Heartsworth Nursing: CPR Withheld From Full Code Resident - OK
The resident, whose cognition was documented as fully intact, had a physician's order designating them a full code, meaning staff were required to perform CPR if their heart stopped. No one did. Instead, a licensed practical nurse checked a blood pressure reading, declared the resident dead, and told staff to clean the body. Two nursing assistants who had never performed aftercare before washed the resident, brushed their hair, and covered them with a sheet.
By the time the assistant director of nursing learned what had happened, the body had already been removed from Heartsworth Center for Nursing and Rehabilitation.
Federal inspectors who investigated the incident cited the facility for immediate jeopardy, the most serious level of deficiency the Centers for Medicare and Medicaid Services issues, indicating a situation that has caused or is likely to cause serious injury or death.
The sequence of events, reconstructed through inspector interviews with the two nursing assistants, the licensed practical nurse, and the assistant director of nursing, describes a facility where a nurse made a unilateral decision to forgo resuscitation on a patient who had not consented to that outcome, then apparently walked to a computer while two aides cleaned the body of a person who was supposed to still be fighting for their life.
CNA 2 was the one who found the resident. They went into the room for a routine check, noticed the resident did not respond when spoken to and did not appear to be breathing, and went to find LPN 1. The nurse entered the room, placed a blood pressure cuff on the resident's arm, checked the reading, and said, according to CNA 2: "She's dead." CNA 2 asked what they should do. LPN 1 said to clean the resident up, then, CNA 2 told inspectors, walked over to look at a computer. CNA 2 did not know what the nurse was doing there.
CNA 2 had never cleaned a deceased person before. They went to find CNA 1, who was working on a different hall entirely. CNA 1's first question, when told a resident had died, was whether the resident was a DNR or a full code, because the aftercare procedure was different. CNA 2 told them they hadn't done CPR, so they assumed there must have been a DNR order. CNA 1 accepted that logic and went to help.
What CNA 1 found when they got to the room was a resident whose upper body clothing was soaked in foul-smelling vomit. When they rolled the body to the sides during cleaning, more of the substance came out of the resident's mouth. CNA 1 told inspectors the skin looked normal except the veins appeared bluer than those of a living person. There was no blue or purple discoloration to the skin. The body was limp.
CNA 2 described the same scene: pale skin, no discoloration, a limp body. When they rolled the resident to clean them, vomit came from the mouth and nose. There appeared to be some blood in it.
The two aides removed the resident's clothing and brief, washed the body, brushed the hair, and covered the resident with a sheet.
LPN 1 had not called a code. Had not called 911. Had not initiated CPR. Had not, apparently, checked the resident's code status before telling the aides to begin aftercare.
The assistant director of nursing found out about the death through a text message from LPN 1 saying the resident was deceased and describing what had been done. The ADON texted back asking whether CPR had been performed. LPN 1 did not reply. The ADON texted again. This time, LPN 1 called.
On the phone, LPN 1 told the ADON that the resident had vomit on them. The ADON told inspectors their response was direct: that did not matter if the resident was a full code, and if they were, CPR should have been performed. The ADON then looked up Resident 3's code status themselves. The order was clear. Full code.
LPN 1's explanation, when pressed, was that the resident was on hospice care and had a DNR.
Neither was true. The ADON contacted the resident's hospice service. There was no DNR on file. The resident was not, as far as the hospice service knew, designated as do-not-resuscitate. The ADON told inspectors plainly: Resident 3 should have received CPR on the day they died.
By then it was approximately 10:00 a.m. and the ADON had driven to the facility. The body was already gone.
Resident 3's medical record showed a BIMS score of 15, the highest possible score on the Brief Interview for Mental Status, indicating fully intact cognition. This was not a resident who lacked the capacity to make decisions about their own care. This was someone who had, at some point, sat with a physician and indicated they wanted to be resuscitated. That choice was documented. It was in the chart. LPN 1 either did not check it or checked it and proceeded anyway.
The inspection report does not say which.
What it does say is that when CNA 2 asked LPN 1 what to do after discovering an unresponsive resident, the answer was not "call 911" or "start chest compressions" or "I need to check the chart." The answer was to clean the body. And when CNA 1, a nursing assistant on a completely different hall with no direct knowledge of this resident, thought to ask about code status before beginning aftercare, no one with a license thought to do the same before forgoing resuscitation entirely.
CNA 1 had asked the right question. They got the wrong answer, accepted it, and helped wash and dress a person who, under their own documented wishes and their physician's standing order, should have had someone's hands on their chest.
The facility received a citation at the immediate jeopardy level under F0678, which covers the requirement that residents receive cardiopulmonary resuscitation when it is indicated and ordered. Inspectors noted that few residents were affected.
That number is one.
Resident 3 had intact cognition. They had chosen to be a full code. They had vomit on their clothing when they were found, and more came out of their mouth when two nursing assistants, doing their best with a task neither had done before, turned the body to wash it. Whether the vomit was related to whatever caused the resident to stop breathing, the inspection report does not say. What it says is that no one who held a license and had the authority to act tried to bring this person back.
The ADON said Resident 3 should have received CPR. The hospice service confirmed there was no DNR. The physician's order was in the chart.
None of it mattered by 10:00 a.m., when the ADON arrived at Heartsworth Center and the room was already empty.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Heartsworth Center For Nursing & Rehabilitation from 2025-09-18 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 27, 2026 · Our methodology
Heartsworth Center For Nursing & Rehabilitation in Vinita, OK was cited for violations during a health inspection on September 18, 2025.
Instead, a licensed practical nurse checked a blood pressure reading, declared the resident dead, and told staff to clean the body.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.