse
|
Numerator 5 · Denominator 53 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.2 |
2.0
0.2 pts worse
|
1.9
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 2.3 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.3 |
2.2
0.1 pts worse
|
1.8
0.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 2.2 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
94.9%
5.1 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
96.1%
3.9 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.3% |
3.9%
2.4 pts worse
|
3.3%
3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.2% · Q2 6.7% · Q3 5.1% · Q4 6.3% · 4Q avg 6.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.4% |
1.4%
About the same
|
11.4%
10 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.9% · Q3 1.3% · Q4 1.4% · 4Q avg 1.4% |
| Percentage of long-stay residents who lose too much weight | 1.5% |
4.9%
3.4 pts better
|
5.4%
3.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 0.0% · Q3 1.5% · Q4 2.8% · 4Q avg 1.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 17.4% |
21.8%
4.4 pts better
|
19.6%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.3% · Q2 20.0% · Q3 17.4% · Q4 14.1% · 4Q avg 17.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 6.0% |
12.5%
6.5 pts better
|
16.7%
10.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 2.1% · Q3 7.3% · Q4 7.5% · 4Q avg 6.0% · 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 | 10.3% |
11.4%
1.1 pts better
|
16.3%
6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.0% · Q2 4.3% · Q3 12.3% · Q4 9.9% · 4Q avg 10.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 19.7% |
10.4%
9.3 pts worse
|
14.9%
4.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 36.5% · Q2 13.6% · Q3 17.7% · Q4 13.8% · 4Q avg 19.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.7%
0.7 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.4% |
1.1%
2.3 pts worse
|
1.7%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 1.4% · Q3 5.2% · Q4 3.8% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 14.6% |
14.6%
About the same
|
19.8%
5.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 12.7% · Q3 13.9% · Q4 12.4% · 4Q avg 14.6% |
| Percentage of long-stay residents with pressure ulcers | 1.8% |
4.6%
2.8 pts better
|
5.1%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.7% · Q3 1.7% · Q4 1.8% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.1% |
81.8%
17.3 pts better
|
81.7%
17.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 98.8% · Q4 97.5% · 4Q avg 99.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 15.6% |
13.8%
1.8 pts worse
|
12.0%
3.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 15.6% · Observed 16.0% · Expected 11.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.4%
1.4 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.8% |
77.9%
20.9 pts better
|
79.7%
19.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.6% |
25.2%
2.4 pts worse
|
23.9%
3.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.6% · Observed 29.3% · Expected 25.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-31 · Fire 2024-05-31
0 health deficiencies
No concentrated health issue counts in this cycle.
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2023-04-28 · Fire 2023-04-28
15 health deficiencies
Top issue: Infection Control (3 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-05-31
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2024-06-17
F · Potential for more than minimal harm
2024-05-31
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-06-17
F · Potential for more than minimal harm
2024-05-31
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-06-17
F · Potential for more than minimal harm
2023-04-28
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2023-06-01
F · Potential for more than minimal harm
2023-04-28
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-06-01
F · Potential for more than minimal harm
2023-04-28
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-06-01
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-06-05
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 2025-07-04
E · Potential for more than minimal harm
2025-06-05
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 2025-07-04
D · Potential for more than minimal harm
2025-06-05
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 2025-07-04
F · Potential for more than minimal harm
2023-04-28
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 2023-06-01
E · Potential for more than minimal harm
2023-04-28
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-06-01
E · Potential for more than minimal harm
2023-04-28
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-06-01
E · Potential for more than minimal harm
2023-04-28
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2023-06-01
E · Potential for more than minimal harm
2023-04-28
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-06-01
E · Potential for more than minimal harm
2023-04-28
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-06-01
E · Potential for more than minimal harm
2023-04-28
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-06-01
E · Potential for more than minimal harm
2023-04-28
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-06-01
E · Potential for more than minimal harm
2023-04-28
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 2023-06-01
E · Potential for more than minimal harm
2023-04-28
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-06-01
E · Potential for more than minimal harm
2023-04-28
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 2023-06-01
D · Potential for more than minimal harm
2023-04-28
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-06-01
D · Potential for more than minimal harm
2023-04-28
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 2023-06-01
C · Minimal harm
2023-04-28
F848 · Administration Deficiencies
Health
Provide a neutral and fair arbitration process and agree to arbitrator and venue.
Corrected 2023-04-28
B · Minimal harm
2023-04-28
F888 · Infection Control Deficiencies
Health
Ensure staff are vaccinated for COVID-19
Corrected 2023-04-28
Penalties and ownership
What sits behind the stars
Ownership
Rhs Nursing, LLC
5% Or Greater Direct Ownership Interest · Organization
Hathorn, Michael
5% Or Greater Indirect Ownership Interest · Individual
M&M Hathorn, LLC
5% Or Greater Indirect Ownership Interest · Organization
Mundy, Karen
W-2 Managing Employee · Individual
Schaap, Don
5% Or Greater Indirect Ownership Interest · Individual
Schaap, Kimberly
5% Or Greater Indirect Ownership Interest · Individual
Schaap, LLC
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Other facilities in reach
#1
Brooken Hill Health And Rehab, LLC
Fort Smith, AR
0-star overall rating with 0-star inspections
#2
The Blossoms At Fort Smith Rehab & Nursing Center
Fort Smith, AR
2-star overall rating with 2-star inspections with 8 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Covington Court Health And Rehabilitation Center
Fort Smith, AR
3-star overall rating with 3-star inspections with $12,196 in total fines with 1 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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